Most older people, when in failing health, strongly prefer to stay in their own homes. Few can do it without assistance.

Claudia Weston is a composite portrait of the legions of women (almost all paid homecare workers are women) who provide the quotidian but absolutely essential care to these elderly clients.

She works for a public program serving low income clients that, based on a care plan, determines the number of hours of service that each client will receive. Her salary is low and she is not reimbursed for her transportation time. She is not permitted to take tips or even small gifts from her clients. Claudia is a good caregiver; she is attentive to her clients, tries to understand what their unusual actions might mean, and seeks to respond within the constraints of other demands. She listens and communicates effectively. Like many caregivers, she is a single mother whose caregiving does not end when she walks away from her last client of the day.

By 7 a.m., Claudia Weston had showered, dressed, packed four lunches, gotten her children dressed for school, assigned their after school chores, and checked in with her mother, who was becoming more and more confused and forgetful. Her mother's condition, and her son Jimmy's recurrent asthma worried her a great deal especially since she couldn't afford to take time off. Days without work mean days without pay.

She loaded her already weary body into her 1987 Nova along with her lunch, a change of clothing, and a small picture her son Jimmy had made for one client. The gas gauge was close to empty, but if she was lucky she'd make it through the day. If not, she'd get a gallon of gas; she didn't have the money for more if she was to get some food for dinner. Money troubles were not new. Somehow she always managed.

Negotiating the Bath
By 7:30, she parked in front of Mrs. Carmichael's run-down bungalow on Chicago's South Side. She'd been a good client, generally grateful for any help—except on the days that she got her bath. She hated it, resisting Claudia, screaming in rage, and insisting that she's clean enough. Today was bath day. The women greeted each other warmly; Claudia asked how she had slept because Mrs. Carmichael's arthritis was so severe that she usually tossed and turned all night trying to get comfortable.

But it was soon obvious that things were changing. Mrs. Carmichael accused Claudia of stealing food from her freezer, and she griped about the neighbors who wanted her house. Her memory loss, some confusion, and growing paranoia were threatening the easy relationship that the two women had developed. Claudia saw what was happening and so she sat quietly with her for a few minutes sharing some stories of the past few days. But she knew she only had two hours this morning and there was much to do.

She very gently told Mrs. Carmichael that it was time for a bath and a good rub-down. She reminded her how much she liked the oil on her dry skin and the feel of clean, fresh clothes (Mrs. Carmichael was either occasionally incontinent or found it too much of an effort to struggle to the bathroom at night, so her stench was pretty penetrating). Claudia could guess why Mrs. Carmichael hated bath day so much. She went into the bathroom and returned, assuring Mrs. Carmichael that no stranger was there and that the windows were tightly closed. She also covered the mirror in case Mrs. Carmichael no longer recognized herself and thought the image in the mirror was a stranger.

Claudia promised Mrs. Carmichael that she could undress herself, although Claudia would be standing by to help if needed. She also promised her that she would be able to stay covered for much of the bath. These caring practices worked, and Mrs. Carmichael finally agreed to be led to the bathroom. Claudia did exactly as she promised. Mrs. Carmichael even put her fingers in the water before getting in to make sure the water wouldn't burn. Claudia completed the bath with minimal dousing to herself and a fairly calm Mrs. Carmichael. One more bath done.

Time Squeeze
She changed the sheets, threw the soiled ones into the washing machine, and prepared lunch. But the bath took far longer than usual, and time was running out. Claudia had to be at her next client's house—at least a thirty minute drive—in an hour. And this client, Mr. Frank, was demanding, especially about punctuality. A former military man, he timed just about every move that Claudia made, making her feel very nervous so that no matter what she was doing, it was not good enough.

She rushed through all her other tasks at Mrs. Carmichael's, leaving her lunch on the table but not sitting down with her as she often did. Mrs. Carmichael, who had no family and received few visitors, counted on those few minutes of shared time. Claudia was like family to her. As Claudia was preparing to leave, having explained to Mrs. Carmichael that Mr. Frank demanded punctuality, Mrs. Carmichael began to sulk, insisting that he could wait and that he was probably too "senile" to know the time anyway. Claudia insisted that she had to leave, as she now had less than ten minutes to get to Mr. Frank's house. She gave Mrs. Carmichael the small picture that her son Jimmy had made but left her unhappy and angry. She wondered if she might have to stop by before she went home for the evening. Though this was against her agency's rules, she couldn't help worrying about Mrs. Carmichael.

