Beyond “DEATH and Dying” – Part 3

Anger

Meet Harry.  Every building has one – the resident who is NEVER HAPPY.  “The oatmeal is lumpy.”  The building’s too cold; you keep the thermostat too low. You people don’t understand or care about the needs of old people!  I never had this problem at home.”

Sound familiar?  It might be Harry, or Mabel, or Mrs. Smith but the common characteristics are that you can’t seem to make them happy and they often lash out at employees and even other residents for no apparent reason.  They may be very vocal in complaining about other resident’s “disabilities” – e.g. he states loudly in the dining room “There are too many #*&^! walkers in this place; they’ve put me in a nursing home with a bunch of old, sick people!”

In “On Death and Dying”,  Dr. Elisabeth Kubler-Ross taught us that ANGER is a normal human reaction as a part of the process of grieving for a loss.  She says: “When the first stage of denial[1] cannot be maintained any longer, it is replaced by feelings of anger, rage, envy, and resentment.”  Many older Americans don’t understand WHY they have suffered this loss – i.e. the death of a spouse, inability to easily accomplish physical tasks that used to be second-nature to them, a reduction in mental capacity and clarity, or even the loss of certain bodily functions such as continence.  These cause a great deal of frustration for the individual who questions what he/she did wrong to now be faced with this loss.  They ask “Why me and not so-and-so?”  As a result, they often express their resentment towards others who are not similarly affected.

Dr. Kubler-Ross points out that anger is often “displaced in all directions … almost at random” and that family and staff members often find it very difficult to cope with.  Even worse, the anger often feeds on itself and leads to an increasingly problematic cycle.  Especially when the resident believes they have been forced to move into the facility, “the visiting family is received with little cheerfulness and anticipation, which makes the encounter a painful event.”  The family members “either respond with grief and tears, guilt or shame, or avoid future visits, which only increases the resident’s[2] discomfort and anger.”  And, of course, that just drops the problem in the lap of the on-site management.

Compounding this situation is the senior’s perceived loss of independence and control, coupled with their fear of the unknown.  They faced many challenges throughout their adult life and generally found a way to overcome or at least handle those concerns.  Now, they are being forced to deal with the effects of aging and their own mortality, while society and even their own family tell them that they need “help”.   So, if they can’t control their own situation today, what chance do they have to control it in the future?

We know that Harry uses a cane but we don’t know why at this point.  It could be arthritis, a joint replacement, effects of a stroke, or general weakness.  However, when he sees the walkers in the dining room, he knows that might be the next step for him.  He doesn’t want to be reminded of that potential or that he doesn’t know how to stop it from happening so he “acts out” his anger.

How Does this Concept Impact Marketing?

Consider the following points:

• Unhappy residents are not long-term residents. They will move themselves out, their family will get tired of the complaints and move them out, or their angst may lead to an earlier death.  Regardless, the community will have to find a new resident to fill the vacancy.
• STUFF HAPPENS in any building.  Most of the time, residents are relatively understanding and management can fix the problems and move on.  However, the “angry resident” stirs the pot with their irrational complaints.  Sooner or later, the rest of the residents begin questioning whether the complainer is “all wrong” and become less tolerant of the management and staff.
• Likewise, family members forget how difficult Harry used to be for them to handle and have a tendency to start blaming the staff for Harry’s attitude.  {They’re wrong of course, but who’s talking rationally?}  This can lead to negative publicity in the general community.
• You obviously don’t want Harry to interact with prospective residents during a tour or marketing event.

We once found a “disgruntled” resident who liked to sit outside the front door of a building that had a very low closing rate.  We then found out that the resident was expressing her anger to everyone that came into the building.

What Can We Do?

First, resist the temptation to take the quick move-in that is driven by the children instead of the potential resident.  You are risking a time-bomb if the prospective resident doesn’t take an active part in the tour, discussions, etc. and at least buys into the decision.   Don’t “gang-up” with the family members to force the prospect to move in before they have completed the psychological grieving process. [3]

As discussed in earlier parts of this series, communication is key.  The more you understand about the types of losses the individual has recently endured (See Part 1 for examples), the better you will be able to help de-fuse the anger.  However, this requires that you take the time and spend the energy to establish a personal relationship with the prospect / resident.

Understand that anger is a normal AND NECESSARY step in the healthy grief process.   Educate your staff to the importance of remaining calm and not allowing the resident to “bait” them into losing their temper.  Kubler-Ross advises: “don’t get into unnecessary arguments” over issues that are “often totally irrelevant.”  Remind the staff that the anger being displayed generally has nothing to do with them!

Avoid the tendency to ignore and further isolate the troublesome resident.  This gives them a legitimate reason for complaining and often leads to further “acting out” with escalating demands and louder and more public complaints.

Give them some attention.  Similar to a misbehaving child, their behavior is a cry for help.  They want to be “unique”, but still loved and accepted.  They need to know that someone knows they are there and cares for them.  At the same time, let them know that they don’t have to raise their voice to get your attention.

One of the secrets to managing grief is to generate HOPE for the future.  Recognizing the natural fears of the senior residents, focus on their CAPABILITIES instead of disabilities.  Encourage them to try new things, make new friends, etc.  The key is to get them to look favorably to the future which will cause the past losses to fade in importance.

