I have often told the story of how my mother's experience living in a nursing home influenced my thinking about assisted living. Her determination to live a normal life led me to embrace the values that have come to be widely associated with assisted living--independence, choice, dignity, privacy, individuality and a homelike environment. My listeners have usually laughed with me when I told how my mother thumbed her nose at the advice of the aging experts (me) by choosing a place to live that ranked lowest by all professional measures of quality. Everyone who knows me, professionally and personally, agrees that this personal experience shaped me intellectually and emotionally as I have relentlessly pursued the development of assisted living as a viable long-term care option.

In the academic sense, I took an inductive approach to problem solving by taking specific examples and generalizing to the larger issues related to quality in long-term care. Over the past 20 years this has resulted in an increasing diminishment of my original emotional response and its replacement by a more reasoned approach to these issues.

But in the past several months, I have been reconnected in a very real way to all of the issues of long-term care by the decline in my mother-in-law's ability to live independently. In the past month, we have struggled to reach the decision that she needed to move to an assisted living residence. This brought home once again the difficulty of negotiating a solution that balances the conflict between the desire of older adults to live life as they always have and the fear of those who love them that harm will come to them. In short, it has made me more attuned to the emotion underlying the focus of this article--the pursuit of artful compromise.

It seems to me that there is a fundamental question that must be addressed for compromise to be reached. It is: Who is the customer? Realistically, the perceived customer is, at different times, the older adult and the family or some other personal representative of the older person. But the customer may also be a third-party payer such as Medicaid or a professional advocate representing the larger public interest. Because the different customers may have potentially conflicting perspectives, the provider must often deal with conflicting views about a variety of issues including things as critical as the type and amount of services to be provided or the degree of autonomy that may be exercised by the older adult.

In the real world of long-term care, older persons often are the consumers of least importance even though they, in effect, are the end users. It is easy to understand how this happens. When asked, the older person often opts for less intervention or service than the family or the involved professional feels is needed. Several common situations highlight this disparity including the administration of cpr, aggressive treatment of disease or even something as mundane as participation in planned activities.

The dilemma is even more clouded if there is any question of cognitive disability. At what level of incapacity for making decisions and with what types of decisions should impaired decision-making invalidate the expressed desires of the older person? Ironically the other customers--the family, the payer or the advocate--are often quick to supplant or override the desires of the older person in the name of what is "good" for her or him in matters both large and small. And truthfully, it is hard for the provider to ignore the desires of those bound by affection, of those paying the bill or of those whose professional opinion matters.

So pervasive is the influence of secondary users that they affect virtually every decision providers make even when the cognitive ability of the older person is not in question. For example, because family members are viewed as central in the identification and selection of a residence, the developers of assisted living facilities often create an environment to which adult children will relate and not necessarily one that the older consumer would choose. Or operators may be more focused on what the surveyor thinks of their documentation than on anything else.

Let me illustrate with an actual example. A woman living in an assisted living residence wishes to remain in her pajamas all day, refusing to brush her teeth, take a bath or comb her hair. The daughter threatens to stop taking her mother out because she is embarrassed by the way her mother looks. She accuses the residence of not helping her mother and calls the state ombudsman's office. The ombudsman visits and confirms that the woman looks unkempt and appears very thin. A complaint is filed.

Meanwhile, a physical therapy evaluation has been ordered by the woman's physician after a visit with her confirms the daughter's complaint that her mother can barely walk. The provider claims that the woman routinely refuses assistance and has not been willing to follow the exercise routine prescribed by a home health agency. By now, the woman is refusing medications and meals. Home health has visited twice, and the ombudsman has returned. The state comes and finds no rules violations, but the woman does not improve, the daughter becomes more upset and the ombudsman complains aloud that this situation has been permitted to develop.

Ironically, in spite of all the talking going on, no one is really communicating in this situation. While this might seem an obvious problem, it is not very different from what frequently happens when there is no defined process for communication to occur--and compromise can only occur if there is communication.

It is a daily struggle to balance competing views of what is "right" or "good" for an individual while recognizing that at times all views can be legitimate even when they are in conflict. This struggle is the pursuit of artful compromise.

In truth, the pursuit of artful compromise is littered with barriers, not the least of which is the fact that conflicting values and interests govern the beliefs and resulting behaviors of older adults, their families and the professionals involved in making decisions about their lives.

