Chapter 7
Having the Difficult Discussions
There are certain discussions that are more difficult for family members to have than others. This is especially true when the subject is the physical or mental decline of a loved one. The discussions, which could be one or several, involve what changes may be needed and what that means not only for the individual in question but for the family unit as a whole. Family dynamics can complicate the matter further. Whether it’s a single relative, multiple siblings, or other family members monitoring and determining an individual’s future, the roles each play can become tense, if not downright combative. Chances are that not everyone involved will see the circumstances the same way or agree with the plan of action discussed as the solution to provide the best care.
Usually within a family, there will be some who won’t agree that something needs to change. Most likely, this will be your loved one, although it can be anyone who is in denial, has something to hide, or believes everyone else is wrong.
It takes a great deal of observation, consideration, and planning to have these discussions without causing hurt feelings and family rifts. It may not always work, but if you take time to consider the best manner in which to have them, where to have them, and how to honor everyone’s feelings without sacrificing the best interests of your loved one, there is a good chance you will succeed.
Bringing the Family Together
The issues surrounding a loved one who is in decline or has suffered a crisis are difficult and stressful. Bringing a family together to address these issues can be complicated and difficult. Often, adult children or other relatives do not live in the same geographic location, and timing is critical. Perhaps they don’t have a good relationship now or never have. Adding in the stress of facing a loved one who may be very resistant to the idea of change, it’s easy to see why tempers fly, egos bruise, and feelings get hurt. It can take a great deal of patience and effort to bring everyone together and get everyone on the same page where your elder is concerned. Typically, one person has to take the lead and begin the process.
Usually, those who easily and successfully manage this type of situation have had healthy, respectful relationships with their family in the past. When the relationships aren’t so good, coming together as an effective team can be almost impossible. One of the first things to do when faced with the necessity of discussing your loved one’s condition and needed solutions is to reach out to those who aren’t getting along and mend fences as quickly and effectively as you can. This will help prevent future conversations from turning into a time-wasting game of “Who’s to Blame” or an overall complaint session that loses focus on the important matter at hand—your loved one’s needs and care. The following steps offer some direction as how to begin the process of uniting the family and creating an atmosphere where you can all work together respectfully and productively.
• Make a list of all family members that have a vested interest in your loved one and would want to participate in her care. You may have to draw a hard line with some and inform them that they won’t be involved if they aren’t willing to participate in the caregiving and financial aspects or other means of positive support. This doesn’t mean that you won’t inform them of important matters or listen to their opinion, it just means they may not have as strong of a say in the decision-making process, if any.
• Decide how communication will best be handled. This might be in person, over the phone, text messages, e-mail, or Skype. Remember that people communicate differently, and you may have to use several different methods.
• Reach out with goodwill. Make sure family members know they are being contacted because you understand they care and would want to be involved. Let them know you appreciate their advice and help.
• Acknowledge that everyone has the right to an opinion. Explain that everyone will have a chance to be heard.
• Inform them that, if there is disagreement, the services of an unbiased third party may have to be enlisted. That third party could be a professional mediator.
• Stress that if someone is not up for participating in the process, she will not be judged. By the same token, make it clear that she will also not have the right to complain about any outcomes she doesn’t agree with.
• Remind everyone that this is about your loved one and not each other. This is the time to come together and work on behalf of somebody who needs all of you.
• Reinforce anything positive about your relationship with all concerned, and thank everyone for being a part of the solution to the situation.
If you are part of a family that is close and gets along well, then you are lucky! Nonetheless, it still helps to follow some, if not all, of the aforementioned steps to ensure that everyone understands the ground rules for communication and how decisions will be made. Having the family in agreement (as much as possible) makes it easier to discuss what is being noticed, thoughts on how to improve the situation, and resources that need to be considered.
Developing a Strategy for Your Discussion
Creighton Abrams, the US Army general who commanded military operations in the Vietnam War, once said “When eating an elephant, take one bite at a time.” This can easily apply to handling a difficult conversation or an overwhelming situation—break it down into smaller pieces and tackle each one separately.
After you’ve mended fences when necessary, and are ready to begin your discussion, it’s best to have a strategy in place to manage the multiple personalities, interests, and desires. It’s also important to recognize personal boundaries. One family member may be fully engaged as a caregiver and handling it well, while another may feel that he can only contribute financially because he was never emotionally close to the senior. Keep an open mind and do not judge anyone by the boundaries he sets. By being gracious and listening, you will make everyone feel respected and safe to speak his mind.