PLEASE SHARE YOUR EXPERIENCE(s) WITH ANGRY RESIDENTS BY COMMENTING BELOW. A short background synopsis of the individual would be appreciated.  Indicate how you learned of the underlying losses that were driving their behavior and how you dealt with the situation.

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[1] See “BEYOND DEATH” and Dying – Part 2 for a more detailed discussion of the denial stage.

[2] Changed from the original “patient’s”.

[3] NOTE:  I recognize that different rules apply for admissions to Alzheimer’s / memory care units.

Beyond “DEATH and Dying” – Part 2

Moving Past Denial

One of the common mistakes in grief management is not allowing feelings of DENIAL. This is often demonstrated by relatives attempting to force the individual who has suffered a loss to “face reality” and move on with their life.   Yet, Dr. Elisabeth Kubler-Ross in her renowned book “On Death and Dying” states that initial denial is an important temporary defense and serves “as a buffer after unexpected shocking news”.[1] She  goes on to suggest that this defense mechanism is necessary to allow the individual adequate time to adjust to their loss and notes that it may be combined with a tendency towards isolation – wanting to be “left alone”.  Family and other caregivers should understand that this is part of a healthy grieving process. [2]

This knowledge impacts the senior living industry because move-ins are a PROCESS more than an EVENT.  An individual in denial is unlikely to recognize the value of a move-in at this stage.  At the same time, it would be a mistake to write them off from marketing efforts:

• They became a prospect when they demonstrated interest in the senior living community.  Although you may not know their particular “need”, BUILDING A RELATIONSHIP will move towards an ultimate move-in.
• Most aging adults are constantly dealing with some form of loss.  A move-in will occur when the senior perceives more value in the lifestyle offered by the community than in their existing situation.  This process takes time.
• Previously, it took 8 – 9 prospects per unit to fill an independent living community.  With today’s economy, those numbers have almost doubled to 15+ per unit.
• By maintaining communication and social interaction, management may help the person move beyond the denial stage.  Dr. Kubler-Ross states that people may be selective in choosing which individuals to whom they communicate feelings of denial.  In practice, they may be more open to discussing future plans with the manager/marketer than with their own family members.

The first step in recognizing the denial stage is on-going conversation to learn what losses the senior has experienced (See Part 1 for examples).  This requires an investment of personal time and energy in each relationship – it won’t happen by simply inviting prospects to Special Events and/or calling every 6 months.

The marketing strategy for this stage is DON’T PUSH!  Long term success is more likely by simply “making a friend”, being positive and understanding that it’s part of the process if your overtures are initially rejected.  Be subtle when communicating the benefits of your community.  In time, these may be seen as positive alternatives to the prospect’s current situation and help in their acceptance of their loss – but it can’t be forced!

Liz’s CASE STUDY will help illustrate these points:  She is 85 years old and a widow for 5 years.  She now lives alone with her cat in her home of 20 years.

Liz is in reasonably good health but suffers from arthritis with several knee and shoulder surgeries in the past few years.  She has limited mobility, using a cane for walking any distance.  She continues to drive (around town only) and remains active with her church.

Anne, Liz’s adult daughter, recently stopped by and expressed concern about her mother’s ability to keep up with her house.  Although Liz has a cleaning lady, a lawn service and a handyman when needed, Anne is concerned that the house and yard are more than “Mom” can handle.  Liz has great friends that help out but they are getting older and have their own health issues.  Anne explained that she works and lives out-of-state.  She is finding it increasing difficult to visit and help with things around the house.

Liz has been upset because she wasn’t able to put up her Christmas tree.  Unlike past years, Anne was unable to visit and handle it this year.  So now, Anne has come to you for help – what do you do?

Obviously, the first step is to meet Liz.  Since this is apparently her daughter’s idea, you can expect some resistance.  A traditional way to become acquainted with Liz is by inviting her to a Special Event, but a more intimate approach may be to invite Anne and her mother for a personal visit, including a meal and/or participation in a planned group activity.

The objective of this first meeting should be to initiate a relationship.  During that process, you will identify various walls that Liz has erected as reasons why she can’t move in.  Some of these barriers are a result of the DENIAL of her current situation, while others are related to pre-conceived notions about senior living communities.  These apprehensions may be caused by outdated perceptions of “old-folks” homes or past experience with other levels of care such as nursing homes.

You will need to overcome these barriers, but in the initial stage, it is best to simply educate the prospective resident and her family.  Speak of your efforts to PROMOTE INDEPENDENCE, insure privacy and treat all residents with dignity and respect.  Focus on what the resident “can do” vs the “cannots”.  Utilize the information you’ve gathered to address specifics (e.g. Liz’s pet cat) before they become issues.

Make a follow-up in-home visit with Liz after Anne has departed.  Liz will probably be feeling a little lonely and welcome the visit, which should generate a wealth of information about her current situation.

Finally, here’s a word of caution.  It is very tempting to “gang-up” with Anne and coerce Liz into a premature move-in.  Yes, this might assuage Anne’s guilt feelings, but remember that the customer is Liz – not her daughter.  She won’t become a happy and satisfied resident until she moves past denial.

