The legacy of Charlie and Virginia.

There I was, holding the phone; mouth hanging open, a stifled scream on my lips, and a tear in my eye. I had just been given the news that an elderly man had shot and killed his wife and then himself. This heinous crime was committed by a dear, sweet man I had just met a few days before. He had killed his wife even though he had told me how much he loved her. I had also met the woman he loved and was impressed by the light in her eyes when she spoke of him.

How did this horror happen? In retrospect, there were many contributing factors. I played a part in this tragedy, as did the nursing home staff, the physician, and everyone else who came in contact with this unfortunate family. Allow me to tell you this story from the beginning.

Their daughter told me all about Charlie and Virginia: "He looks like an older version of Errol Flynn and acts like it! He is very debonair and quite the southern gentleman--he'll fit in nicely at this facility. As for Mom, she uses a walker and has some short-term memory loss; she's 79 years old. About a week ago she fell on concrete and bruised her back. The tests revealed no apparent damage, but since then she has become incontinent, maybe from a fear of falling when she tries to go to the bathroom alone. Dad has been helping her, but he is 84 and can't do everything by himself."

After her fall, the family took Virginia to the doctor, who placed her in a rehab unit for physical therapy to increase her mobility and general strengthening. During her stay there, Charlie came to our assisted living facility with his family and picked a lovely double suite for the two of them. The family had convinced him that he and Virginia could no longer live in their house alone. Since we had seen and assessed Charlie as completely independent, I visited the rehab unit to assess Virginia for her appropriateness for assisted living and for the level of care she required. I met Virginia (with family permission), had access to her chart, and was able to discuss her care and treatment with the physical therapist and Social Services caseworker.

Virginia appeared to be a lovely lady, albeit somewhat withdrawn and exhibiting signs of depression. Her physician noted in the record her "worsening dementia." She was on Prozac 20 mg daily without resolution of the overt signs of depression. The therapist noted that she had refused therapy twice and indicated that Virginia could do much more but chose not to. The therapist said that with strong encouragement, Virginia could overcome her mobility problems and become independent in her ambulation once again.

Social Services noted that Virginia had a "low appetite," and the department made the family aware of available alternatives, such as a feeding tube, should Virginia continue to refuse food. The family, though, reacted very emotionally when this subject was discussed. The caseworker, meanwhile, expressed concern about how Virginia's PT refusals might affect her Medicare coverage and was equally concerned about Virginia's "low morale." The caseworker noted that Virginia had to be "strongly encouraged" to do anything. Both the therapist and the caseworker were concerned that, with further treatment refusals, Virginia might have to be discharged from the facility.

It appeared that depression was the underlying cause of Virginia's not eating and lack of motivation for therapy; she had given up on life. Yet there had been no clear discussion with or among staff regarding the need to approach the physician or family with this issue. There had been no discussion regarding possible intervention with a different type of medication or a dosage change for the Prozac.

Because the managers at our assisted living facility believed that the greatest threat to Virginia was her depression, we decided, as a group, that Virginia would not be an appropriate candidate for admission unless her mental state could be significantly improved. We continued to work on a plan that we thought would be suitable for addressing Virginia's mental state and lack of mobility.

We scheduled a conference with the family for the next afternoon to discuss the need to bring Virginia to an optimum level of functioning prior to admission to the facility. The plan would include a recommendation of psychiatric help, as well as continued therapy to increase Virginia's mobility.

The morning before the conference, though, I got a call from Social Services at the rehab unit, who informed me that Virginia had refused therapy again, leaving them with no other option but to discharge her. I told them about the family conference scheduled for that very afternoon and asked them to please delay implementing their decision until afterward. The director of Social Services agreed to wait, and I promised to call her back with the family's decision.

Virginia's care plan called for immediate admission to a geriatric psychiatric treatment center for evaluation and stabilization. After treatment, Virginia would require transfer to another facility for continued physical rehabilitation, and we suggested and made arrangements for admission to a rehab unit after her mental status was stabilized. If the plan worked well, we were confident that Virginia would be able to live with her husband Charlie in the double suite the family had previously chosen in our facility. The entire plan, however, was contingent upon stabilizing Virginia's mental health status as a priority, even before attempting to manage and resolve her physical limitations.

