"Don’t Just Do Something, Stand There!"

My last blog post discussed why medicine is so intolerant of uncertainty and inaction, and how this has resulted in a culture of overtesting and overtreatment.

All of us as patients and doctors are at fault for feeding into this system of waste and harm. However, there are some active voices of resistance. Here are some examples:

Dr. Jerome Groopman, internist and author of the excellent book, How Doctors Think, writes about how he teaches medical students to “don’t just do something—stand there.” Very few situations in medicine require immediate action. It may be uncomfortable to apply the tincture of time as a treatment, and many doctors find it easier to order a test than to discuss the pros and cons of the test with a patient.

However, we need to remember our first principle, primum non nocere: first do no harm. Dr. Abraham Verghese writes about the importance of restraint and self-awareness in his novel, Cutting For Stone. Here is the protagonist, a doctor himself, speaking about his father:

My father, for whose skills as a surgeon I have the deepest respect, says, "The operation with the best outcome is the one you decide not to do." Knowing when not to operate, knowing when I am in over my head, knowing when to call for the assistance of a surgeon of my father's caliber--that kind of talent, that kind of "brilliance," goes unheralded.

Doctors: think carefully. Engage in thoughtful discussion with your patient, and decide together what’s best for him. Remember that no testing and no treatment may be the best course of action.

If you have to do something, consider a novel treatment that Dr. Aaron Stupple coins “a listening infusion.” During his internship, Dr. Stupple faced resistance when he questioned his supervisors on the necessity of costly tests and invasive treatments. As the most junior person on the team, he couldn’t override their decisions, but he could add his own treatment. He made it a routine to visit patients and talk to them, often staying hours after everyone else to finish his “listening infusion”. He didn’t obtain more test results, but somehow he knew more about his patients than anyone else. He didn’t give them a pill, but somehow his patients felt better at the end of the day.

This is what doctoring should be about. A recent study of resident doctors found that only 12% of their time was spent interacting with patients, versus 40% interacting with the computer. The doctor may find everything about a person’s laboratory tests, but nothing about her family or values. “Personalized medicine” and “patient-centered care” are hot buzzwords, but it’s not just about finding someone’s DNA and redoing the waiting room area. Improving medical care must begin with personalizing care to the patient and listening to her story.

We must bring back the art of medicine and the art of healing, and treat all of our patients with a “listening infusion”. Then, “don’t just do something—stand there”! Changing any deeply-entrenched culture is hard, but it can happen: one doctor at a time, one patient at a time.

When More Isn’t Better

It was the beginning of my third year of medical school. I had just started my first clinical rotation. My very first patient was Ray, a middle-aged man with pancreatitis.

I presented his case to the team. “What are Ranson’s criteria?” the attending physician asked.

My mind went blank. “Uh, I’m not sure,” I said.

“Next time, you’d better be sure,” the attending said. He turned to my colleague, who promptly gave the correct answer.

On that first day of medical training, I learned that “I don’t know” is not an acceptable answer. If you don’t know, look it up. Make it up you have to. Whatever you do, never admit that you don’t know.

Not surprisingly, doctors end up not tolerating uncertainty. In our high-tech era, this means more is done. A patient has seemingly vague symptoms, so the doctor orders some laboratory tests “just to get a baseline”. A doctor doesn’t know what’s causing the headache, so she orders a CT or MRI “just to see”. Medical students are rewarded for pursuing obscure diagnoses, so they order increasingly esoteric tests “just in case”.

This insidious practice has resulted in a culture of overtesting and overtreatment. Studies show that 30% of all medical care—at the tune of $700 million per year—is waste. Not only does this impose a heavy financial burden on society and on patients, it also results in avoidable harm. Every test has risks and potential side effects. A CT scan has a risk of radiation, for example, that may lead to cancer later in life. And one test often leads to another, even riskier, test.

Recently, my husband had an itchy rash on his arms. He mentioned this to a dermatologist friend, who recommended that he come into the office for a skin biopsy. I asked how the biopsy would change my husband’s management: regardless of what it showed, wouldn't he still use a steroid cream? Sure, the dermatologist said, but at least we’d have more information.

