The question of safety is a critical one with respect to caregiver stress, the ability of families to leave the person they care for on their own, and the decision to seek some form of 24 hour supervision (live-in help, a move to assisted living, or to a nursing home). These are agonizing decisions for all concerned.
One of the things that makes decisions like this so difficult is that people commonly disagree on how much risk they can tolerate. In my experience, many patients with dementia would gladly tolerate more risk than would the people who care for them. This is a tricky issue, because their decision to tolerate risk might not be fully informed. How we should proceed in cases like this will vary, and is most dependent on the individual circumstances. In general, I find a few questions helpful, and this is how I usually frame it - the case here is Mr. Y, who is widowed and lives in his own home. His caregiver daughter, Ms. Y, is concerned because of a couple of recent instances in which he has made poor judgments, resulting in unsafe actions (for example, he locked himself out of his house in the winter, and walked several blocks to a corner store).
Tell me what is the worst thing that you can imagine happening if you stayed on your own.
Nothing bad will happen. I can look after myself. I've lived there longer than either of you has been alive.
But surely you can think of something bad happening. What about when you locked yourself out?
Who? I never did that.
You did sir, and instead of going to the neighbour's house, you walked to Lee's [the corner store] without your jacket, and with only your slippers on your feet.
You're telling me I streaked then? That must have been a sight. Whaddya think Molly? - your Dad's a streaker now. Thank goodness Mom was alive to see it.
Look we're really not going to get anywhere like this. Are you telling me that you don't remember locking yourself out?
Well you did, and Molly had to come home from work to let you in. She worries about you, and she winds up being responsible. What do you think about that?
It's not very good for her, I guess. I don't want to be like that.
This is a time when people often think about moving from their own home, to a place where someone can keep an eye on them.
It's against this background that people can be made aware of their dilemma, even if they don't remember it. When decisions are obvious like this, it is helpful, but even when patients' preferences clash with each other - the desire to live alone versus the desire to not be a burden - making choices explicit can be helpful for families struggling to decide. Often what happens in the physician's office is not that new information comes up, but that things that have been left unsaid get said.