I called the family to make sure they would all be present at the case conference. But I was told that "all hell had broken loose." There had been an apparent breakdown in communications at the rehab unit, where the caseworker had told the family early that morning that Virginia was being transferred to private-pay effective immediately because of her refusal of therapy for the third time. The family was furious at the manner in which this was handled and decided to pull Virginia out of rehab and take her home.

Time had become critical, and a plan had to be put in place immediately to ensure a successful outcome. Over the phone, I explained the suggested plan to the family. I told them in frank detail what I thought was going on with Virginia. I indicated that specialized intervention from the psychiatric center could be an enormous help to Virginia and to them. I went on to tell them about the follow-up rehab program that would be undertaken once Virginia's mental status had been stabilized. When these courses of treatment were completed, I told them, Virginia and Charlie would have the opportunity to live happily and productively at our assisted living facility.

I gave the family the telephone numbers for the psychiatric unit, which was awaiting their call; the rehab unit had already agreed to accept Virginia once she was discharged from the psychiatric center. The family agreed with my assessment of Virginia's state of mind and plan for improvement, and we ended the call.

When I phoned the family the next day to reinforce the plan prior to their putting it in action that weekend, I got no answer but left a message. Fridays are always busy, I reasoned, and I didn't call them back later in the day, nor did they return my call.

On Monday morning, I called the family to find out if everything had gone according to plan. Receiving no answer again at the family home, I called Charlie and Virginia's residence. The person who answered the phone sounded strange; it was not a voice I recognized. I told the person who I was and asked to speak to the son or daughter. The daughter came on the phone and told me that early that morning Charlie had shot and killed Virginia and then himself.

After my initial shock, I began frantically questioning myself. What had happened after my last conversation with the family three days earlier? Perhaps, I thought, they couldn't deal with the cumbersome details of arranging an admission to a specialized facility. Perhaps the family thought they could deal with Charlie and Virginia alone. Perhaps Charlie and Virginia insisted on staying at home. Perhaps, perhaps, perhaps ... a thousand things could have happened. Could haves, should haves, maybes, mights.... No amount of speculation could or ever will change the terrible facts of this case.

One thing I do know: The system failed. The system failed to recognize and adequately deal with Virginia's signs and symptoms of depression. The system that was built to help senior citizens cope with the countless horrors of getting too old too quickly failed to adequately meet the needs of this loving couple. The system failed a family that needed help, failed a couple that needed help, failed a woman who was desperate for help, and ultimately failed the man who loved her.

I know that Charlie and Virginia chose to take their lives, even though their family was supportive and wanted the very best for them. I also know that these two people who loved each other were placed in a position of making a decision neither of them should have had to make. If I surmise correctly that the family had difficulty convincing Charlie and Virginia to go along with the plan, I'd say this: Yes, it is hard to get tough with the people we love. Yes, it is hard to go against the parents who have always taken care of us. Yes, it is hard to make people do something they don't want to do. And it is especially hard to know when to step in to make decisions over our parents' objections. But, in the end, it is hardest of all to suffer the consequences of acquiescence.

I believe the legacy of Charlie and Virginia will be remembered forever--that their legacy will become the foundation for a new determination within all healthcare workers to recognize and appropriately treat depression and related disorders in the elderly. I also hope that a part of this legacy will be for healthcare workers to look at the person before them and to do everything in their power to help them, and I mean help in the fullest sense--providing not just what the situation requires, but what the person needs.

I hope that Charlie and Virginia's legacy will help adult children of aged parents to understand that tough love is better than allowing parents to make decisions that are clearly not in their best interest. I hope their legacy will allow children to throw away guilt and replace it with action based on understanding. And I hope Charlie and Virginia's legacy will contribute new hope to all people facing the prospect of entering an assisted living facility--the hope that what needs to be done will be done to give them their best chance at continuing to enjoy life.

The story of Charlie and Virginia needn't be only a tragedy. It can be a new beginning.

BY ELAINE R. DAVIS, CPHQ 

Elaine R. Davis, CPHQ, is marketing director at Great Oaks, an assisted living community in Monroe, Georgia. For further information, phone [phone] or visit www.greatoaks.net. To comment on this article, please send e-mail to [e-mail].