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Living and Dying in a Long-term Care Facility Notes From a Nursing Doctor

By Gilah Silber
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Nursing Home Doctor Chronicles Life For Residents and Staff in Long-Term Care

In Living and Dying in a Long-Term Care Facility, an experienced nursing home physician offers families suddenly faced with finding long term care for a chronically ill member a candid and comprehensive view of what life is like in such institutions for residents and those who care for them.

Dr. Gilah Silber’s book is more than a primer for anxious families shopping for the right nursing home. Subtitled Notes from a Nursing Home Doctor,  it dispels the widely held stereotype of a nursing home resident as "a little old lady gossiping in front of a television."   Alongside the elderly may reside a middle-aged AIDS patient and a young paraplegic.

Dr. Silber, MD, draws on her practice of more than a decade to provide portraits of residents whose lives "point up the problems and predicaments of old age and chronic illness, some of which can be "solved and some of which cannot." These residents' individual stories -- by turns fascinating, funny, exasperating, and moving -- "speak for themselves," she states,"as do our medical, business, social and ethical norms, which are played out in the institutions that provide long-term care.

Four Illustrative Portraits Adaptations of four residents’ stories included in this book illustrate the highly diverse nature of personalities in Dr. Silber’s extensive practice and, arguably, in the total U.S. nursing home population.

Hope Brown.  At eighty Hope Brown suffered from pulmonary disease, cardiac disease and arthritis. Dependent on oxygen and other medications, Hope was in and out of hospitals and nursing homes to convalesce after surgeries. When she eventually became a permanent resident of a nursing home she adopted a rigorous regimen, making exhausting trips two and from the dining room to meet nutritional daily requirements set by the facility and persistently taking part in therapy and recreational activities. Later as Hope’s energy level declined, she drew on skills and artistry she used in earlier in life to design a successful line of children’s clothing to benefit fellow residents. To solve problems staff aides encountered in maintaining cleanliness of incontinent residents with dementia she designed outfits that looked attractive and took care of the hygiene issue. When it became apparent that a resident was allergic to disposable diapers, she designed a cloth alternative that was easily laundered. Hope continued to share her skills and knowledge even after she entered hospice. In a note to her daughter after her mother died peacefully at age 104, Dr. Silber wrote, “she never lost her spirit.”

Rose Jamison. Mrs. Jamison arrived at an upscale facility when she was 82, accompanied by her two fashionably dressed daughters, Julia and Emma. She had advanced Parkinson’s disease but otherwise was healthy, and her mind was lucid and alert. At first she seemed to adjust well to her new surroundings. Yet, before very long, an odd pattern in her behavior emerged. Every few weeks, Rose took to her bed for no apparent reason. From there, she would sound the alarm and telephone her daughters, then head off to the emergency room. On calmer days, she would merely complain. Consultations with multiple specialists and numerous tests shed little light on her physical problems, to the frustration of her daughters who complained that no one was solving the mystery of their mother’s bouts of illness. The good news, however, was that she recovered just as quickly as she became ill.
 
Her mood swings baffled members of the home’s care team. One day a nursing aide observed that her periods of withdrawal seemed to coincides with lack of attention from her two daughters.  Both of them were devoted to their mother, and when she saw a specialist or went to the emergency room she spent time with one or both of them. However, both women held demanding professional positions, which at times limited the time they spent with her.

The care plan staff convened a conference that both daughters were asked to attend. After listening to staff members’ observations, both women acknowledged that their mother probably felt abandoned even though she acquiesced to a family consensus that it would be better that she enter long-term care. They agreed  each would visit their mother weekly on separate days.

Results of the plan were dramatic. Rose was elected chair of the resident council and became involved in organizing senior activities across several long-term facilities. “Mrs. Jamison’s eventual adjustment to long-term care was attributed to cooperation between a functional care team and a functional family, a plan Dr. Silber characterizes as normal. “Together we were able to identify her needs and work cooperatively to satisfy them.”