Nothing against our well-intentioned friend, but this is a case where more information isn’t better. Why get a biopsy—an invasive procedure with risks including bleeding and infection—when it wouldn’t change the management or the outcome? Yet, tests are done all the time to quench the insatiable curiosity inherent in medicine: we just have to know.

Here’s another common scenario. A young woman comes in with abdominal pain. She’s able to eat and drink and looks well, but has a pain in her belly that’s bothering her. Many doctors would order a CT scan of her abdomen to make sure there’s not something bad going on. But what is this bad thing—how likely is it? How does the patient feel about the risks of the test, versus the risks of watchful waiting? If she’s fine waiting, then why expose this young person to unnecessary radiation, when it would be just as reasonable to wait to see if she gets better the next day?

More tests and better technologies are not the solution to improving clinical care. In fact, we know that 80% of diagnoses can be made without any tests at all, but by carefully listening to the patient’s story. I’m an emergency physician, yet even in the emergency setting, it is rare that a patient requires one particular test, and that test must be done right now.

Here’s what to do instead. Doctors: talk to your patients. If you’re not sure, tell them. Patients prefer honesty to false reassurance. Instead of reflexively ordering a test, discuss the benefit of the tincture of time. Remember that our first principle is to “Do no harm”. I just met two doctors, Tanner Caverly and Brandon Combs, who started an educational initiative to encourage doctors-in-training to write vignettes of medical overuse. To them, and to a growing number of physicians including the Lown Institute’s Right Care Alliance (of which I'm a proud member), preventing overuse is an ethical imperative.

Patients: insist on being an equal and active partner in your care. Ask “why” and “how”. Why is this test ordered? How will this test change my management? Make sure you know your diagnosis. Assure your doctor that it’s OK if she is not 100% sure; you don’t demand certainty, but you do expect transparency.

It’s taken me nearly ten years to unlearn the bravado I acquired in medical training and to learn that uncertainty isn’t bad; more isn’t always better; and less can be more. As the great cardiologist and humanist Dr. Bernard Lown says, you should always feel better after having gone to your doctor. We need to focus on healing by teaching and practicing the art of listening, compassion, and kindness.

The Low-Tech Revolution To Healthcare Reform

Steve is a 52-year old father of four. Soon after losing his job as a carpenter, he begins to have sharp stomach pains. His primary doctor examines him for a few minutes and then sends him to specialists: a GI doctor, who performs an endoscopy, and a cardiologist, who performs a cardiac catheterization. Both tests are normal, but he develops an aneurysm and a bad pneumonia, and has to spend the next week in the hospital. His medical bill is over $75,000, and Steve has to declare bankruptcy—all because of tests he never needed to begin with.

**

Sandy is a 46-year old grade school teacher who has been feeling unwell for a couple of months: she’s short of breath, feels tired all the time, and has a cough that wouldn’t go away. She goes to her doctor, who tells her it’s just a cold. Her symptoms get worse to the point she can longer go to work, and her doctor diagnoses her with depression and prescribes her some Prozac. That doesn’t help, so her doctor prescribes her Valium for her “anxiety”. It’s not until nearly a year later that she is finally diagnosed with breast cancer—cancer that, by then, has spread to her livers, her lungs, and her brain.

**

Science has brought about many importance advances, but also contributed to costly, harmful, and dehumanized medical care. Of the $2.7 trillion our country spends on healthcare every year, 30%--over $700 million—is wasted on unnecessary tests and treatments. Two out of every three families who declare bankruptcy do so because of excessive medical bills. Overtreatment isn’t just expensive, but it’s bad care. As Steve experienced, every intervention—even a simple blood test—has potential side effects. This doesn’t mean to never get tests, but rather to be certain that the test or treatment is needed.

At the same time medical costs are ballooning, healthcare has become more fragmented and less coordinated. The idea of having “your” doctor is becoming a relic of the past, and patients are shuttled to more and more specialists who have their own incentives. And medical care isn’t becoming safer: according to the Institute of Medicine, 100,000 people die every year because of medical error. The number one cause of medical error is misdiagnosis, which is evident in Sandy’s case: if the diagnosis is wrong, then the tests and the treatment will be wrong as well.

 

Politicians and administrators have proposed many solutions to these current system ailments. They are all based on the premise that more has to be done. More checklists. More tracking. More accountability. More technology. While some of these efforts may be beneficial, there is a far simpler and more fundamental reform that is needed: for patients to tell their story, and for doctors to listen.