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[1] “On Death and Dying”, Elisabeth Kubler-Ross, M.D., 1969

[2] NOTE:  An extreme or extended denial phase must be treated by professionals.

Beyond “DEATH and Dying” — Part 1

Managing Grief to Improve Occupancy

Introduction

Forty years ago, Dr. Elisabeth Kubler-Ross wrote “On Death and Dying” and her theories have been used ever since to help caregivers provide support to terminal patients.  BUT, THESE SAME CONCEPTS APPLY TO EVERY ONE OF US EVERY DAY!

Because we work with seniors, dying and the prospect of death are something with which we deal; however this article will    expand Kubler-Ross’ theories into everyday life, dealing with all forms of GRIEF.  By learning her “5 Stages of Grief” and applying them to all aspects of a current or prospective resident’s life, you will be able to build a better relationship with that individual and achieve higher occupancy levels.

Basically, GRIEF MANAGEMENT = Learning to Accept Loss! Kubler-Ross stated that a human will – and must – go through 4 stages of grief before reaching the 5^th stage of ACCEPTANCE, as depicted below:

This diagram shows that the stages are progressive, but that the individual may regress from one stage to another before finally reaching a level of acceptance.  Hope is the one emotion that influences this behavior.

Whenever any of us suffers any type of loss, we grieve and must progress through these stages to cope with the situation and maintain good emotional health.  Here’s an example to demonstrate how these emotions play out in a real-life situation:

You are driving down the highway when you see flashing lights in your rear-view mirror – what’s your first reaction (after quickly checking the speedometer)?  DENIAL – it’s not a policeman and/or he’s not after me – right?

Then, when he pulls in behind you and motions you to move over, don’t you tend to get a little angry?  Don’t you think, “why is he picking on me, there were at least 3 other cars that went speeding past me – why didn’t he catch them instead of me?”

Next comes a little bargaining – and HOPE that maybe you can get off with a warning this time:  “Officer, I didn’t mean to speed, I didn’t see that the speed limit changed, I was just over the speed limit for a little bit there – I don’t normally speed, etc.”  And then there’s the silent prayer – “Dear Lord, I promise I’ll never speed again if you just let me NOT GET A TICKET TODAY!”

But, you get your ticket and notice to pay a fine or appear in court.  Now, you’re embarrassed (after all, you got caught “breaking the law”), and hurt financially (maybe you have to forgo buying something that you wanted).  Every time you look at that notice, you get a little angry again and try to figure out some way to avoid paying the fine.  Then, you just get depressed over the whole episode – LIFE’S NOT FAIR!

Finally, you decide to just pay the fine and get on with your life – you’ve reached ACCEPTANCE.

Of course, the losses faced by seniors are much more serious, but the process is the same.  In building a relationship with that individual, it is important to understand what losses they have endured and their psychological stage in the grieving process related to that loss.  One or more of those “losses” will likely have a direct impact on their decision to move into a senior living community.

Common examples of losses encountered by seniors include:

The death of the spouse or other long-term companion. This is particularly problematic when the death occurs unexpectedly and the surviving spouse has not prepared for the death.  Several classic cases are a) the husband who has always handled all of the finances for the couple passes away, leaving the wife over-whelmed with the details of wrapping up his finances and b) the wife who dies first with the husband unprepared to deal with daily household activities.

Loss of some type of physical ability. The senior may have had a stroke or heart attack resulting in limited mobility.  They could have restrictions in their activities as the result of a fall or surgery.  Or, they may face on-going decline in eyesight or hearing, effects of arthritis, diabetes or other chronic disease.

Some level of diminished mental capacity. This may be as simple as increasing forgetfulness or early stages of Alzheimer’s or other dementia.  Often, this “loss” is noticed and expressed as a concern by family members.

The Spouse or other caregiver experiences a decline in their own health and becomes unable to provide the previous level of support. It’s not uncommon to see a fairly rapid decline in the health and condition of one spouse after the other suffers an acute episode.   In other situations, the single individual may have one or more friends who provide various caregiving services (e.g. take them to doctor visits).  When that friend is unable to continue that service, the senior loses a degree of independence.

Child / grandchild caregiver moved away. Especially in today’s volatile economy, a senior may not be able to count on their adult child remaining in place and able to provide care services for them.

Driving privileges suspended.  This may be a result of doctor’s orders due to physical or mental capacity, family members’ “taking away the keys”, or state licensing restrictions.

If the individual suffering one or more of these losses is already a resident in your senior living community, you can enrich their experience by understanding the impact of the loss on their life and independence.  By providing HOPE and demonstrating alternatives, you will be able to retain the resident and delay or prevent their “discharge” to a higher level of care!

For the prospective resident, the KEY is to build an effective relationship that will lead to a move-in.  Learn the type of losses the senior has endured and then understand their stage of grief.  The right marketing approach must then be customized for that loss and stage of grief!

Part 2 of this series will discuss the Denial Stage and what you should do to effectively market individuals in that phase.

You may also want to view the PowerPoint Presentation on SlideShare.