About a year later, however, changes in nursing staff and administration of the facility upset Mrs. Jamison’s equilibrium. New staff members, whom she disdained as “clumsy” newcomers, never learned to accommodate her moods. Her complaints persisted as her care management continued under a succession of plans, labeled by the author as normal, bickering, threatening, passive, and a no care plan.

As the series of plans progressed Mrs. Jamison’s complaints persisted and her condition continued to decline. Eventually she refused to eat or take nutritional supplements. This prompted the staff nutritionist to arrange  another conference with. Mrs. Jamison and one of her daughters at which Rose reaffirmed her resistance to eating, defiantly proclaiming: “I will die drinking wine and eating chocolates.” Under facility policy the only remaining option was hospice care. Obeying her mother’s wishes, her daughter signed her up for hospice. Mrs. Jamison died the following spring. A glass of red wine and a box of dark chocolates, supplied by her dutiful daughters, were at her fingertips.

Steve Harper and Antoinette.  The story emerged gradually, first in a phone call from Thelma Lewis, a nurse. Speaking haltingly, she noted that “Two residents were caught attempting sex. There was no real problem,” she explained, “but we’ve written it up as a resident-to-resident altercation.” Reminded that sex was not usually a medical problem, she added with a giggle, “With Steve Harper involved, I would’ve bet on success the first time around.” At about fifty years of age, Steve was the resident sex symbol. He had a history of drug and alcohol use, which led to a couple of falls. The first time that he fell and hit his head, he had internal bleeding that required neurosurgery. He experienced residual memory loss but could take care of his own needs. A few months later, he fell and hit his head again. This time the damage was more dramatic. He required repeat surgery and was on life support for some time. He went home eventually, but his injuries seriously compromised his memory and impulse control. Not long after that, he was in a fight in a bar, where someone else got badly hurt. He was admitted to the home straight out of prison, after serving a ten-year sentence. Before his accident Steve had been a fashion photographer for high-profile magazines, such as Glamour and Cosmopolitan, supplementing his income at as a bartender. Even after the accidents and imprisonment, he could have passed for a GQ model.  Half the staff had a crush on him, as did many of the elderly women residents. Age had not diminished their ability to appreciate sex appeal, even if all they could manage to do was look.

Joan, the facility’s dietician, supplied details that Thelma Lewis had omitted. According to Joan, Steve Harper claimed not to have had sex during his prison term. Nevertheless, he was selective in his encounters with women. Recently, a new resident was admitted who apparently met Steve’s standards. In her late forties, Antoinette had a nice figure (including breast implants) and, Joan reported, she was “very coquettish and experienced.”  She had a history of chronic mental illness and diabetes. She enjoyed painting, and had done a portrait of Steve. It seemed inevitable to Joan they would attempt to “know each other better.”

One night two nursing assistants heard loud sounds emanating from behind Steve’s closed door. Fearing that Steve or his roommate had fallen, the two young women burst through the door without knocking, interrupting the couple’s romantic rendezvous. According to the two nursing assistants, however, Steve “tumbled off the bed before anything had actually “happened.” Joan, however was convinced “Steve and Tony finally had their “honeymoon.”   
 
Subsequently Steve and Tony established themselves as a happy couple at the facility, where they reside in a locked behavioral unit. They no longer attempt sex—they have succeeded many times. Their main issue these days is jealousy among the other men: Tony has strayed afew times, but Steve always forgives her. Luckily for them, the current administrator tolerates discreet sexual activity between consenting adults.

Living and Dying in a Long-Term Care Facility: Notes of a Nursing Home Doctor, By Gilah Silber, M.D. (179 pp.) is available from Amazon.com at $14.95.  Editors and writers seeking additional information or who wish to request review copies may contact Simpson Lawson, 301-656-7023; This email address is being protected from spam bots, you need Javascript enabled to view it )

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