Whether to include your loved one in the early discussions may be unclear at first. There can be some cases where involving your senior would not be advisable. Here are a few guidelines as to if or when to include him.
• If there is serious discord among family members, especially among siblings, attempt to resolve some of these issues first, and find common ground regarding your loved one before involving him. It can be disturbing for a parent to see his children fighting, and even worse if they are fighting because of him.
• Include your loved one from the start if he has recognized the need for care and initiated conversations with you or other family members about the challenges involved.
• If anything that needs to be discussed would be embarrassing or hurtful to your loved one, and having him there will inhibit honest and open conversation, then perhaps his participation should come at a later time. For instance, if your father has not realized he’s been having accidents in public and walks around with stains on his pants, you might want to talk in private and discuss a solution. Then you can discuss it with him alone, so that he won’t feel ashamed or self-conscious.
• If your senior is resistant to any suggestions that he needs care, and you feel the discussion will be met with anger, resentment, or hostility, it’s best to have the initial discussion without him. You can then develop a strategy on how to raise the issue and make sure everyone concerned is on the same page first.
• Finally, if your loved one has dementia, or for some other reason cannot understand or remember what you are discussing, then you need to move forward without him. This can change once some decisions have been made and a plan of action established. If you include your loved one too soon, he may become confused, anxious, or frightened.
Once it’s been decided who will be included in the conversation, the following suggestions will be helpful in ensuring that everyone is comfortable and able to speak freely and that the meeting will be productive.
• Set an agenda and make sure everyone knows what topics will be discussed. Ask in advance if anyone has a specific matter she would like to talk about and include it. Now is the time to get it all out in the open.
• Establish ground rules that everyone will have a chance to talk. All others must listen politely and give the others their time.
• Recruit one or more members of the discussion to take notes. Thoughts and ideas can be revisited, if needed.
• Ask that participants be prepared and have facts to support their ideas. For instance, if you feel she can’t afford to move to a community, but could stay in her own home if she hired a housecleaning service and a landscaper, have pricing available for both options so that you can show financial proof for your suggestion.
• Remember that there can be more than one solution to a problem, and be willing to compromise.
• Agree to disagree. Insist that participants be courteous and civil toward others.
• End the meeting by reiterating what was decided, what has to happen before the next meeting, who is in charge of what, and when the next meeting will occur.
Although these suggestions will help prepare you for the meeting, there are situations where a little private coaching on how to respond or handle specific comments or attitudes can be helpful. The following are common statements that will give you some ideas on how to respond or diffuse resistance:
• “I don’t think Mom needs any care. She seemed fine to me at Christmas.” This is a common attitude, especially when one member is the caregiver and the remaining family doesn’t contribute much, if any, to the care of their loved one, particularly if they live in another state. Point out that an individual can often pull it all together for a few hours or days to present a perfect picture to someone he or she has short periods of contact with. A good way to respond to this is, “I don’t think you understand what I see daily or what I personally do to help Mom. If you don’t recognize or believe what is happening and how hard I’m working at providing care, then I suggest you let Mom come live with you for a while, or you can come home and take care of her for a while. I’m sure you will appreciate my concerns then. Otherwise, I need your support in making these decisions and doing what needs to be done.”
• “I don’t understand why we pay for Dad to live in a community. I can move in with him, and he can pay me instead.” There are cases where this could be an ideal answer to a caregiving dilemma, but proceed with caution. Think hard about the reputation of the person moving in. Does the person have a history of responsible behavior? It is not uncommon to see a relative who has had a track record of money problems, is unable to hold a job, or has suffered from drug/alcohol abuse to offer this solution because it is to that person’s benefit. They may have great intentions in the beginning, but if he or she loses interest, falls off the wagon, abuses the situation, or fails to provide adequate care, then your loved one may suffer.
A great way to address this suggestion is to say, “I understand that you want to help Dad and that it would be an ideal arrangement for you, but there would be some requirements for the family to consider you moving in and becoming the primary caregiver. Are you willing to take training classes and become a certified caregiver? Will you sign an employee agreement or will you be an independent contractor? We would want to make sure taxes are being properly paid. If we move forward, I will insist on more than one person having access to Dad’s bank and financial records to ensure full transparency. Are you comfortable reporting back to the family? If not, then maybe we need to seek another way to make sure Dad is taken care of.”