By far the greatest barrier may be the conflict in values that typically centers around balancing safety and autonomy. Almost never is there complete harmony among the various consumers on what the balance should be or how to achieve it. Older people want the "right to folly." This often involves making decisions that place them at risk. As a result, whether out of love or societal concern for a vulnerable person, others take on the role of in loco parentis, and the older adult is often treated like a child with diminished capacity regardless of cognitive ability.

Refusing to take medications, ignoring professional advice, acting like a couch potato or refusing offers of assistance are viewed with alarm and suspicion by family members, yet the older person may well feel she or he has a right to choose these behaviors. Imagine the reaction of someone whose employer decides to control such "unsafe" practices outside the workplace as smoking, driving, diet, exercise or debt.

The underlying assumption behind family members' reactions to these situations is that no one would willfully make poor decisions or act upon them unless he or she were not mentally competent or could not get the help needed. That is, someone must be at fault. But these suspicions are almost never dealt with directly, and this creates a formidable barrier to reaching compromises that preserve the autonomy of the older person relative to his or her ability to make informed decisions while addressing legitimate concerns about the consequences of these decisions.

Providers often feel trapped between what they see as the academic rhetoric of autonomy and the reality of looking bad and being blamed if something happens as a result of poor consumer decision making.

To reach artful compromise in such situations requires that all interested parties, and, most particularly, the older person, acknowledge and talk frankly about the legitimacy of different values, including the impact those differences have on the balance between safety and autonomy.

Competing interests also act to impede successful aging in place. In part the competition is the result of a struggle over who will "control" what happens to the "client," a struggle engaged in by families, advocates and a multitude of professionals. Sometimes it seems as if all want to exercise final decision-making authority without accepting the responsibility for putting together an integrated plan of services. In addition, the final decision maker wishes to be absolved of personal responsibility and protected from liability. All too often the resulting "plan" follows reimbursement paths or available service instead of actual need or preference. To the person who takes on the role of case manger--whether a family member, a provider or an advocate--this is a tale all too familiar, and it is a tale often told.

What is not often said is that this lack of fit is exacerbated by unspoken agendas. In the real world there are families whose decisions are colored by long-standing animosity, selfishness and greed. There are providers who maximize reimbursement from third-party payers by giving services of little or no benefit. And there are public advocates whose client agendas are more driven by agency budgets or political purposes than the clients' actual interests.

Admitting at the outset that there are multiple customers likely to have competing desires should generate an understanding of how critical the process of communication is to developing an integrated plan to support the direct user of services. Often this does not happen because the individual goals of the secondary users are ultimately more important to each of them than is the well-being of the older person being served.

There are two techniques that can lead to better teamwork--consultation and mediation--but often they are not used at all or are practiced so poorly that they do not work. Listening, especially carefully listening, seems to be becoming a lost art, yet this skill is at the heart of artful compromise. Frank discussion is difficult when individuals fail to acknowledge their underlying motivations, often self-protection and guilt. Having an outcome that is tolerable to, or at least accepted by all the major players takes more time up front to negotiate. So the effort to be efficient, along with the effort to minimize legitimate disagreement, creates an atmosphere of avoidance, suspicion and, often, adversity.

But time consuming and difficult as it is, the only successful path to artful compromise is effective communication among the provider and the other players--with a place of honor for the ultimate customer, the older person.

Do a long-term care advocate's views on safety diverge from the tenant's notions of a satisfying life?

Naturally, I cannot know the motivation of every advocate, but I can describe the influence of my own formative experiences: A hospital social work supervisor once defined my role in nursing home placement cases as being little more than the messenger of immutables. During a nursing home care conference, a licensed psychologist stood up, placed his hands on the table and announced that I was as crazy as my client. And worst of all, while visiting a filthy old boarding house that would make a prison warden blanch, I saw an emaciated old woman dying of cancer on a sheetless bed. From such experiences I have become an advocate of respecting client autonomy and protecting vulnerable adults from maltreatment, a standard that would solve every dilemma if only all cases were clean-cut.

There are, after all, conflicting philosophies of "speaking for" someone. And when we plumb the role of advocacy and question the boundaries of intervention, we are ultimately asking about an individual's or a program's central values. Are we speaking for the client in the client's voice, or are we speaking for the client in our own voice? In the language of ethics, is the governing principle one of "substituted judgment" or is it "best interest"?