The story is a core element of all human cultures. We all know what makes a good story: it is personal; it engages emotion; it has meaning; it grabs your attention from the start. Understanding each other’s stories is the basis for establishing connection, relationship, and trust. In medicine, the story is key to sound medical care. Studies have shown that 80% of diagnoses can be made just based on the story alone. That’s better than any test or combination of tests!

Listening to your story is also a critical aspect of healing. If your doctor didn’t listen to you, how can you be sure that he understood what you have, much less how you can develop a trusting partnership? Yet, doctors are listening less and less. A 1984 study found that patients are interrupted after just 18 seconds. A more recent study found that patients now have just 10-12 seconds to speak.

Over the last year, I have traveled to 48 cities across the U.S. to talk to people about their healthcare. Nearly everyone had a story of how not listening led to a bad outcome. That’s how I met Steve. Like many others, Steve considers himself to be lucky to be alive, but is he so lucky? He feels no better after having gone to his doctors, and now has lost his savings and his home. He suffered complications from tests he never needed in the first place, and he has no trust that doctors will do the right thing for him and his family the next time.

As for Sandy, I know her well too. You see, Sandy was my mother. I was a medical student when she called me to tell me about her symptoms and how her doctor wasn’t listening. I knew that something was wrong. My mother was an immigrant who worked hard all her life, who never complained about anything. Yet, I didn’t know how to help her communicate with her doctor so that he would really understand the gravity of her situation.

It took me a decade—first as a caregiver to my mother, and then as a practicing physician and patient advocate—to figure out that the story is absolutely fundamental to medical practice. Indeed, it can save your life.

Imagine, how different would it have been if Steve started out his story to his doctor by talking about his financial concern and his recent unemployment, how it was making him anxious and have stomach pains. How different would it have been for my mother to say that she’d never sought medical care for anything, but now she was feeling so poorly she could barely get out of bed any more.

And how different would it have been if their doctors listened. Some argue that doctors don’t have time to do so. While doctors are under more time pressure than ever before, it doesn’t take any longer to listen—in fact, it saves the time that’s wasted instead on asking endless close-ended questions and ordering unnecessary tests. Others insist that these tests have to be done because of fear of malpractice. Yet, the number one cause of malpractice is lack of communication, and patients should not have to pay the price for doctors’ fear.

I wish I learned this critical lesson a decade earlier. Not a day goes by that I don’t think about how things could have been different if my mother and I knew what I know now. As a physician and medical educator, I teach my patients and my students that what will really change medicine isn’t the latest IPhone app or newest genetic test, but rather a return to medicine as a healing art.

This requires action by both patients and doctors. Patients, tell your story. Know what goes into a compelling story. Practice it before going to your doctor, then make sure your doctor hears it. Doctors, know that you have to listen. Not just type on your computer and nod your head, but really listen.

Ultimately, transforming healthcare doesn’t require more politics or more technology. Rather, it requires refocusing on the most basic part of ourselves—our story and our human connection. This revolution, the low-tech revolution, is the real solution to healthcare reform.

Guest Post: Lessons Learned In Caregiving

This is a special guest post from contributor Marcela De Vivo. 

One month ago, my son had major hip surgery at a major children’s hospital in southern California. I was so pleased when he came out of surgery without any complications.  “The worst is over,” I thought.

Little did I know that the worst was about to begin.

The day after his surgery, I noticed Nathan’s vital signs were erratic. He looked a little bit too pale and sluggish. I mentioned my observations to his nurse, who called the doctor. I requested for them to draw blood and look at his numbers. The doctor did not listen. No blood was drawn, and my son was left alone to continue his “recovery”.

The following day, Nathan wouldn’t wake up. Again, I told the doctors my concern and asked for blood work, but was once again ignored. As the day continued, my son became more and more pale. His heart rate was consistently elevated, and his respiratory rate became lower and lower. Then, it happened—his oxygen saturation dropped below 70 and he turned blue. Doctors rushed in and finally they realized that something was seriously wrong. 

This time, they drew his blood. Sure enough, the results showed that he was severely anemic. He had lost a lot of blood during surgery and needed a transfusion. Fortunately he recovered and no major damage resulted. 

