I have some friends who are planning to homeschool their kids one day.  When I’ve asked them why, they said their decisions was not a slam against teachers – in fact, one of them was a teacher herself.  Rather, they felt that teachers are put in an impossible position, and education suffers as a result.  On one hand, teachers are charged with teaching every child to the best of their ability.  On the other, they’re given dozens of often rowdy students to manage and are mostly evaluated not by teaching quality but by the mounds of paperwork – lesson plans and so on – that dominate their evenings and weekends.  Each individual teacher might be a paragon of educational talent, but they’re working in a system whose goals are a combination of teaching, warehousing kids so they stay conveniently out of grownups’ way during the daytime, and doing the occasional heartbreaking bit of social work.  And so if you really want to educate your kids, the argument goes, you’re better off teaching them at home, where you can really make teaching the focus.

I’m not sure I totally buy that argument when it comes to schooling, but it definitely applies to nursing homes.  Our Lady of an Undisclosed Location is the hospital of choice for several nursing homes, and so even though I haven’t seen the inside of the local nursing homes myself, I began to build up a picture from the patients that they send our way, like an astronomer inferring the existence of a planet from the debris it drags along its orbit.

I was once taking care of a frail old woman who insisted on getting up to go to the bedside commode by herself.  Usually, we’d have the nurse help pull them to a stand and then walk them over to the commode, but because she insisted, we instead hovered worriedly beside the bed, ready to catch her if she started to stumble.  But I had to ask – why was she so insistent about this, of all things?  And the story she told went something like this.

Imagine you run a nursing home.  You want to take the best possible care of your patients, but the nursing home makes money from each patient they carry.  So of course the natural strategy is to expand your census until you’re just barely able to keep up with the patients you have.  As a caring human being, of course, you might not want to go this route.  You might want to just take good care of a smaller number of patients.  But you know that even if you don’t expand, your competitors will, and soon you’ll be out of business and unable to take care of any patients at all.

Imagine you work for Medicare.  You’re glad to see so many elderly people being taken care of, but you’re well aware of the temptation for nursing homes to cram in so many patients that they can’t take care of them all.  Now, for most normal service businesses, you might just let the market work it out.  Word of mouth would let people know which nursing homes to avoid, just like people learn to avoid bad restaurants.  But the sort of people who need to be in nursing homes are not, as a rule, the sort of people who are actively posting reviews on Yelp, so you decide to take matters into your own hands by creating quality metrics to judge nursing home performance.

Now, one of the worst things that can happen to an elderly person is a fall.  As people age, their bones become more brittle, and their ability to heal falters.  Of patients sent to the hospital after a fall, 40% never regain independent function, and 25% die within a year.  Now, it’s hard to tell someone living at home alone to never fall, but in a nursing home, where you have people supervising the patients at all times, it’s pretty reasonable to expect falls to be extremely rare.  So, you institute a new rule: every time someone falls in a nursing home, you dock the nursing home a good chunk of its pay.  Not quite as good as getting those Yelp reviews maybe, but having some quality metrics is a lot better than letting nursing homes run amok.

Except when we go back to the nursing home, we see the vast yawning gulf between the letter and the spirit of the law.  Oh, the law works – the nursing home is keen to prevent falls and avoid paying the fine.  If anything, the fear gets magnified each step down the chain of command.  If you’re a shift nurse, you really don’t want your patient falling on your shift.  It would mean no end of paperwork, having to explain yourself to your supervisor, and worst of all, getting that “friendly reminder” mass e-mail that doesn’t quite refer to you by name but nevertheless has everyone gossiping the next day.

So you are careful to prevent falls.  Very careful.  So careful that you hover anxiously around whenever patients try to get up out of their beds, and insist on carrying most of their weight when they do.  And so patients have to go through a whole process just to get up to go to the bathroom, and their muscles and coordination get weaker and weaker for lack of practice.

This may be a good point to mention that muscle mass is one of the strongest predictors of mortality in the elderly.  By overzealously preventing falls in the short run, we’re literally making our elders weaker and likely increase their overall mortality.

So, despite everyone acting in perfectly good faith, we have a system that makes nursing home residents less independent, less happy, and sicker in the long run. That’s why this old lady was so eager to do something as simple as try to get up by herself.  As soon as she was outside the watchful eyes of the nursing home, she wanted to regain some of the function that the well-meaning nursing home had drained from her.

But hey, at least the fall statistics look great!