In the Long-Term Care Ombudsman Program, as I have known it, we go to bat for people in the way they ask us to help. The program is rooted in the philosophy of individual rights. Ombudsmen are not supposed to protect clients from themselves but to act as intermediaries between clients and facilities. This is quite different from the philosophy that drives the work of adult protective services programs, which are traditionally linked with child protective agencies and have a duty to protect the health and welfare of clients.

Far from the caricature of ombudsmen as militant, protect-at-all-costs advocates who are the enemies of client or tenant autonomy, my experience has been that the client advocacy that sets off the most sparks is that of standing by the client who has been labeled noncompliant by a physician or the staff of a facility.

The role of advocacy in assisted living is comparable in substance to advocacy for clients in other kinds of long-term care facilities. Conflicts between client and facility include problems around admission, costs, service quality and, easily the most heated, eviction. Ironically, rights of appeal in involuntary discharge are much more thoroughly expressed in nursing home law and rules.

In addition to client-facility conflict, there are also possible conflicts between clients and government. One example is the need for replacement eyeglasses in advance of the frequency stipulated by a state's Medicaid or managed care program. Everyone will recognize the frustration of excessive paperwork, unmet promises and seemingly endless delays while changes in a client's vision make it harder for her or him to walk down steps.

Advocacy in assisted living is not limited to casework interventions. Advocacy that promotes client self-reliance, client self-advocacy and community education is crucial for success. Policy-level advocacy to promote service availability, affordability and quality standards is the third leg of our ombudsman program; with respect to assisted living facilities, there has been a reluctance on the part of government agencies to set standards, making policy-level advocacy all the more important.

When extreme frailty or cognitive impairment strikes an older person, his or her family members are suddenly forced with a wrenching decision. With the oft-repeated plea, "Just don't send me to a nursing home," ringing in their ears, the family members agonize about what to do. Today, thankfully, the family has a greater choice of options available than ever before. And the long-term care setting that has realized the greatest market explosion in the past few years is assisted living.

My father resided in an assisted living facility in Oregon for the last 15 months of his life. As his responsible family member, I can personally attest to the conflicts that arise between a family member and the facility providing care. But as a professional, social work­trained gerontologist, I also had better insight into the limitations that service providers face when trying to respond to family demands.

First, let us look at what goes on within a family when placement of a loved one in a long-term care facility becomes necessary. Probably, the first reaction is denial. "Maybe he can still make it on his own with a little assistance at home." "Maybe I'm exaggerating the problems I see." Few older persons today live with their children or other relatives, so contact is only intermittent. Family members may be suspicious and a little worried about the difficulties experienced by the older person, but they may tend to minimize the extent of the problem.

In my case, my father lived with my husband and me for about a year before he moved into an assisted living facility, so I was keenly aware of his increasing decrements, decrements that could be masked on his "good" days. But it was hard to convince my brothers, who visited intermittently, of the true extent of his limitations. When they visited, my father psychologically "got up" for the visit and appeared unchanged from his earlier days. If my brothers had been responsible for liaison with the assisted living facility after he moved in, they would have had very unrealistic notions about the extent of his care needs.

Once it is recognized that placement is necessary, often after an acute episode that leads to hospitalization, families realize that they are clueless about the options that are available. Generally, they know only about nursing homes. They may rely on their physicians for placement advice, but physicians, too, are frequently unaware of the full range of community options.

Once placement occurs, the primary concern presented by families to the staff is to "keep him safe," or "take good care of her." Protection, not autonomy, is the family's guiding principle. This attitude is in direct conflict with the principles underlying assisted living facilities, in particular, wherein tenant autonomy and independence is emphasized over and above control and protective dependence. The challenge, then, to the staff of long-term care facilities is to advocate for the values that the older resident prefers--values of independence, privacy, autonomy, choice and decision-making freedom--and to educate families about both the care needs and the preferences of their older family member.

On the other side of the coin, if an assisted living facility was selected primarily because of its focus on autonomy, the family member may sometimes come into conflict with staff who may "talk the talk, but not walk the walk." In other words, staff who come to work at an assisted living facility from a nursing home setting may have difficulty themselves adhering to these principles of autonomy. In that case, it will be the family member who is the advocate and educator. In either scenario, however, the opportunities for conflict are rife.

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