One day, our parents won't be able to drive, to climb stairs, or maybe even change their own clothes or feed themselves. As painful as thinking about this might be, we need to prepare to help them be comfortable and safe in their last stages of their lives. Here are the things to consider.
No one wants to think about their parents at the end of their days, much less talk about it. In fact, 75% of adults haven't had an in-depth discussion with their parents about things like living arrangements in retirement, long-term care, inheritance, and funeral wishes, according to a study by Merrill Lynch and Age Wave. But it's not just we adult children who are avoiding the "big talk"—nearly a third of people ages 50 and up haven't even had such discussions with their spouse yet.
It's the elephant in the room. It's also one of the most important, difficult subjects you and your family will ever face. Sadly, your parents could one day be fine and then suddenly the next day need a great amount of care, so the more prepared you are in advance, the less stressful this might be for your whole family.
Arrange a Family Meeting for "The Talk"
This isn't a conversation that you can just bring up out of the blue one day over the phone with your parents and siblings—"So, mom, have you thought about moving to a nursing home?"—or during a holiday visit, when stress and family conflicts are already more likely to arise. It's better to plan a family meeting with your parents and siblings (if you're not an only child) and prepare for it by reassessing your own financial situation and feelings. (That could be the hardest part—getting through your own grief as you contemplate your parents' last years and no longer having them in your life. Have a box of tissues on hand.)
When arranging the meeting, you can say: "The purpose of this meeting is to talk about getting mom and dad the best care for their needs and wishes as they get older" (or something similar but less awkward). Your parents or your siblings might be reluctant to have this talk, but make it a point that it's important everyone is involved.
Shelly Sun, CEO and Co-founder of BrightStar Care, offers these tips:
Have the conversation in person. Video chat, phone, or email won't provide you with honest emotions or feedback.
Prepare questions in advance so you won't feel rushed or scrambling to get your thoughts together. (See below for some questions to ask.)
During the conversation, provide undivided full attention so it won't seem like you're forcing an agenda.
Write important points in a notebook to record details and to reference in the future.
Depending on your family, this could be a very heated conversation, a very quiet one, or maybe one that drags out every emotion you have. Whatever you do, listen. This might be the best example of a time when you need to stop thinking about what you'll say next in order to truly listen to what the other person is saying.
Okay, so what do you need to discuss? The big question is where your parents will live out the end of their days and how to pay for it. You'll want to talk about: your parents' current well-being, what their plans or hopes are for when they can no longer live independently, their financial resources, and how you (and your siblings) can help. The information below could help make this uncomfortable discussion go more smoothly.
Find Out Your Parents' Needs and Wishes
During the discussion, find out what your parents' plans are, if they have any. Do they want to "age in-place" (stay in their own home) or move closer to one of their kids? Would it make more sense to move to a less expensive home—perhaps a senior independent living community (aka a retirement community) where they'll have more interaction with other seniors? Or would their needs be better served by an assisted living residence or a nursing home? (We'll explore these options in a minute.)
You and your siblings should also observe your parents' current health and ability to live independently, so you'll know if they need assistance now. Stacey Hilton of Visiting Angels tells us to look for these warning signs:
Poor eating habits
weight loss or no appetite – are they able to still cook for themselves? Do they stock their fridge with healthy foods
Poor hygiene
– do they have body odor? Are they bathing and changing their clothes like they used to? Are they neglecting their nails and teeth?
Neglecting their home
– is it not as clean as you remember?
Forgetfulness
– a good indicator are scorched pots and pans, it shows they may be forgetting that dinner is cooking on the stove. Also, are they missing appointments or have lots of unopened mail? Are they losing money, paying bills twice, or hiding money?
Support system –
Do they have a strong support system in town to lean on if they need help?
Mobility and driving –
Are they still mobile? Can they get out of bed, up the stairs and into showers without slipping or falling? Can they still safely drive themselves to the grocery store, doctor appointments, etc…? (a good way to determine this is to check their car for new dents, scratches, etc…)
One of the more dreadful subjects, but one that might need to be broached sooner than the others, is that "car key conversation." If your parents aren't able to drive safely anymore, you'll need to persuade them to give up the car keys or take them away legally if necessary.
For more considerations, see this helpful senior safety and well-being checklist (PDF) from A Place for Mom.
Weigh the Senior Care and Housing Options
Your parents might be quite independent today, but chances are one day they will need that long-term care (by one estimate, at least 70% of seniors will). There are several types of long-term care solutions, ranging from assisted living communities to in-home aid. Making the best choice depends on your parents' health needs, your resources, and your collective wishes.