This experience highlights a lesson I learned long ago as a mother of a severely disabled child: advocacy is KEY. This is just one of many lessons I’ve had the opportunity to learn. I’ve learned to find ways to help my son engage with his environment, to allow him to participate with other children his age, and to speak up for him against a school district that thinks him “unteachable.” 

I’ve learned, too, that your role as a caregiver is fundamental in the physical and emotional well being of the person you are caring for. Learning to be a better caregiver can help reduce the inherent stress that comes from so great of a responsibility. A good caregiver cares about the dignity, welfare and feelings of the recipient of the care.

Here a few ideas I’d like to share with you that you can improve your experience as a caregiver, as well as the experience of the person you are caring for: 

Patient Care

Do treat your patient/loved one with respect and dignity. Although your patient/loved one may revert to childlike behavior, he/she always needs to be treated as an adult. It could be demeaning to them to be treated as somehow lesser as a result of symptoms from the illness. Treat them as you would want to be treated yourself if you were receiving the care.

 

Don't assume that the care-receiver has nothing to contribute. Again, always treat your loved one with respect. He or she may be disabled in some ways, but that is not to say that they are useless and helpless as well. Even if they are not able to do much for themselves, give them every opportunity to cooperate in their own self-care. My son is unable to speak, but is able to answer yes by blinking and no by shaking this head. Through this rudimentary method of communication, we give him as many choices as possible: do you want this shirt or that shirt? Do you want to draw with this color? Watch that movie? This simple communication technique gives him control over his environment and the opportunity to engage with us.

Do engage in physical contact. Many of the ill, infirm or elderly who need care experience less and less human contact, especially if the condition continues for a long period of time. A hug, pat on the shoulder or light touch on the arm can improve the patient/family member’s mood and outlook.

Don’t exclude the patient during conversations. Even if the primary decisions are not made by the patient, direct questions and comments should be directed to all people in the room, including the patient/family member. Don’t act like they’re invisible, especially when discussing their care. Let the patient know that they are still important and that their attention and input matter. 

Do use verbal and visual cues. Miscommunication can be result of your patient or family member being unable to hear or see you. By using both verbal and visual cues, you decrease the chance of misunderstandings. 

Do stay organized. You will reduce a lot of stress by keeping track of all the little details required to care for your parent or patient. Make sure you have a master contact list of doctors, family members, apartment managers, neighbors, etc. whose assistance you may need. Keep track of all medications and timing of medications on a calendar or spreadsheet.  

Self care 
All too often, caregivers forget to take time to nurture themselves and find the support that they need. By taking care of themselves, caregivers improve their ability to help others. 

Do reach out for help. It is also important that you have support as a caregiver as well. If you find yourself floundering emotionally or physically from the responsibility of caring for someone else, reach out to friends, family, or find a support group. Ask family and friends to help out with the care—or with the mundane everyday tasks that you may have let slide, like household chores, grocery shopping, car maintenance, etc. Hire help if you need it. 

Don't forego sleep. It’s easy to sacrifice sleep when under duress; however, sleep deprivation has serious consequences. You will be less able to solve problems and concentrate, which can make you more impatient and cross—all of which leads to poor quality caregiving. You will be a much better caregiver when well-rested. 

Do practice coping skills. Avoid additional stressors when possible and try to maintain your self-composure while under pressure (being well-rested helps you resist giving in to your temper). Consider meditation or yoga to improve your ability to cope with stress. 

Don't compare yourself to others. Every situation is different; every relationship is different. Do the best you can for your loved one by treating him or her with dignity and respect and meeting all of his or her needs. Comparing yourself to others will only increase your stress and anxiety.

I hope these tips will help improve the quality of your caregiving and the quality of your experience as a caregiver. Taking care of yourself is a must, especially in the face of so much responsibility. And remember that you must be your own—and your loved one’s—best advocate.

Marcela De Vivo is a freelance writer from Los Angeles whose writing covers several various topics, including marketing, healthcare, technology and more. As a caregiver herself, she understands how stressful it can be and incorporates meditation and yoga to manage that stress. You can read more about her journey with her son at www.prayfornathan.org.

