On this episode of Kentucky Health, host Dr. Wayne Tuckson speaks with Bonnie Lazor, M.D., a practicing geriatrician and the medical director of Nazareth Home in Louisville. Lazor discusses helping seniors and family members make long-term decisions about care when facing a progressive chronic disease.
How Nursing Homes Help Patients Achieve a Better Quality of Life
Being diagnosed with a chronic disease that gets progressively worse over time and will eventually be terminal is something that most people don’t want to spend a lot of time thinking about, but such diseases are common among an aging population. Patients with chronic progressive diseases may spend years in a nursing home or an assisted-care facility or before they pass away, and over that time they deal with concerns about loss of physical ability, medical costs, and mental and emotional wellbeing. The prospect of those challenges make the decision about moving into one of these facilities a significant life event for many people.
“The nursing homes of today generally have two service lines,” Dr. Lazor says. “We have rehab to home, and the intention of rehab to home is the patient comes from acute hospitalization, they’re weak or have had a decline, and we’re going to tune them up and build them back, to go back home. And then you have those people that are only coming to us later in life with very chronic and severe diseases, whether it’s Parkinson’s, congestive heart failure, end-stage lung disease, end-stage diabetes, all of those chronic diseases.”
While most people would prefer to spend their final years living at home, even if they lose some of their self-sufficiency and freedom, Lazor contends that for many elders burdened with chronic disease, entering a nursing home will result in a better quality of life and be less expensive as well. “If you truly need medical care because you’re finding yourself more in the hospital rather than home – wherever home is – then a good facility that offers quality care is going to be able to keep you more out of trouble than if you were at home,” she says.
Each patient entering a nursing home has his or her unique needs based on their disease, but all of them at some point will be faced with a choice between extending the lifespan or doing everything possible to live a full life even if it means allowing the disease to progress naturally.
Lazor says that she’s never been intimidated when discussing quantity vs. quality of life with patients and families. She meets with them, informs them about the patient’s medical condition and prognosis, and then works with them to devise a plan that meets their expectations for what’s to come, with the patient’s goals coming first.
“It’s always seemed very natural to me, it’s just another part of one’s life,” she explains. “It’s just as important as when you were born, it’s that whole journey through life, and what’s important to you, and your goals, the choices you have to make.”
For many patients, controlling symptoms of their disease is the main objective, Lazor says. Pain management is very important across a wide spectrum of conditions, and relieving physical pain or other debilitating symptoms such as shortness of breath can lead to a reduction in mental stress and anxiety for many elders. “I feel like if we focus on quality, and relieve the stress of the disease, we actually see these people live longer,” she notes.
Lazor says that the ongoing COVID-19 pandemic (in the midst of a lull in cases at the time of the show’s taping) has had an impact on senior care across the U.S. At Nazareth Home, the staff were able to prevent an major outbreak in infections among the residents, but long-term isolation caused problems for many elders, many of whom were stable before the virus came. “We saw a big decline in their cognition, their functional ability and physical ability from not being able to socialize,” she ways.
The changes in daily care for patients during the pandemic caused widespread anxiety, which affected family members and staff as well. Family members used to seeing their loved ones were forced to communicate remotely, and staff turnover due to burnout was another challenge, Lazor says.
The Value of Nazareth Home’s HELD Program
To help their residents improve their health and enjoy their time at Nazareth Home, the staff has created a program called Helping Embrace Life Decisions (HELD). The name and acronym were thought of by CEO Mary Haynes, Lazor says.
“I’ve been with Nazareth Home for almost 20 years, and what’s great about their forward-thinking team is that they’re always looking at what’s going on with the elder (population),” Lazor adds. “How are demographics changing? What services do we need to provide? We started to realize that people were coming to us more frail and with more difficult chronic diseases.”
This trend applied to both patients who were planning on living at Nazareth Home permanently and those there for just a short while as they underwent rehab. For both groups, the Nazareth Home team came up with a program that provided a comprehensive education plan explaining options for care that helps patients develop individualized plans and improve quality of life.
“It was all about being innovative, pulling a team of experts together that can help provide the options that are available – because again, I’m not walking in that elder’s shoes, I’d like to know what they want,” Lazor says.
The process starts with a consultation that includes family members, Lazor says, and during that meeting the patient’s chronic disease will be explained in full, including its expected progression and remedies for pain and loss of function. “It’s not disjointed, it’s more holistic about that person,” she says.
Nazareth Home partnered with Pallitus, a part of Hosparus Health in Louisville, to devise a symptom management plan to serve patients in the HELD program. Pallitus provides another geriatrician to work alongside Lazor, and nurse practitioners contribute to the major medical decisions as well. Lazor says that social workers and nurses from Nazareth Home who interact with the elders daily are also part of the team.
As part of the HELD program and with Nazareth Home residents in general, Lazor and her team supervise physical activity for residents. She says that the correlation between physical activity and good health is still very important, even if when are limited in movement. “We have a very good therapy program,” she says, “and it may be simple goals (for patients). If for example they have arthritis and are wheelchair-bound – we’re not going to change that, because they’re more debilitated if we push them too much.”
With regards to diet, Lazor says that she used to joke that “if you made it to 90, you have a right to say what you want to eat, and you can also have a little bit of alcohol.” She admits that Nazareth Home patients don’t have an unlimited diet and endless drinking tab, but says that the larger problem for elderly patients is a lack of appetite.
“If we try to be too strict with their diet, they’re not going to eat, and we need nutrition or we see weight loss, which can be more detrimental when an illness comes around,” she says.
According to Lazor, having discussions with patients about the end of life is not as difficult as outsiders imagine; she says that looking back through her career, only a handful of people have been taken aback when that subject was brought up. That’s because Lazor believes most elders are attuned to their own health status and outlook.
“Often times, it’s the families that don’t want to hear it, because we don’t want to lose our loved ones,” she says. “We all know that one day we have to prepare, so I look at it like, we just got done with the Super Bowl, and I always say, we’re having that game plan going in, that strategy.”