She arrived at Mr. Frank's house fifteen minutes late. Even Claudia couldn't control the traffic on the freeway. She parked and rushed in to find him standing at the door glaring at his watch. Mr. Frank, a recent widower after sixty-two years of marriage, was accustomed to having his wife take care of all the details of his life—cooking his meals, cleaning up after him, and lately, supporting his failing ego and physical strength. He suffered from congestive heart failure and diabetes that was controllable by diet. But he could do little without becoming completely exhausted, a state that frustrated and angered him. His expectations and demands seemed to accelerate as a result. As soon as Claudia arrived, he reprimanded her for tardiness and barked orders at her—clean the living room; change my bed; get some food prepared to put in the freezer; make me my lunch; get my dog bathed and fed. And so it went.

Claudia knew that lunch had to come first since he needed to eat regularly and his special diet took time to prepare. While doing this, she opened her own lunch bag and started nibbling on her sandwich; breakfast had been many hours ago. Mr. Frank walked into the kitchen, yelled at her for eating on "his time" and demanded that she feed and bathe the dog (not exactly a part of the care plan). Claudia refused, and a battle of words set in. While he was no longer strong enough to overpower her physically, she feared his anger and potential aggressiveness. He did try to grab the knife out of her hand, almost cutting her finger.

Pulling Rank
Back she went to preparing his lunch, trying as best as she could to ignore his demands. But when she put his lunch out, he complained that it was not as tasty as his late wife, Clara's cooking. She told him to eat his lunch or she would have to report it to her supervisor, who would undoubtedly call his doctor. That threat did it. For the military man in him acknowledged rank and he knew, despite his bravado, that he had little power left.

Claudia had discussed Mr. Frank with her supervisor. Suspecting that his physical limitations made him feel both powerless and unworthy, they thought of ways to help restore some sense of self-worth. So that day, Claudia told him about her son Samuel who couldn't seem to complete any projects, tasks, or anything else on time. She asked if he would help Samuel develop ways to become better organized. Maybe he could jot down some ideas before she left that day and they could talk about how they worked next time.

It seemed to work for the moment. He sat down, ate his lunch, and asked her questions. He wrote while she completed her chores (she did not bathe the dog although she did put out a plate of food). As she was getting ready to leave Mr. Frank gave her the list and a checklist to mark accomplishments. She thanked him and promised to report what happened on her next visit.

The Dreaded 'To Do' List
She headed back to her car. The temperature was probably well over ninety; she hadn't finished her lunch, and it looked like she would have to get that gallon of gas. She knew that Mrs. Kramer, her next client, would be tough. Her house was hot and she insisted on keeping the windows shut against "drafts." She hated having her nails clipped—one task for that day—and she never remembered when Claudia had last been there. Claudia also expected a long list of "to dos" from Mrs. Kramer's daughter who seemed to visit only to post her lists.

Arriving at Mrs. Kramer's, she found exactly what she had anticipated. Mrs. Kramer accused her of not coming all week, then she started to cry that no one ever came to visit her and she begged Claudia to stay with her because she was so afraid of being alone.

Claudia was distraught. The house was so hot she could hardly breathe; by now she wanted to be done and out. Rapidly advancing dementia was the last thing she wanted to face. She forced herself to remember that Mrs. Kramer was lonely, scared, and not responsible for her condition. But she also knew that she was close to her limit. She chose her tasks carefully. Knowing that a full bath would be out of the question, she filled a pan of warm water and gently washed the exposed parts of Mrs. Kramer's body even though it would mean tackling the daughter's angry recriminations later that night.

Since the sponge bath worked so well, Claudia told Mrs. Kramer that it was time for her manicure and a pedicure; she soaked Mrs. Kramer's toenails and fingernails so that cutting would be easier. Mrs. Kramer actually seemed soothed by the warm water and the gentle massaging. Maybe Claudia had touched upon something that mattered to Mrs. Kramer but she didn't have time to do any more fussing that day because she had to get the laundry done and prepare the evening meal.

Quick Thinking
As soon as she started walking out of the room, Mrs. Kramer began to whimper. Claudia took Mrs. Kramer's hand and led her to a chair in the kitchen but that made her agitated again. She jumped up and tried to wrest the paring knife from Claudia. Claudia had to think fast. She gave Mrs. Kramer a potato and a very dull potato peeler and recruited her help in preparing dinner. That worked for five minutes and so the afternoon went.

Finally Claudia left Mrs. Kramer knowing that she had completed few of the tasks on her list but feeling that at least they had some good moments and that she had also honored her own needs. It was nearly 6 p.m. and she still had to stop at the grocery, go home, prepare dinner for the children, and probably call Mrs. Carmichael, if not stop by.

She also knew that she would have to bring food over to her mother's house or she wouldn't eat anything at all. Fortunately, Claudia lived nearby. She only hoped that her mother had not fallen or got into any other trouble during the day. She still dreaded the call she expected from Mrs. Kramer's daughter. She got home exhausted and was surprised when she found her lunch still partly uneaten in the bag. Her pay for that day would be about $40.