As reported in the July 20 issue of this paper, Eastern Plumas Health Care’s skilled nursing facilities (SNFs) have made a healthy comeback from the dismal scene three years ago when the state was attempting to reduce rates significantly and also take back that amount retroactively. The hospital and the community joined together in a David and Goliath fight against the state and won. The fact that the two SNFs—one in Portola and one in Loyalton—are doing so well, is a testament to both hospital staff and the community at large.

But, what makes these facilities so vital to this small rural community? One answer is these facilities are in a small, rural community. There aren’t any other choices in two counties, save a very small SNF at Seneca Hospital in Chester, at the north end of the county nearly two hours from Portola.

A second reason follows from the first: residents of a small rural community are more likely to have their safety net of friends and family close to home. And, they appreciate the intimate family setting that their local skilled nursing facilities afford.
On the other hand, while we’re lucky to have them, living in one of these facilities is not the future any of us imagines for ourselves. It’s also tied, inevitably, to the difficulty most of us have acknowledging our own, and our loved ones’ deaths. So, many of us and many of our loved ones, don’t do anything until the last minute.

And yet, these end of life choices are some of the most momentous ones we’ll ever face. There is a wealth of current literature for this type of planning as the tidal wave of baby boomers reaches the age where elder care and end of life planning is relevant. Always trendsetters, they are typically more educated, and may just be more aware and better planners when it comes to the end. Time will tell.

One thing is certain–shutting your eyes tight against the vanishing point on the horizon in no way erases that reality or the requisite need for planning. Whether you’re helping your parents, or managing your own affairs, entering this phase with your eyes wide open, creating a plan, and letting others know about it, is vital. Many resources stress the fact that if you plan, even as your abilities shrink, you can have a future that affords you a level of dignity and independence.

In our community, if you or your loved one wants to remain here through the end of life, there’s a fair chance you’ll at least consider the Portola or Loyalton SNF at some point. Here, then, are some thoughts from the inside by the people who know these facilities best. A discussion with the Directors of Nursing at both the Portola and Loyalton skilled nursing facilities reveal some strong parallels and point out some typical pitfalls, stresses, and grief, as well as reason for hope.

Portola SNF
Lorraine Noble, Director of Nursing at the Portola facility, emphasized the guilt that family members are burdened with when they first visit, as well as during the several week “transition period” when the family member is brought into the facility.
Typically, said Noble, it’s daughters bringing in mothers, or husbands bringing in wives with Alzheimers. “They just can’t do it anymore,” she said, “so there’s huge guilt.” There is a very large Alzheimers population in the area, according to Noble. She shows her staff a video that depicts the progression from home care to skilled nursing for Alzheimer’s patients. “It shows staff what these people have gone through—because they’ve gone through a lot.”

The transition is difficult, she said, but after a couple weeks, the staff gets to know residents and what they need. Families are encouraged to visit as often as possible and to engage in daily activities with their resident family member. “I tell them, we don’t sleep. Call us if you’re up at 1:00 a.m. and you’re concerned,” said Noble.

After the first couple of weeks, she holds a care conference, and the interdisciplinary team attends, including doctor, nurses, dietary, and social services. “We go through everything from pain levels to how [the new resident] is getting along with their roommate. We learn a lot about family dynamics,” which according to Noble, can often be important in delivering the best care to the patient.

The SNF, she said, is so important to these families, because “we take the burden off families that have spent many years caring for an elderly parent or spouse. It lets them be the husband, wife, son, or daughter again and spend quality time with their loved one.”

One of the difficulties in an isolated, rural area, is that it lacks the support services available in urban areas. There are no adult daycare centers or residential care centers; when families can no longer care for their loved ones at home, the Portola and Loyalton SNFs are often the only good options. On the positive side, families here participate with residents more than is typical in larger cities. “Quite a few folks come in daily,” said Noble. Also, there are a number of families who “live down below,” but whose parents are in the Graeagle area. These children have visited here for years, and now they’re coming to see their parents in the SNF. It’s a natural, if initially difficult, transition.

She said she has about three families a week visit the Portola facility, “looking into long term care to see what they need to do to get their loved one in, and if it’s the right option.” There are a lot of returns—patients who were here previously for rehabilitation after getting out of the hospital who have declined to the point where they need long term skilled nursing care.
“A lot of the staff here were baby sat by these folks,” said Noble. “So, they’ve come full circle… we are one big family; we share so much together.”

Loyalton SNF
Tomala King, Loyalton SNF’s new Director of Nursing echoed many of Noble’s thoughts, including the difficulty of transition for families and residents and the vital role that the SNF staff plays in bringing a sense of family and much needed support services to all members, not just the resident. But, she also shared some more philosophical observations on elder care and the end of life process, which she witnesses every day.

She began with an example: a patient in her early 50s came in with her caregiver. She has a progressive disease, and her doctors have told her and her husband that it’s time now for long term care. “This one is hard,” said King, “because of their age . . . we needed to give them time to come to terms with it.” King said she called and checked in every few days. She also let the woman pick out her room. “We’ll help her make it as homelike as possible.”

King explained that she not only told the husband that he was free to take her out whenever he wished, but that he was encouraged to join them for their coffee mornings—a new ritual since King arrived at the facility. She said the husband told her he’d walk the dog over in the morning–that the walk would do him good. “We’ll try to make him a part of our family here. They just weren’t expecting this so soon,” said Tomala, adding, “This is a hard job.”

When asked how she, her staff, and patients deal with the future, which necessarily is imbued with the sense of an ending, King said, “I take it day to day.” And, she embellished with another story. A patient of hers who had been a school teacher, now suffered from dementia. One day when King was lifting her out of bed, in a moment of clarity, the woman looked King in the eye and said, “Can you imagine what tomorrow will be?”

“Nothing in school or life really prepares us for these end of life realities,” King observed. “Your perspective is related to character. How you lived your life, how good you were, the things you accomplished,” all add up to how patients feel about their lives near the end, she said. “Patients say things like, ‘I’ve had a good life,’ or ‘I’m tired, it’s my time.’ Others who maybe didn’t have such a good life tend to struggle. It’s taught me to live with no regrets, always do the best I can—that’s how life should be.”

A sadder scenario, she said, is those patients “who sit around depressed and just want to go. Their mind’s ready, but the body isn’t.” King puts her beliefs into motion on a daily basis, encouraging residents, learning about their lives so she and her staff can help them live more comfortably. Things that make residents feel better, more like themselves, such as having their hair and nails done, or putting pictures on the walls that remind them of home, are things staff can do to help them feel good. “Because you’re here doesn’t mean you have to stop living,” said King.

Finally, King mirrored Noble’s emphasis on the vital importance of a caring staff. “Other places might have a big fancy building, but what matters is human experience,” said King. “A place like this can be much more intimate and caring. We are like family here.”