To serve as a caregiver for a family member is, for many, an important chance to give back. Yet whether caregiving is offered out of love or obligation, it tends to take its toll. Over the years, I have seen many patients who themselves had not had health care for years because they had been intensively focused on caring for someone else. Caregivers often decide to stick it out until the person they care for has passed. When they finally come to the clinic, they are often exhausted, depressed and physically ill.

Younger caregivers may miss out on education and professional opportunities while older caregivers may be more physically vulnerable. Studies have shown that the greatest challenge can be when the infirm have mental health issues including dementia. The quality of the relationship between the caregiver and the infirm largely determines the degree of burden felt.

Before the instruments of insurance and credit became the norm, families tended to be bigger and one of the siblings was often expected to care for mom and dad when they could no longer care for themselves. This began to change, especially in mainland China, when the population started to have access to credit. If people are financially leveraged, it is much more difficult to opt out of the working world when the health of a family member takes a turn.

For a minority of the population, long-term care insurance helps take up the slack. But for most, even those with general health insurance, LTC is not even on their radar. I recall as a resident treating a well-off gentleman who got into a bad motorcycle accident on Hawaii island. He required multiple orthopedic and brain surgeries. In the end, he could walk and talk but not well enough to work or to be at home alone. His spouse, also a well-educated and successful professional, wrote to family, close friends and providers after he was discharged from rehab. "We thought we were covered when it came to insurance," she said, "but we didn’t even think about long-term care." It drained their savings.

LTC insurance often winds up on the bottom of the list compared to health insurance, life insurance, car insurance, mortgage insurance and other products that cover property, liability and business interruption. For many, LTC insurance also appears to be among the most expensive for what it covers and one never knows if it will be needed at all. To be sure, in the case of a hasty death, it is of no use.

For those without LTC insurance, government payers will offer some benefits, but the patient’s income and asset level must be very low to qualify. Those without LTC who end up with chronic disease often go through gymnastics to transfer assets to their children so that, after a waiting period, they can qualify for government-covered care.

Even when LTC policies are engaged, the logistics still can be problematic. My own father recently passed away from Parkinson’s disease. He had a generous LTC policy in regards to total dollars available, but the maximum monthly benefit did not cover the expenses of a caregiver in the home. Even though he tapped into the LTC policy over a two-year period, he was only able to utilize one-third of the available benefit because of the daily and monthly benefit restriction.

Those without willing family members or available financial resources may resort to paying an individual who is not trained, vetted or qualified. Although some get lucky, there is no end to the horror stories from theft to abuse when casual help is involved.

To the extent possible, it is essential to prepare for the potential need for long-term care. This is not a covered benefit of general health insurance. Neither long-term care insurance nor financial resources alone assures an optimally supportive and nurturing care environment. The decision to employ a less expensive, untrained provider is risky. Whether by plan or by default, if the caregiver is a family member, especially when the long-term infirmity involves mental health, it is essential to be sensitive to the emotional and physical burden placed upon the caregiver. Even when intensively focused on caregiving, maintaining one’s own health through balance is indispensable.

Ira “Kawika” Zunin, MD, MPH, MBA, is a practicing physician. He is medical director of Manakai O Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.