Why older patients resist help at home
The 84-year-old man who had suffered a mini-stroke was insistent as he spoke to a social worker about being discharged from the hospital: He didn’t want anyone coming into his home, and he didn’t think he needed any help.
So the social worker canceled an order for home healthcare services. And the patient went back to his apartment without plans for follow-up care in place.
When his daughter, Lisa Winstel, found out what had happened she was furious. She’d spent a lot of time trying to convince her father that a few weeks of help at home was a good idea. And she’d asked the social worker to be in touch if there were any problems.
Or there are circumstances at home — perhaps hoarding, perhaps physical neglect — that an older adult doesn’t want someone to see. Or the patient’s cognition is compromised and he doesn’t understand his needs or limitations. Or cost is a concern.
A better way to communicate
Often, a breakdown in communication is responsible. Patients haven’t been told, in clear and concrete terms, which services would be provided, by whom, for how long, how much it would cost, and what the expected benefit would be. Since they don’t understand what they’re getting into, they resist, Rosati said.
Kathy Bowles, director of the Center for Home Care Policy & Research at the Visiting Nurse Service of New York, suggests a plain-language, positive way to convey this information. For example: “A nurse will check your medications and make sure they’re all in order. She’ll assess if you need physical therapy to help you regain your strength. And she’ll teach you and family members how to care for you once home care is over.”
“A lot of resistance arises from pride,” said Bowles, also a professor of nursing excellence at the University of Pennsylvania. “The conversation has to change from ‘Look, we think you really need help,’ to ‘We want to help you take care of yourself.’ ”
Emphasizing that a physician has recommended home healthcare can also be helpful. “In my experience, if a doctor says, ‘I’d like a nurse to come see you and check that you’re feeling better,’ people are fairly responsive,” Kernisan said.
Instead of arguing with an older adult who says, “I don’t want any assistance,” try to follow up by asking, “Tell me more. What are you concerned about?” Kernisan suggested.
This isn’t to suggest that persuading an older adult to accept unwanted help is easy. It’s not. Last year, Winstel’s father had a medical device implanted in his spine to relieve pain from spinal stenosis — an outpatient procedure. Once again, he declined postoperative help.
Two days later, Winstel got a phone call from her dad, who had collapsed and couldn’t get up from the floor. Winstel said she’d call 911. “No, I don’t want someone coming in and finding me like this,” her father insisted. “You have to come.”
Later, at the hospital, doctors diagnosed an adverse reaction to medication and a surgical site infection on her father’s back. “He lives alone. He can’t reach back there. He wasn’t caring for the wound properly,” Winstel explained.
Extensive, heated conversations followed, during which her father insisted he was never going to change. “For him, living independently carries risks, and he’s willing to accept those risks,” Winstel said.
She hopes the new report on seniors refusing home healthcare will jump-start a conversation about how to bring caregivers into the process and how recommendations should be conveyed.
“As the daughter of someone who has refused care, understanding that this is something lots of people go through makes me feel a little less crazy,” Winstel said.
— Kaiser Health News
