NURSING HOMES: Everybody's Nightmare
And it's old and old it's sad and old it’s sad. James Joyce, Finnegans Wake
It was horribly swift. The elderly, most of them in their beds, had settied for the night last Monday on the
third floor of a nursing home in Mississauga, a sprawling community on Metropolitan Toronto’s western border. In Room 315, William Johnston, an 85year-old patient confined to a wheelchair, had been secretly smoking even though it was against regulations. Perhaps he fell asleep. No one knows, but at 9:30 a fire started in his room. And then, with incredible speed, it raced from room to room, spreading thick, black, impenetrable smoke which smothered the whole floor and seeped to the floors below.
Dr. H. Beatty Cotnam, Ontario’s chief coroner, estimated that the 21 invalids who died—12 women and nine men ranging in age from 52 to 96—didn’t have a chance. They would have been overcome by smoke within one or two minutes. Most of them were found dead in their beds and only Johnston* suffered burns to his body. Just four people escaped from the third and top floor of the 10-year-old Extendicare Ltd. nursing home. As soon as the blaze
started, smoke detector alarms were set off and specially designed fire doors, required by law in Ontario’s nursing homes, automatically closed.
It was 9:35 when the fire department was called. A woman’s voice told firemen: “Come quick.” Then the line went dead, but after a few seconds she called again. “Come quick, we have a fire,” she said, giving the address. Three minutes later firemen arrived to find elderly men and women at their windows waving sheets, pleading to be saved. Some were taken down on ladders and others were strapped to stretchers and lowered by ropes. Some patients, confused, senile perhaps, smiled throughout the rescue operation. Many cried as they were wrapped in blankets and gathered on the home’s
*Johnston married another resident of the home, Joyce Van Wert, 66, last Dec. 1. Ironically, she was taken to hospital just before the blaze and so survived.
front lawn. Neighbors joined in the rescue. One, John Ward, 17, jumped onto his bicycle and raced to the scene. For three hours he helped to carry the old to safety. “People were crying out everywhere ‘Nurse, nurse, please help me,’ ” he said. “The smoke was so thick in some of the rooms that you couldn’t see anything. You just went toward the voice, scooped up the person and brought them out.” In all, 177 patients from the home were rescued. Some went to other nursing homes and 35 who suffered a variety of injuries were taken to hospitals.
The speed of the blaze baffled firemen. District Chief Boyd McKee said “it’s not ordinary” for a fire to generate the heat, smoke and gases that his men found. Two policemen, 10 firemen and dozens of patients were treated for smoke inhalation. On Thursday, a 100year-old patient, Ernest Banks, died in hospital after being taken there following the fire. Two other patients were still in serious condition at week’s end. Although staff at the home was quick to
use fire extinguishers, the only sprinklers in the building were in the basement. In Ontario, they are not required in municipalities with fire departments, yet sprinklers in nursing homes are not a new thought. A coroner’s jury in Toronto recommended in 1977 that sprinklers be installed in the hallways of all nursing homes, but the recommendation was ignored.
The horror of the Mississauga nursing home blaze pointed up for all Canadians the nightmare of caring for the old in an aging society. The issues are many. They relate not only to safety but to care and to society’s attitude toward the old. In 1976, there were more than two million Canadians 65 and over. The trend will continue, and by the year 2001 between 11 per cent and 13 per cent (three to SV2 million) Canadians will be 65 and over. The question is, how will the increasing numbers of old be treated? What proportion of them will end their lives in nursing homes? Who, should run such homes? Should they be run for private profit?
The Extendicare home in which 21 perished has a “very good reputation. They’re a very well-operated chain,” says John Maynard, executive director of the Ontario Nursing Home Association. “If it can happen there, it can happen anywhere.” Extendicare, in fact, has tolled the bell for the old-style fam-
ily-run nursing home establishment. Increasingly—and most observers say it is a good thing—the chains are taking over the care of the old. And in recent years, propped up by generous government subsidies, the chains have been reporting dramatic profits. No one knows the financial possibilities better than Harold Livergant, founder and chairman of Toronto-based Extendicare. A former provincial health bureaucrat, Livergant, 55, has watched his company grow from a tiny one-home
operation in 1968 to the largest health care chain in Canada, an empire comprising 49 homes here and in the United States with assets last year of more than $77 million. Extendicare’s aftertax profit was $3.9 million in 1979, and Livergant predicts a doubling of profits over the next four years.
The nursing home surge has attracted other major investors, including Edward and Peter Bronfman’s Trizec Equities—the nation’s fifth-largest public real estate development company—which operates more than 20 homes across the country. Trizec, with assets of more than $1 billion, recently tried unsuccessfully to take over
Extendicare. Another chain is Calgarybased Villacentres which, from its nursing home profits, has gained ownership of three major hotels, a shopping centre development and oil and gas leases.
The boom in nursing home chains developed in the early 1970s when governments, faced with increased demands from the old for services, moved into subsidizing health costs in a major way. They were a break for the elderly and a gift for the chains. Extendicare, for example, reported losses in 1970 and 1971, but by 1973 (Ontario’s subsidy program was announced the year before) profits were more than $900,000, and they have been rising ever since. “It’s impossible for a nursing home chain to lose money,” says Randy Sykes, a senior re-
searcher for the Canadian Union of Public Employees (see box). “The rates are set to guarantee them a profit.” The owner of a Winnipeg nursing home would agree. He was quoted last April as saying: “Since the government took over financing, this place is a gold mine.”