• “I don’t have time to deal with this. Aunt June is a danger to herself. She needs to move into a care home right now.” Sometimes in a rush to fix a problem, family members will jump to the final solution in what should be a longer journey through multiple options. Taking more time and exhausting each and every option available may make more sense. “I know that you are worried about Aunt June, and I agree that something needs to be done, but I think you’re jumping into having her move out of her home too fast. Yes, she isn’t taking as good of care of herself or the home as she should, but she’s perfectly capable of working with us to figure out what help is needed and then hiring someone. Plus, she loves her home, has friends in the neighborhood, and would miss her senior center. I’d like to give her a chance to bring support into her home, see how it works, and then if or when that doesn’t work any longer, we can talk about the possibility of her moving to a community.”
One final word of advice: Remember that it is always appropriate and OK to say that you need time to think about what has just been discussed before you answer or agree to anything. Ask for a few hours or a day or two to digest the information and get back to the family on your feelings. Stepping away for a short period of time can bring clarity to the moment and help you make the right choices.
Doing Your Homework First
One of your most powerful tools for family conversations is to become educated on all topics that might arise. This might include what resources can provide support, what the cost will be, and how you can pay for it. By preparing and knowing how you will address any questions or complaints, you will be better able to handle any fear, anger, or other emotions that may develop.
Earlier in this chapter, you learned how to bring your family together to begin discussing any health concerns related to your loved one. You have met and have come to terms with the idea of either bringing care into the private home or moving your senior to a care community. Now the most difficult discussion(s) of all must happen—speaking with your loved one about your worries, suggestions, and perhaps laying it all out and telling your senior what has to happen whether he or she agrees or not. Your first steps in making this meeting as successful as possible are to gather your facts, determine what resistance to expect, and think ahead about how to address that resistance thoughtfully and knowledgably. Understand that this may be the first of several discussions that may need to take place before your senior is ready to entertain your point of view.
The two biggest obstacles to any change will be your loved one’s fears and his or her desire to maintain control. It’s difficult for many to understand what our elders have seen or grown up with. Most will tell you that their parents and grandparents took in older relatives and cared for them at home. Those who weren’t able to do so had to send them to nursing homes where the philosophy and practices were significantly different than they are today. Your elder may remember people being abandoned by family, drugged until they couldn’t function, and sometimes abused. Who can blame them for worrying about this once you point out that they need more help than the family can provide?
You can combat this fear by pulling together as much proof as possible that it will be different before approaching them. Here are some issues that will support you when discussing your concerns and suggestions as to how to solve them.
• Your loved one needs minimal help with chores around the house. This is perhaps the easiest need to begin with. Make a list of what you notice each time you visit—items that need repairing, yard work left undone or neglected, disarray or clutter in the home, bad odors or filth, rotten and expired food, or any other signs that your loved one is no longer able meet the normal day-to-day care of his or her home. If necessary, take pictures.
• Your senior looks disheveled or smells bad, you don’t think he or she is eating well or bathing regularly, or perhaps you see signs that your loved one isn’t managing medications properly. Document how often you notice any particular indicator of self-neglect. Speak with your elder’s pharmacist or anyone who visits the home about your concerns. Include their comments in your documentation.
• Your elder has declined to the point that you feel he or she is unsafe alone at home and needs to move. Keep a record of your concerns and how often problems are occurring. Did Mom fall three times last month? Was Dad admitted to the hospital twice in six months because he mixed up his medications? Have your parents both lost a significant amount of weight because they aren’t eating regularly? Did Aunt Phyllis forget about the stove, and a dish towel caught on fire? This is the perfect time to discuss your worries with their medical professionals, neighbors, or any other person who may be able to point out the same observations. Ask if they will support your efforts to move your loved one, if needed.
This documentation will help prevent you from drawing a blank and forgetting what issues you worried about when faced with an argumentative and angry elder.
Next, you need to have as much knowledge and physical evidence about the solutions you are going to suggest as possible. Armed with actual proof rather than guesses or estimates may quickly diffuse your loved one’s arguments.
• Determine what services your loved one needs, and investigate resources. Identify individuals or agencies that can address those needs and gather information to present. Being able to show your senior a website or a brochure will indicate that you are serious and have done your homework.
• Get estimates in writing whenever possible. If you are considering bringing anyone into the home to provide services, like a housecleaner, companion, or home care aide, ask for a formal written estimate. If you can’t get a formal estimate, take detailed notes and be able to present quotes to your loved one so there will be no question as to how much it will cost.