Assisted Living Communities (aka Personal Care Homes) are designed for seniors who can no longer live safely on their own but who don't need around-the-clock medical care. Residents live in their own private apartments, and services provided include daily living assistance, medication help, meals in a shared dining room, and housekeeping. Some take Medicaid, but most are privately paid.
Average cost (per LongTermCare.gov): $3,293 per month for a one-bedroom unit
Nursing homes provide seniors with a high level of medical care and are a better choice for those with complex medical conditions, since licensed nurses are available 24 hours a day. Long-term residents typically share a room (but private rooms are available) and eat together in a central dining room. Most people also pay out of pocket for nursing homes, but you might be eligible to get help from Medicaid for these (very high) expenses if you run out of money.
Average cost: $205 per day or $6,235 per month. For a private room: $229 per day or $6,965 per month
Home care services allow seniors to stay in their homes while receiving assistance from home health aides for Activities of Daily Living (ADLs), such as bathing, dressing, getting to appointments, and preparing meals. You can hire in-home personal care on a once-a-week basis, daily, or for around-the-clock care.
Average cost: $21 per hour
Adult day health care locations are community-based centers where seniors can get healthcare services, social activities, and therapeutic services. They offer a reprieve for family caregivers (especially working ones) and a social environment for seniors who don't need 24-hour care.
Average cost: $67 per day
There are other options as well, including independent living communities (retirement villages for seniors who are very independent and have few medical problems), which cost between $1,500 and $3,500 a month, and respite care, for short-term stays.
Here's a breakdown of a few senior housing options:
These are just average costs, though, which will vary by area. To find specifics for your location, head to this interactive map at Genworth for the median cost per state and region.
Once you've decided on the type of living arrangement, compare senior living communities near you at these sites:
Medicare's nursing home compare: nursing homes that are Medicare and Medicaid-certified, along with ratings, inspection reports, and other measures of quality
Eldercare.gov: The Department of Health and Human Service's senior community services locator, where you can find adult day programs, housing options, in-home services, and other types of assistance
A Place for Mom: a free service that finds senior living communities based on your needs (FYI, they're paid by their partner communities)
Decide on Whether or Not to Be Your Parents' Caregiver
The numbers above likely shock those of us who haven't given much thought to our parents' need for care when they're older. (In New York, the median cost for a semi-private room in a nursing home is over $10,000 a month.) With the costs of long-term care so high—often even more than we might make in a month altogether—the most affordable option might be to care for your parents in their own home or move them into yours. If you have a strong relationship with your parents, it's also the option you might lean towards first, since sending your parents to a home can (unjustly) feel like you've abandoned them. But there are some very important considerations here.
The emotional toll: Being the primary caregiver and living again under the same roof with your parents is an enormous role reversal. Now you're taking care of mom and dad, the people you've counted on for support and strength but whose health and quality of life might be deteriorating before your eyes. Not everyone will have the emotional—and physical—strength needed to provide the day-to-day care, like bathing, feeding, or dressing elderly parents, particularly if they're frail, have a serious illness, or can't remember who you are. It's devastating just thinking about it.
Logistical problems: On top of that: you might not have much room in your home to begin with, you might currently be living and working thousands of miles away, and your workplace might not be very flexible with time to tend to your parents (who could be considered dependents just as much as your kids would). There are a number of sacrifices you might have to weigh, similar to ones parents have to make for their kids, but in some respects even harder.
Financial costs: If your parents stay in their home or in yours, you might still have to hire a home health aide (possibly for thousands of dollars a month) and do home improvement projects that make life easier for the elderly, such as modifying a kitchen with cabinets and appliances that reduce the need to bend or a bathroom remodel that swaps a bathtub or traditional shower with a walk-in shower.
Splitting "the burden": If you have siblings, it gets even harder: Who will take the responsibility? The sibling doing most of the caregiving could easily get resentful of the others, and those who aren't doing the caregiving could feel guilty. In this case, Diane Carbo, RN, suggests setting up a family care contract, in which the family member taking responsibility of the elderly parents gets paid from family funds. This reduces resentment and can offer other benefits:
Having a formalized care giver contract can allow the aging senior to utilize their assets to remain at home, receive quality care and financially reward the individual that is providing that care. This can provide the family caregiver with protection should the other family members pursue legal action after the aging senior is deceased. It is unfortunate, but it does happen more often than you think.
(Why is being part of a family so hard??)
Ultimately, your parents' health and needs should influence this decision the most. If they need 24/7 care or have complicated health issues, they'll likely be better off with long-term care housing. On the other hand, if you are able to take care of them, there's something to be said for spending as much time with your parents before they die. Whatever option you decide on with your family, remind everyone that it's about keeping your parents' best interests at heart.