Choosing Hospitals Wisely (Is There Such a Thing?)

Here’s a thought experiment presented a recent conference on healthcare consumer (ah hem, patient) advocacy. Let’s say that you’re told you need surgery of your knee. It’s an elective surgery to repair a torn knee ligament, the ACL. Your insurance covers part, but not all, of the cost. How do you choose which hospital to go to?

At the moment, there is very little information for you to make such a decision. Many people will choose the hospital they normally go to or that their doctor is affiliated with. For the purposes of this thought experiment, let’s say that the following information is available to you:

·      Type of hospital (large academic hospital versus small community hospital versus orthopedic specialty hospital)

·      Number of ACL surgeries per year

·      Rate of infection and complications

·      Length of stay

·      Patient satisfaction

·      Total cost to system

·      Total out-of-pocket cost to you

What factors would be most important to you in making your decision?

Healthcare choices are highly personal, and it’s not surprising that participants at the conference came up with widely different answers. Many said that they would rely on recommendations. Citing that user-originated online ratings of hospitals are not yet widespread, they stated that they would ask for feedback from family and friends.

“These are the people I trust, so I trust their judgment and experiences,” several group said. “If I ask a stranger, their values may be different from mine.”



Some looked at the potential negative consequences. “Hospital-acquired infections and complications are bad, and I want to avoid those at all cost,” a participant said. It’s not clear, though, whether data will be granular enough to provide specifics that are helpful in the comparison. What if hospital-acquired infections for the hospital overall are high, but complications for that procedure are low? Are there certain complications that are worse than others—maybe you’d put up with pneumonia, but not if your wrong knee were operated on?

Others tend to value the potential positives. Some like the idea of going to academic centers, which are seen as “better” than community sites; some others like orthopedic specialty hospitals because of their brand-name appeal. A higher number of procedures connotes confidence, as does greater patient satisfaction.

Interestingly, cost was much lower in the decision algorithm. Nobody cited cost to the system as a factor. This was not surprising, but what was surprising was that cost to individual was also not a major factor. As one participant put it, “I don’t want a discount surgeon.” There still seems to be the belief that the more expensive is better, or at least that no expenses should be spared when it comes to health—at least for those middle-class conference participants.

Finally, many would not even make the choice at all. They would go based on the recommendation of their doctor. According to multiple participants, asking their doctor about the possibility of a hospital different from their recommendation was difficulty. “How do I even go about addressing it?” they asked asked.

This exercise underscores an important realization: in the movement to empower patients, we must keep in mind that healthcare is not transparent, and not a true market. There is a difference between shopping for a TV and shopping for a surgeon. This is not to say that more information isn’t better; it is important for us as patients to get more information so as to make a better decision. But we must also be cognizant of the type of information that is available. Even in this information age, little is currently available to make a decision of what doctor or which hospital to choose. Ultimately, it will take time to develop trust in a source enough to rely upon it to supplant word of mouth and personal experience.

Four Years Later: Reflections From the Last Day of Residency

On July 1^st, four years ago, I walked through Mass General and Brigham & Women’s Hospitals with an odd mixture of fear, relief, and excitement. Now, as I leave the hospital after my last shift of emergency medicine residency training, I am filled with a similar hodgepodge of emotions and reflections.

#1. “You were terrified of being a doctor!” I mentioned this article to the attending who oversaw my first shift as a newly-minted doctor. That day is forever etched in my mind; did he remember it? Much to my great embarrassment, he chuckled and said, of course. “I kept telling you not to worry if you don’t know something, but you were scared of everything!”

Though I knew that I was there to learn, it took me a while to get over my insecurities about not knowing so that I could focus on learning. And the learning was everywhere—on every single shift, I learned from great clinicians not just about diagnosis and treatment, but also important lessons on how to lead a team, how to teach, and, most importantly, how to help people who come to us in their time of need. I’ve been incredibly fortunate to have learned from many colleagues along the way, including the amazingly skillful and compassionate nurses at Brigham & Mass General. As my mentors say, it is called the practice of medicine for a reason, and we should embrace, rather than fear, the learning.

#2. “Mistakes will happen.” Every doctor has made a mistake some time in her life. Whether it’s a technical error (i.e. inserting a long IV into an artery rather than a vein), a systems error (i.e. ordering a medication for the wrong patient), or a communication error (i.e. angering a patient or colleague), all of us graduating residents will have made some kind of error. I myself made all three of these errors, and more.