• Discuss details with family members if you are suggesting your senior move in with relatives. If moving in with family is a possibility, discuss how that will be handled. For example, be able to explain that Mom’s two young grandsons are eager to get a bunk bed and share a room so that Grandma can live with them or that her beloved Shih Tzu is welcome and she won’t have to give up her pet. The worst thing that can happen is to begin a conversation like this and have your senior discover that it wasn’t well thought out or that someone in the household isn’t in agreement with the proposed plan.
• Visit care communities and take pictures, collect information packages, and narrow the options. If moving in with family isn’t an option and the only other solution is that your senior move to a care community, it’s imperative that you spend time investigating the possibilities and selecting the best candidates before speaking with your loved one. At this point in time, you may want to enlist the services of an assisted living referral agent who can help you understand the level of care needed, the type of community that would be the best fit, and which communities could best provide those requirements. Then you can do the following:
☐ Call and schedule tours with selected communities.
☐ Openly and honestly discuss your loved one’s needs with the staff member conducting the tour.
☐ Take pictures of the community, the grounds, and the apartments or rooms you are shown.
☐ Discuss costs and ask for a pricing sheet for base rates and any other expenses related to providing services or care.
☐ Ask for an information package to take with you.
Having the Discussion
At this point, you should be ready to approach your loved one and get the ball rolling. It is normal to be nervous, scared, or worried about his or her reaction and how it might affect your relationship. Having the discussion with your senior about the fact that he or she is aging and unable to properly care for himself or herself any longer can be uncomfortable and emotional. It can be especially difficult for children who have to face parents who have always been the authority figures in their life for the dreaded “talk.” Fortunately, if you’ve done the previously suggested work and follow the suggestions here, you may be surprised at how well your elder listens to you and find that any resistance begins to melt away.
The Best Location for the Discussion
Surprisingly, many people give little thought as to the setting in which the discussion happens. That is understandable if, in the middle of a situation or crisis, you feel it’s necessary to begin mentioning that things need to change now. The location and atmosphere you choose to have such a private, intimate, and potentially life-changing conversation can make all the difference to the outcome. For instance, if you and your brother have been talking about moving Dad to an assisted living facility, don’t bring it up to him while dining in a nice restaurant for his birthday. It’s likely the discussion will not go well.
When selecting the location, make sure your senior is relaxed, comfortable, and feels safe. It’s also a good idea to decide on a setting where your loved one can retreat if necessary, gather his or her emotions, and calm down. However, it’s important not only that your elder is at ease but that all other parties are as well. If your mother is a hoarder and being in her home makes you tense and upset, then the conversation will probably reflect those feelings.
Think about where you can best achieve your goal of comfort and privacy. Here are some thoughts when choosing that location.
• Is there plenty of room, and are there comfortable chairs for all participants to sit?
• Will there be outside interferences, such as children rushing in or dogs jumping on people?
• Can everyone be heard without raising voices?
• Is it private enough that participants can express their emotions without embarrassment?
• Are there any time constraints on occupying the space?
The Best Time for the Discussion
The ideal time frame for having any discussions is before your loved one begins to show signs of needing help. But frankly, the subject rarely comes up until there have been symptoms or incidents indicating that help is already needed. Considering the timing of the discussion is equally as important as the location. Ensure that all participants are relaxed, able to say what’s on their minds, and don’t feel rushed or pressured. The following dos and don’ts will help you determine the best time to engage your senior.
Dos
• Pick a date and time when all members can easily be available for the discussion.
• Make sure you have all contributors updated on details and that they understand the goals of the meeting before setting the date.
• If your senior brings the subject up first, let the conversation unfold at that time and then suggest a family meeting as well.
• Meet during a crisis unless absolutely necessary. Delay the discussion until everyone has a chance to digest what has happened and all the details are clear.
• Engage your loved one if they aren’t feeling well.
• Suggest meeting before you have time to fully prepare and practice what you’re going to say.
How to Approach the Subject
Your method of approaching the subject can determine whether or not your senior feels ambushed or is shocked that you even feel the conversation is necessary. It is ideal if you can bring the subject up slowly rather than diving right in. Try switching places with your loved one and imagine how he or she might like to be approached. Have you seen signs that your elder is already aware that assistance is needed, or does he or she seem to feel fully capable and might be offended that you would suggest otherwise? Your approach needs to offer insight to and welcome contribution from your loved one. The fact is, your loved one may already know something is happening, so think about comments that might break the ice before blurting anything out.