The Big Mac assembly-line approach on aging might be an answer, but perhaps not always. In Saskatchewan, for example, there is a shifting away from institutions to a program that allows the old to stay at home. While it may not be a unique program, it is a scheme that offers four basic support services-
nursing, “meals on wheels,” homemaking and home maintenance. Maura Gillis, the acting director of the senior citizens’ division with the department of social services, says other provinces have agencies that deliver similar programs, but no other has as comprehensive a program as the one in her province. Harry Mullens, executive director of the Provincial Senior Citizen’s Council, claims that safety within the nursing homes is not a problem; rather, the challenge is to find more imaginative designs and to improve lifestyles for the residents. The last death in a Saskatchewan special-care home because of fire was last October, when a man died in his wheelchair from cigarette smoking. “We were fortunate to have a sprinkling system because it came on immediately and soaked the room and prevented the fire from spreading,” said Elsie Yanko, administrator at Pioneer Village in Regina, where the incident occurred.
Bob Gawley, deputy provincial fire commissioner, says Saskatchewan has stringent fire regulations for nursing homes and he doubts that one person a year would die because of a fire in one of them. Regulations call for any specialcare home taller than one storey to be constructed of fire-resistant material, thus eliminating wood frame buildings. Further, the Fire Prevention Act stipulates that homes of more than one storey must have sprinkler systems. The law, which was passed in 1974, is not retroactive, but the department of social services has offered to pay for 90 per cent of the cost of installing sprinkler systems in homes that are not fitted with them. Gawley says only four homes have not taken advantage of the program.
The real hardship faced by nursing home residents, Mullens says, is the financial burden. Even in the province that pioneered Canadian socialized medicine, nursing care does not come cheap. Although the government eliminated a number of years ago the annual medicare premium paid by families, it hasn’t done the same for the old. There is no provincial subsidy for Level 1 care, the cheapest, which costs an average of $386 a month. Level 2 pensioners receive $167 a month, but pay a monthly average across the province of $618. The Level 3 subsidy is $497, but the average per month cost is $1,116.
A major problem across Canada is that there is no real co-ordination in standards and inspections. And that is only with licensed homes for the old. The philosophy, however, is simple: no news is good news. In Alberta, for example, about one-half of the province’s 77 nursing homes are publicly operated. Says Gary Chatfield, deputy hospitals minister: “There are no more than a
very few that my staff has any concerns about.” Of 7,025 beds in nursing homes, only one-third are privately owned and the remainder are equally divided between homes operated by community groups and volunteer organizations.
In British Columbia, William Foster, president of the Federated Legislative Council, the umbrella group for the more than 30 B.C. senior citizens’ associations, said he “hasn’t had any complaints in years” about fire hazards in nursing homes. Ontario, like most other provinces, has had a small but persistent fire fatality rate in nursing homes— none as bizarre as the Mississauga fire toll but, nevertheless, a number of potential disasters caused, mainly, by old, inept smokers. Since 1976 there have been 177 fires in Ontario nursing homes, involving 37 deaths and 75 injuries.
It’s a serious problem and one that concerns not only safety, but freedom. Ed Marleau, president of the Canadian Long Term Care Association, puts it this way: “We can make institutions 103 per cent safe if we put residents in a stainless steel container, but the main thing is to give residents the independence and dignity of individuals—to allow them to help themselves. Do you
stop them from smoking, something that gives them a real pleasure, and has all their life? Do you restrict their smoking when you know they like to smoke and like to get away with it when they’re not supposed to?”
A more severe problem exists for the old who live in unlicensed, private boarding homes. These are the poor who, unlike the well-off old who live in a medical hotel-like environment, find themselves, perhaps unknowingly, at the mercy of incompetents and charlatans. A study in Metro Toronto last year showed that the old, in many cases, are living in what might as well be 19thcentury poorhouses. They are overcrowded and under-supervised, and residents are improperly medicated. Such conditions have led to the worst disasters—in Quebec (see box) and in Newfoundland, where in 1976 a fire broke out in a two-storey wooden nursing home and 20 patients died. An inquiry
found that the alcoholic husband of the administrator was drunk, there had« been a party, the patients were overmedicated—and that the four in the family who ran the home were the only ones who escaped.
Frightening as it may be, incompetent as are some so-called nursing homes, and competent as are others, the real question concerning the old is care. In some cultures there are no nursing homes. The children care for the old just as the children were cared for. But that doesn’t seem to be a standard in North American society—nor, apparently, in Britain either, according to Birmingham University geriatrics Professor Bernard Issacs. “It seems that many of those who survive into old age enter a phase of pre-death in which
they outlive the vigor of their bodies and the wisdom of their brains,” says Isaacs. “The century that followed Darwin has yielded a new biological phenomenon: the survival of the unfittest.” Perhaps the most telling comment on nursing homes comes from author Daniel Baum in his book Warehouses for Death: “People are there to die. Once they walk through the nursing home door they will not walk out again. They are stripped of their assets, given small personal allowance, promised minimal nursing care, regulated severely in their routine and medicated to institutional compliance. In a very real sense, they are encapsulated and warehoused for death. They are removed from the community, and the community accordingly does not have to see either old age or death.”
On Sept. 15, Dr. Cotnam will open his inquest into the deaths at the Mississauga nursing home. At 63, Ontario’s coroner has won a deserved reputation for toughness and honesty, and for this inquest, perhaps one of the last before he retires, he has made a pledge: “I will probe every facet of nursing home life in Ontario.” Which could bring everybody’s nightmare a little closer to the dawn.
With files from John Masters in Vancouver« Suzanne Zwarun in Calgary« Dale Eisler in Regina« Margot Brewer, Linda McQuaig, Rod Mickleburgh and Matthew Teitelbaum in Toronto« David Folster in Saint John« and Geoff Hunt in St. John’s.