With the volume of patients we will see throughout our careers, being the cause of medical error and interpersonal conflict is a terrifying and humbling thought. A wise physician said to me that just as residency is the time to learn how to practice medicine right, it’s also the time to learn skills like how to disclose mistakes to patients, and how to deal with conflict. “Don’t shy away from difficult situations,” he told me. “Put yourself in the middle of them to see what others do, and then develop your own style.”

#3. “That man has a name, and it’s not ‘the chest pain in room 8.’” As busy residents with long to-do lists, we often fall prey to the tendency to dehumanize our patients and brand them as chief complaints to quickly decide their disposition. On the surface, this might appear to save time, but dig a little deeper, and such algorithmic, depersonalized medicine results in unnecessary tests, misdiagnosis, and worse patient experience.

Furthermore, practicing cookbook medicine is not why we chose to become doctors. My work became much more meaningful when I made a commitment to connect with each patient, no matter how busy I am. I learned that the “old guy with dementia” was a world-renowned philosopher, that the “the onc patient with fever and neutropenia” had ten children with her preschool sweetheart. As physicians, we are privileged to hear so many stories from so many people. Cherish this gift we’re given to share in our patients’ rich lives. Our healthcare system isolates patients and disenfranchises families; we have the power to practice real patient- and family-centered medicine.

#4. “Residency is hard, and you have to take care of yourself.” My best friend from medical school, who had just completed his pediatric residency, warned me about this before I started intern year. How right he was. Work hours may have improved since our forefathers trained, but residents still work a lot and are exposed to high-stress situations with life-and-death consequences. Studies have shown that rates of depression and burnout increase sharply during training, yet the “hidden curriculum” of medical training still favors bravado over openness. Residents are taught to “suck it up” instead of talking about difficult situations and taking care of ourselves.

This is not the way it has to be! I learned this lesson the hard way during second year of residency, when my mother died. I suppressed my emotions rather than seek help, and saw how easy it is to feel isolated. Fight this impulse and stay connected. Find peers you can reflect with and openly speak about your experiences. Nourish the other people in your life and recognize their critical role in helping you through this process. For me, it was my wonderfully supportive husband and my friends who sustained me and kept me grounded. Make time for these people in your life. I cannot think of anyone who regrets the time spent with our loved ones and laments, “if only I spent that day reading one more research article!”

#5. “Emergency medicine is a phenomenal field.” The first grand rounds lecture I heard as an intern was by Dr. Larry Weiss, then President of AAEM. He spoke about how emergency medicine is an ideal specialty for advocacy: as the frontlines of medical care who interact with every aspect of the healthcare system, we are the most well-positioned physicians to advocate for our patients, our communities, and our society. We see the problems with public health—smoking, obesity, gun violence, etc. We see the problems with under-, over-, and misutilization of healthcare. And we have the ability and power to act on these problems every day.

In my fourth year of medical school, I selected emergency medicine as a specialty because I wanted the ability to treat any patient, anywhere. Being one of the emergency providers who took of care victims of the Boston bombings made me grateful for my training and for the skills I’ve learned along the way. We in emergency medicine have the incredible opportunity to utilize our training to do what we love while making a difference to improve care for our patients and to transform our healthcare system.

What else can I say about these last four years? It’s been a rollercoaster ride. Now that I’m about to embark on the next journey as an emergency medicine attending physician, health policy professor, and Director of Patient-Centered Care Research at the George Washington University in D.C., I am filled with exactly the same emotions of fear, relief, and excitement that I came to Boston with. I have learned so much from so many incredible people along the way, and will forever be indebted to the amazing attendings, residents, nurses, physician assistants, and other colleagues at Brigham & Mass General Hospitals.

Now, what will the next years bring? I’ll be on leave for the next month, but stay tuned for more dispatches and reflections, soon to be from the nation’s capitol.

8 Ways to Care for Elderly Loved Ones in Assisted Living

This is a special guest post from contributor Krisca Te.

When the time comes to move a loved one to an assisted living facility (ALF), it can be an emotional period for everyone involved. While it’s undoubtedly the right thing to do when they are no longer capable of living on their own, it is inevitable that some negative feelings will surface. 

