Carter Catlett Williams talks with Paula Gordon and Bill Russell about life, death and nursing homes. While only 5% of people over 65 live in a nursing home, America's swelling number of elders -- people 85 and older are the fastest growing segment of our population -- makes the subject of "nursing homes" increasingly urgent.

Today's "good traditional nursing homes" are run as if they were acute care hospitals, where a patient's life may depend on doing precisely what doctors and nurses say, when and how they say it. This rigid adherence to protocol in an acute care hospital often saves lives. That same approach to people who are long-term residents of nursing homes robs them of dignity and self-respect, removes them from decision making roles, denies them the opportunity to take risks or to have a seat at the table where policies and procedures are made. Ê

Ironically, the "efficiency" sought in today's acute care model is often the first victim. When the needs of the residents come before those of the "system," the cost of doing business often plummets at the same time residents' well-being soars. For example, when Mr. Smith's circadian rhythms determines when breakfast is served instead of the dining room clock, it often takes fewer staff members to meet the needs of a large number of residents than if everyone is marched lock step into a dining room as the clock strikes 8. When meeting Mrs. Jones' emotional needs takes precedence over a shift change, the demands she makes on the staff in the course of the rest of the day may be dramatically reduced - and reported rates of abuse decline. This approach is already successfully in place in Sweden and is beginning to be adopted elsewhere.

We need to begin to change the culture of nursing homes, put people before tasks, shape life around individual needs instead of the rules and regulations of the care delivery system. The innovative new approaches to nursing homes which are promising take many paths but all: Address the human spirit as well as the mind and body. See people living in nursing homes as contributors, not simply recipients. Look for increasingly small signs of what is meaningful to a person as functions diminish. View life as days to be lived until we die.

Our population is aging but youth-obsessed. We resist the challenge to relate living into old age with accepting death. In this conversation, Carter Williams eloquently addresses our urgent need to reinvent nursing homes which may one day be our own dwellings or home to someone we love. We would do well to live fully until we die and insure that those living in nursing homes have the same opportunity.

Segment 1

Carter Catlett Williams sets the stage for this conversation with Paula Gordon and Bill Russell, observing that "putting down age" is rampant in our youth-oriented society, even among gerontologists. Social security's age 65 used to be "old." Now, most people "shift into somewhat different rhythms in between 70 and 75 years old." And the number of people 85 and older is the fastest growing part of America's population. Centenarians' numbers are skyrocketing. "Old" usually carries negative connotations. "My, you're looking old today" is not likely to be taken as a compliment. Ms. Williams suggests "you look marvelous" can include white hair, a lined face, bright eyes. "Look at the strength in a face, the marks of the journey. Our individuality increases as we grow old." Human brains actually continue to grow into our 6th decade, allowing us increased complexity and subtlety.

Segment 2

Ms. Williams describes today's "good traditional nursing homes" -- places seen as efficient and attractive. They are based on the values of acute care hospitals where one needs to do precisely what doctors and nurses say. Ê When that approach is applied to people living indefinitely in a nursing home, it robs them of their self-respect, removes them from decision making roles, denies them the opportunity to take risks or to have a seat at the table where policies and procedures are made. And efficiency -- in whose name accommodating staff changes and shifts takes precedence over people's natural rhythms -- may not be served, either. Ms. Williams describes a Swedish nursing home where everyone awakens on his or her own schedule. Schedules are worked out around the residents' needs and requirements. "It was a touchstone for people feeling good about the day and, in the long run, was also more efficient."

Segment 3

While "good traditional nursing homes" may be very caring, Ms. Williams believes the acute care model simply does not meet the needs of the human spirit. Humans are highly adaptive creatures. As we become physically less robust, it is plausible that we may become more spiritually and mentally robust, as our five senses often compensate for each other. Commercial marketing has come to nursing homes, viewing residents and families as "customers." It does identify residents as the people who can make things better. But residents often hate being "customers." Nursing home residents and homeless people often describe their experiences the same way -- without connections to their earlier lives and communities. Ê We must allow people to take risks. "Life is full of risks. If walking means a great deal to me and walking means I risk falling, don't tell me I can't walk!" Obstacles to this way of thinking include fears of lawsuits and families with "safe deposit box syndrome" ("I'm bringing my mother here, make sure nothing happens to her.") Families and staff members must learn to form partnerships, face "control" issues which may include the temptation to save people from themselves. Ms. Williams believes the idea of being a "parent" to our parents confuses "dependence" with the parent-child relationship. She thinks it robs the adult child of the stage of development where s/he can feel good knowing s/he is an adult on whom the parent can depend. "Playing parent to a parent often plays out dreadfully."

Segment 4

Ms. Williams challenges us to change the culture of nursing homes. Ê"As you treat the staff, so will the staff treat residents." ÊWhen residents OR staff feel control is "somewhere else," it's reflected in the staff's language -- "letting" or "allowing" a resident to do something, using the pathology of disease to describes residents asÊ"strokers" or "dements" or "screamers." She describes the debate between those who feel people suffering from dementia should be isolated in special care units versus those who try to individualize care so that demented people's needs are met while living with others while protecting everyone's rights. One disadvantage to special units is people dread being sent there! "Only 5% of people over 65 live in nursing homes. We must move toward the living continuum approach. Whatever the setting, relationships need to be respectful, not disruptive." We need to shift away from a task-oriented system to one that puts people before tasks. The various good approaches to reshaping nursing homes share common elements: Address the spirit as well as the mind and body. See people living in nursing homes as contributors, not simply recipients. View life as days to be lived ... until we die. At different stages of people's lives, look to increasingly smaller signs of what is meaningful. "Don't see the mask of illness and forget the fascinating person behind the mask. Change the culture by shaping life around the person instead of the system."

Segment 5

Living to old age must be related to our acceptance of death. "Life holds a wide variety of experiences.ÊChange the culture of nursing homes so that we can more fully live until we die."

Related Links:

National Institutes of Health "Institue on Aging"