Get the Estate and Financial Resources in Order
Surprise: Regular health insurance and government medical assistance don't cover long-term care, such as expenses for a nursing home or assisted living communities (if they do, it's usually just a small part). No matter which way you cut it—whether you care for your parents in your home or they stay at a care facility—the financial costs are staggering. To pay for your parents' care, you'll need to tap their retirement funds and other assets, your own savings, and/or possibly use long-term care insurance or similar products.
Your parents' assets. Now's a good time to review your parents' net worth—their retirement savings and other assets (such as their home) minus their debts. Also take into account Social Security, pensions, and any other income. Do they have enough to cover monthly living expenses and the additional long-term care costs? You can use this calculator from Mutual of Omaha to determine how long their money will last, based on regular withdrawals.
It's also a good time to establish financial oversight of your parents' accounts: Get added as a joint account holder to their bank and investment accounts so you can look out for suspicious charges and make sure the bills are paid, gather the most important estate planning documents, and get started on all those other morbid preparations.
Your own savings. It's tough. You're saving for your own retirement—perhaps only years away from it yourself—and maybe also for your kids' college education, but you want to support your parents as well. If you're planning well ahead, you can hopefully find wiggle room in your budget to save for your parents' long-term care or at the very least earmark windfalls, such as unexpected bonuses, to that fund. Agingcare.com found that about a third of Americans spend $300 or more a month out of their own pocket for caregiving expenses, including everyday things like groceries and medical co-payments.
If you have siblings, again, it can be both a more difficult and easier situation. Should you all contribute the same amount for the sake of fairness or on a sliding scale if one sibling makes more than the other? This will depend on your family dynamic.
Long-term care insurance. Long-term care (LTC) insurance could cover the expenses that regular health insurance and Medicaid don't—the huge costs of nursing homes, for example. Janet Perry of Napa Needlepoint says:
We got some for my mother-in-law when she was healthy and in her late 60's. In the last years of her life she broke her hip 3 times requiring stays in rehab hospitals. It would have cleaned out all her money [without] the insurance.
For my mother she had it for a long time, until she was in her early 80's. She moved into a life-care place which takes the place of the long-term care. But she suffered a broken ankle and the several other complications that kept her in and out of residential care for 13 months. If she had not been covered, not only would it have used up all her money, but it would have used up a substantial amount of my brother's and my money as well.
Knowing this is handled makes a huge difference.
The other side of LTC: It's a huge expense. Premiums have skyrocketed over the last few years and some insurers have gotten out of the LTC business altogether because of the rising costs in home care. In 2012, a healthy 60-year old couple might pay an average of $3,335 a year for a policy with $340,000 in benefits, but that was before premium spikes as much as 90% became the norm. Consumer Reports offers helpful advice on buying a policy. Like other insurance products, it's about balancing risks.
Forbes recommends considering an annuity instead. The annuity would cover expenses not just related to stays at a long-term care facility but also other expenses (maybe your parents won't need long-term care), such as rent and groceries, plus you wouldn't have to fight with the insurance company to collect on the policy. Bankrate suggests other alternatives, including using life insurance.
Your best bet is probably to consult a certified financial planner because all of these products have their pros and cons and their fine print requirements. Be especially wary of financial products targeted for the elderly—things like reverse mortgages, advanced funeral planning, and, yes, long-term care insurance. While they can be beneficial, some providers are out to take advantage of families in this delicate situation.
Support Your Parents Emotionally and Care for Yourself
Finally, maybe it won't be just one Big Talk—it might be a series of them. Both you, your parents, and your other family members will likely have a hard time talking about it, because, frankly, the situation sucks and there are so many things to consider. Candi Wingate, president of Care4Hire advises:
Be supportive, as your parents will likely grieve through this process. This transition represents letting go of the home where they raised their family, embracing the fragility that comes with advancing years, saying goodbye to friends and neighbors, and coming to terms (at least in part) with aging and mortality. You and your siblings too may grieve through this process similarly. Support each other. Love one another. Forgive freely as tempers may flare as an expression of grief. Additionally, the support of friends and extended family members is crucial. The facility to which your parents are moving may offer the services of a counselor who can help you and your family cope with the transition at hand as well.
As with every other difficult life decision, the best thing you can do is get informed and communicate honestly with those involved—be brave, be strong, and be patient. And although the focus here is on giving your parents the best care, make sure you take care of yourself as well during this tough time.
Photos by Nanami7 (Shutterstock), OakleyOriginals, Borya, bowler1996p, Soctech, OTA Photos, David, Bergin, Emmett and Elliott.