On your own end, there may be feelings of guilt that you aren’t taking your parent or grandparent in yourself, while for them it means the beginning of the end of their independent lifestyle and will require some pretty big adjustments.

I experienced this firsthand when the time came to move my grandma to an ALF. She had always been very active and independent; she loved playing golf on the weekends, meeting up with friends for bridge games and hosting elaborate dinner parties.

However, as she got older, it gradually became more and more difficult for her to climb up and down the stairs and get around the rather large home where she lived alone. On one occasion she suffered a fall and injured her ankle; luckily it wasn’t too serious, but it did lead us to reevaluate her situation.

When we brought it up with her, she was naturally very distraught at the thought of leaving her home and insisted that she would never move to an ALF where as she put it “everyone was just waiting to die.”

Eventually we suggested that she come along and have a look at some of the places in our area, just to get a feel for what they were like.

Once she saw the facilities, met some of the residents there and talked to the staff, she actually began to warm up to the idea of moving to a smaller place where she would have more help, and also more opportunities for socializing. 

She has since moved to an assisted living facility nearby and although it certainly hasn’t been an easy process for her, she has managed to readjust and is still enjoying most of the same activities she did when she lived in her own home.

I’ve learned that although you can’t change your loved one’s circumstances, there are things you can do to help them through the transition. The most important thing you can do is to simply be there for them and give them your support when they need it.

The following are some of the things that helped in our situation, and hopefully they will be helpful to others as well.

1. Deal with any feelings of guilt first. If you’re feeling guilty about placing your loved one into assisted living, it’s important that you are able to work through those feelings before you move forward as these feelings could negatively influence your loved one’s transition period.

Keep in mind the reasons why you initially decided that moving your parent or grandparent to an ALF was the right move and remember that it will benefit their health and well-being.

2. Talk through any concerns well in advance. If your loved one has any concerns about the move or about what will happen to their current home or belongings once they move, it is important to go over these concerns long before you being any other preparations. Find out what they are worried about and then work towards coming up with solutions that will put their mind at ease.

3. Visit the ALF with them a few times before the move takes place. Most of us are more afraid of what we don’t know than what we do, so taking your relative to visit the facility and acquaint themselves with the grounds, staff and amenities can do a lot to ease their worries and help them adjust more quickly.

Go to a few meals, talk to other residents and familiarize yourselves with the grounds and layout of the facility so that your loved one knows what to expect.

4. Keep in touch as much as possible. During the first few months or even year of your loved one’s transition into assisted living, they will likely be feeling vulnerable and insecure in their new surroundings. Knowing that they can count on your support can go a long way in helping them to adjust. Make regular visits and when you can’t come in person, be sure to phone them or send a little note so that they know they haven’t been forgotten.

5. Help them make new contacts and get involved with activities. Elderly people can often become shy when placed in a new environment and may turn down suggestions of activities or social gatherings. However, getting involved with others in their community and making new contacts is an important part of the adjustment process.

If they seem reluctant to participate, try accompanying them to some of the planned activities and gatherings so they don’t feel too intimidated. There is bound to be some activity your loved one is interested in, whether it’s art, book clubs or music lessons.

6. Don’t coddle. Showing support is important, but make sure you give your parent or grandparent the space to be independent as well.

In the first few days, for example, you may want to visit every day to make sure they know you haven’t abandoned them, but as time goes on, it’s better to space the visits out a bit more so that your loved one doesn’t become too dependent on you.

7. Set up their new living space with familiar furnishings and personal effects. Most elderly people are quite attached to their belongings, and parting with them can be very stressful. Obviously, they will be moving to a smaller environment, so not everything can be moved with them, but incorporating as many of their favorite objects like armchairs, beloved knickknacks and photographs can give the new place a familiar feel.

8. Form good relationships with the staff. You may not always get straight answers from your loved one about how they are doing and whether or not they are adjusting well into their new home, so forming good relationships with the staff can help you stay better informed of their progress and any issues there may be.

Krisca Te works with Open Colleges, Australia's leading provider of TAFE courses equivalent and aged care training. When not working, you can find her on Google+ or spends the day with her baby boy.