• “Mom, we would like to spend a few moments to get your input on a couple of things we’ve noticed recently.”
• “I’ve been struggling to get over here to help you lately. I’ve researched some ideas on services that help people around the house and would like your opinion on them.”
• “Dad, you’ve mentioned a few times that you have been having difficulties with some activities. Can you explain this further for us? We’d like to see what we could do to help.”
If you can get your loved one talking about what has been a problem or concern, it will make it easier for you to admit that you’ve seen the same thing and have been thinking about ways to resolve the matter. By now, your elder will have shown an openness to a discussion or not. Depending on the outcome, you may even be able to adjust your presentation of the facts accordingly. Not knowing how your senior will react can be nerve wracking. Here are some steps you can take to know your material before delivering it to your loved one.
• Prepare a script if it would make you more comfortable.
• Practice your words. Stand in front of a mirror, and say it over and over again until you feel at ease and won’t worry about losing your focus.
• Make notes to have on hand if you’re concerned about forgetting anything.
• Keep your comments precise, and don’t wander off topic.
• Organize documents in the order in which you want to discuss them.
• Ask your loved one for his or her thoughts.
• Remember that your elder has a right to express himself or herself and that your loved one may have valid points to consider.
• Listen to everyone’s comments before responding.
• Don’t allow the meeting to devolve into a complaint session.
• Don’t engage in power plays.
• Understand that there may not be a conclusion with just one meeting, but that it may take several before anything is decided.
How to Respond to Pushback from Your Loved One
No matter how well prepared you are, there will be comments or questions that you wished you had a response for. Think about how often you looked back at a conversation and wished you’d thought of saying this or that, but you were simply caught off guard. Here are a few examples of common statements you might hear when a loved one is resistant to any change and how you might answer them.
• “There’s nothing wrong with me, and I don’t need help.”
“Nobody is saying anything is wrong with you. It’s a normal part of life to eventually need some help. All we want to do it make sure your life is as easy and enjoyable as possible. Please let us tell you what we’ve noticed and how we think we might be able to ease our minds and make sure you’re healthy, happy, and safe for a long time to come.”
• “I can’t afford help.”
“I don’t think that’s true. I’ve done some research and here is the pricing. I believe that, if we carefully plan for your care or apply for any financial resources available, you can comfortably afford . . . (whatever resource you are hoping to put in to place).”
• “Why can’t you take care of me?”
“Mom, there’s nothing I would like more than that, but the facts are (insert your information), and it just isn’t possible. But what I can do is make sure that we find the best care possible for you. I will always be available for you to talk to me about anything you need or any concerns you have, I just won’t be doing the actual caregiving.”
• “You don’t care about me at all.” “I’m not going to do it.” “Why don’t you love me?”
“That’s not true. I’m doing this because I do love you, and I want what’s best for you and for all of us. I want to know how you feel about these solutions, and I want you to help me make the best choices, but something needs to change whether you are willing to help or not. These are your options, and one of them will be the action taken. I would like for you to have a say in the matter and what decisions we make.”
Our elders grew up recognizing certain professionals as authority figures—such as doctors, religious leaders, police officers, and firemen—and they respected and listened to them without question. If these experts told them they needed to do something, it was likely your loved ones would not hesitate to do as instructed.
However, it doesn’t always work that way when we, their family, tell them we have concerns and want to make changes in their life. Often, they react as though we can’t possibly know what we’re talking about. We’re just their kids, and they know better.
A successful tactic to take when speaking with your senior about major changes is to ask one of these experts to be the bad guy. Request to meet ahead of time, in person and without your loved one, to discuss your worries and ask if the expert will support you by initiating the need for change. Usually it is your senior’s doctor who has the greatest experience and intimate knowledge related to your loved one and who can persuade your elder most easily to allow assistance into the home or make a move to a new home.
Using someone else as the messenger of bad news allows you to be the knight in shining armor. Once the shock wears off and your loved one begins to feel angry or upset over the situation, you can step in and say, “I know this is hard on you and that you don’t want to do it. But it has to happen, and I promise that I’m going to find the best caregiver or the best community possible. Don’t worry. I love you and will do everything possible to make this a good experience.”
This approach can often save family members from bearing all the responsibility of insisting on changes and the negative feelings your loved one may express over them.