Frequently I talk to family members faced with making one of the most consequential decisions of their lives – whether or not to place a loved one (usually a parent) in a nursing facility.

Here are some typical comments:

“There is no way that we can care for him at home any longer. It’s just too taxing. We’ve been doing it for a month.”

“We all want her to be home so much, but we just can’t provide the care she needs.”

“We know we can’t continue this (we have our own families at home).”

“Do we jeopardize our father’s health and well-being also (by keeping mother at home) and quite possibly end up dealing with two parents in declining health?”

Before responding, a little history of the modern phenomenon of nursing homes is in order. Although “alms houses” or “poor houses” have always existed for those who were poverty-stricken and alone in the world, it was the assertion of Supreme Court Justice Benjamin Cardozo in writing the majority opinion on the constitutionality of the Social Security Act (1935) that, “The hope behind this statute is to save men and women from the rigors of the poorhouse as well as the haunting fear that such a lot awaits them when the journey’s end is near.” After the passage of the act poorhouses were eradicated, but the nursing-home industry grew dramatically.

Until the Social Security Act was passed, elderly folk who had family were almost always cared for at home. The Medical Facilities Survey and Construction Act of 1954 included legislation that granted federal support for residents of both public and private nursing homes. Between 1960 and 1976, the growth was impressive: there was a 140 percent increase in the number of nursing homes; nursing-home beds increased by over 300 percent; and the profits increased by a whopping 2,000 percent. The passage of Medicare and Medicaid in 1965 proved to be an incentive for the expansion of commercially run homes. By 1979, almost 80 percent of elderly persons who were institutionalized resided in for-profit facilities. According to research from Kalorama Information, the long term care market’s value in the United States was $186 billion in 2005; grew to $258 billion in 2010; and is projected to continue growing at least six percent annually, reaching revenues of $353.5 billion in 2015. Undoubtedly, nursing homes are big business. Yet, today, only two percent of people between the ages of 65 and 75 reside in long-term care facilities. For those over eighty-five, the percentage increases to twenty-five.

Now, back to the readers’ comments. Tough decisions. Who makes the sacrifice? The real clear answer is that the members of each family have to make the choice that is right for them. Every family’s circumstances are different. While the majority of families are choosing home care over facility care, there are consequences – physical, emotional and financial – for either choice. My best advice was first offered two thousand years ago by Someone who described himself as “gentle and humble of heart,” traits to which we should all aspire. His counsel: “Do unto others as you would have them do unto you.”

Statistical facts, unless otherwise noted, provided by FATE (Foundation Aiding the Elderly.)