1. "I will never put my husband in a nursing facility."

    "My mother will have a home with me for as long as she lives."

    How often have you heard another adult care giver say something like that? How often have you said it yourself?

    In his gentle-but-direct book, When Love Gets Tough: The Nursing Home Decision, author and minister Doug Manning explains why this mind set can actually be harmful to elderly loved ones. In some cases, he argues, nursing home placement is actually the most appropriate and loving decision, both for the caregiver and for the patient him or herself.

    Tough Love

    Doug Manning begins his slim (125-page) book with a revolutionary statement: "Love is doing what people need–not just what they want. Love is doing what people need–not what we want."

    Manning then goes on to describe a time when he and his wife attempted to care for his mother-in-law. Eventually, they all reached the decision that his mother in law’s needs simply could not be met at home. A nursing home could offer physical and social benefits that the Manning family couldn’t.

    Sadly, there is often a stigma attached to placing an elderly loved one in a nursing home, and Manning discusses this as well. He explains that the negative view of nursing homes emerged when they were unregulated county poorhouses that really were dreadful places to live. Now, however, nursing  homes are regulated as carefully as nuclear power plants, and most facilities provide an upbeat atmosphere and competent care for their residents.

    Practical Issues

    The second part of When Love Gets Tough is largely devoted to families who have made the nursing home decision. He presents a bill of rights for caregivers. Some of these rights include the right to thoughtfulness from friends and family, the right to rest and respite from the caregiving role, and the right to be appreciated for the efforts they make on their loved one’s behalf.

    The next chapter offers advice for confronting the elderly person with the need to move to a nursing home. Manning recommends directness, absolute honesty (for instance, explaining that the placement will be a permanent one), and holding firm to your decision, even while allowing your loved one to respond and express his or her own feelings.

    Frankly, this is one section of the book where Doug Manning and I don’t see eye to eye. He recommends a direct confrontation with the elderly loved one no matter what that person’s mental status. While I completely agree that a person who is fully cognizant should be given the facts–anything less would be disrespectful–I question the value of trying to explain this decision to someone with advanced dementia.

    Chances are, the person will either not understand at all, or will get very upset and agitated. Then they will forget all about it. You explain it all again, and they became upset again. This pattern continues several times a day until the move is made, and even after the transition is complete, you still have to explain over and over that they are in the facility permanently. Each time your explanation will cause great distress, and the situation won’t get better over time, because your loved one is no longer capable of remembering and processing the information you are giving him or her.

    Rather, I have found that when working with patients with advanced dementia, it is best to wait until immediately before the move before saying casually, "there’s a place where your doctor would like you to stay for a few days. Let’s go look at it together." 

    Often, the person doesn’t realize he or she is in a nursing home at all and may think he or she is in school, at a friend’s house, on a cruise, or even home on the farm. There is no kindness to challenging these delusions as long as they are comforting to the person experiencing them.

    Manning also talks about other practical aspects of placement in this portion of the book. Some of the topics include handling money and legal issues, selecting the facility best suited to meet your loved one’s needs, and developing realistic expectations of nursing home care. A nursing home will never completely take the place of a home environment. There will always be minor problems such as missing socks and food that doesn’t taste quite the way your loved one is used to.

    More significantly, Manning reminds readers that nursing homes can’t work miracles. If your loved one has a disease process that causes rapid weight loss, he or she will probably develop bedsores no matter how conscientiously the staff turns you loved one in bed. If your loved one had a history of falls at home, he or she will probably also have a few falls in the nursing facility.


    Manning acknowledges that getting used to the idea of nursing home placement is a tough emotional process, both for the person going into the nursing home and for his or her family.

    The person being admitted to the facility grieves the loss of the life and the independence he or she once had. This grief may be expressed through tears, depression, complaints, recriminations, and outright anger. It can be hard for family caregivers to see their loved one so upset.

    The natural instinct is to try to squash the complaints and the negativity. This method never works. It only drives the sadness underground where it manifests as physical problems or lack of interest in anything. The only way for your loved one to release negative emotions and start the process of healing and adjusting is to express his or her sadness and anger.

    The greatest gift you can give your loved one at this time is the gift of listening empathetically without judgment or defensiveness. Only then can the process of adjustment begin for both of you.

    Living with the Decision

    In the fourth and final section of this book, Manning takes on the so-called nursing home horror stories and exposes most of them as pure media exploitation of our guilt and fear.

    He also talks about instances when your loved one may try to lay a guilt-trip on you. This behavior is different from the open expression of sadness and anger described above. It is deliberate, manipulative, and designed to make you feel like the worst excuse for a human being since Jack the Ripper stalked nineteenth century London.

    Manning encourages family members to make an equally conscious choice not to accept the guilt-trip. Do what you can for your loved one, he advises adult care givers, but don’t do more than is comfortable or reasonable. As a final thought he adds, "Survival is always selfish."

    Final Thoughts

    When Love Gets Tough: The Nursing Home Decision is an excellent book for anyone struggling with deciding whether or not to put his or her loved one in a nursing facility. It is all but guaranteed to clear away some of the guilt and make the hard choices a little easier to bear.  

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