There are other ways, too, that nursing homes managed to systematically fail in taking care of the elderly. For instance, a lot of patients in nursing homes are demented to various extents.  One way that we grade how demented patient is to assess how much they’re alert and oriented, or “A+O” in our shorthand.  If you’re A+O times 3, that means you know your name, where you are, and what year it is.  As people get older, they start to lose these abilities. First they forget about some faraway abstract facts like what year it is or who the president is. Then they lose awareness of where they are and how they got there. Finally, they forget even their own name, although they can still carry on conversations and attend to their own simple needs. And when you’re that demented, when you’re “A+O time zero,” the world becomes this terrifying place – you’re in a strange building, with no memory of how you got there. Strangers are around you all the time doing incomprehensible uncomfortable things to you. Understandably, some of these patients become quite agitated by this turn of events, which hardly wins them many friends among the nursing staff, and the story often ends with the patients sedated by medications with some pretty nasty side effects, just so the staff can take care of them properly. Again, it’s a sad situation, but it’s hard to really blame anyone involved.

Except that one of the simplest interventions to reduce delirium and improve quality of life for the elderly is to give them a predictable environment, preferably with familiar faces around them. It stands to reason that even a fairly confused old lady would still be comforted by being at home in familiar surroundings and seeing her children around taking care of her. But instead, we put them up in these dorm rooms, with antiseptic lighting, noisy roommates, and a new nurse at the end of every shift.  Once again, nursing homes full of caring and attentive staff members manage to be uncaring and inattentive in the most ironic way possible.

To be fair, taking care of old people is really hard. It demands time, attention, and patience, and to a large extent we as a society have decided that we don’t want adult children to have to carry the full burden of all that. I’m as much a free-market man as anyone else, and it makes sense that once we’ve decided to outsource the care of the elderly, we’d have groups of professionals that try to replicate these services, for a fee. This approach works for a lot of everyday life. I don’t want to change my own oil, so I pay my mechanic to do it. I don’t want to build my own bookshelf, so I run down to IKEA. But what nursing homes show us is that there are some services that simply do not survive the transition to the marketplace. A loving daughter taking care of grandma is qualitatively different from three shifts of nurses checking off the boxes from Medicare guidelines.

There is a philosophical puzzle called the Chinese room that goes something like this. Suppose we have a room full of books, each of which has a set of rules pertaining to Chinese characters. A man with no knowledge of Chinese goes into the room, and sits there. Once in a while, a slip of paper with some Chinese characters comes in through the mail slot. The man examines the paper, applies the rules in the books, and scribbles out some characters in response. It turns out that the man on the other side of the door is a Chinese scholar. And he thinks that he is having a very interesting conversation with his mysterious penpal. Now, the question goes, if the man in the room is doing nothing but following a set of rote instructions, can we really say that he “understands” Chinese? One answer to this dilemma is to say that no, the man does not understand Chinese but the room as a whole does. So while the inside of the room looks a little odd, from the outside, the room is a whole does have the emergent property of understanding Chinese.

Well, in a nursing home we have nurses following instructions from both the administrators of the nursing home and from Medicare. The nurses themselves don’t intrinsically care about the patients in the same way that a son or daughter would – it would simply be impossible to expect that level of emotional labor. Instead they want to go to work, get their work done, and go home, just like anyone else. The administrators know this, and try to write up rules and guidelines that would allow them to treat the patients the way you’d want an elderly parent cared for.  But unlike the Chinese room, even with the best crafted rules, the system demonstrably lacks the emergent property of caring for the elderly.

It would be nice if we could simply revert to the old model of taking care of their parents in multi generational households. But that’s not terribly realistic to ask of everyone. However, there is one area of elder care which I think works reasonably well: the visiting skilled nurse. The notion here is simple. Instead of moving grandma into an institution that takes care of all aspects of her care, the family manages most of the mundane stuff; feeding, conversation, taking walks – and a couple of times a week, a nurse comes by and takes care of the tricky stuff – bathing, making sure the medications are being taken correctly, wound care, and so on.  This, in the best case, is outsourcing done right – with the difficult portions farmed out but done under the supervision of the caring children.

But doing this requires both discipline and courage.  Discipline, because the children need to step up to take on some of the duties of taking care of their parents.  Courage, because in a world where convenience is prized and nursing homes are trusted institutions by family and insurance companies alike, it requires a level of courage to say that no, for some things, care by strangers is simply not the same thing as care by loved ones.  But as my homeschooling friends would probably say, when it comes to the welfare of someone like a child or a parent, the sacrifice is no sacrifice at all.  And so, as strongly as they argue for homeschooling your kids, I would argue in favor of home-care for your parents.