pacify or orientate? Alzheimers... - page 7

So I have worked my third day as a LVN in a LTC facility. Orientated for one day then turned loose...on the alzheimers lock down unit. 21 residents. A little scary, but I am fairly comfortable, so... Read More

  1. by   supernurse65
    Quote from Jesskanurse
    "Therapeutic lying" is absolutely inappropriate. It is unethical and in my opinion, it implies pure laziness on the Nurse's part. Telling the patient what you think 'they want to hear' does nothing for them therapeutically.
    It's sad that so many Nurses just take the easy way out by 'pacifying' these people.

    "Think of a time you've been lied to. Say your 12year old son said he would be at his friend's house but in reality he went to park to skate with a bunch of kids you don't know. You most likely would be upset that your son lied. If you had dementia, however, you may never remember your son saying where he'd be. He gets home and says, "I had a great time at the park." Whether or not you remember does not change the fact that he lied. It is no different when speaking to a client (patient). They may not remember their daughter isn't coming to get them, but it doesn't change that you lied to them."

    Continue to re-orient your client. Why? It's respectful, it helps combat dementia, and redirecting can help rebuild short term memory.


    P.S. The correct term is 'orient,' NOT 'orientate.'

    Maybe you should try working with alzheimer's patients or read a book about it. This is absolutely appropriate.
  2. by   supernurse65
    Quote from Nascar nurse
    No experience working with dementia/alzheimers patients huh? Been doing this over 20 years. The staff the insist on reality orientation gets cussed, hit, bit, spit at, etc and the resident can become agitated beyond belief. The staff the goes w/ the therapuetic lying ends up with calm happy residents. Lazy?? Takes alot more energy to be running around a building pretending to milk cows then just say "There are no cows out there" and walk away.

    :yeahthat: :yeahthat:
  3. by   Multicollinearity
    How we make children feel safe comes to mind. We don't always answer their questions truthfully. We answer what they can handle as age appropriate. I think our approach would be similar with those in the stages of moderate to severe dementia. The aim is the same with a small child. Keep them feeling safe. Keep them feeling secure. Both little children and moderate/severe dementia patients lack the mental capacity to handle (and/or remember) all of the truth. Comfort is the goal.

    Someday when I'm a little old lady - if I have dementia...I hope my nurses will shield me from the truth. Because I would just want comfort and I'd lack the mental capacity to fully understand and remember. But what do I know. I'm just a pre-BSN student. I do know that if my grandmother's nurse had attempted to orient her to reality every time she had asked for her sister or husband (both deceased) it would have been an agonizing scene. You wouldn't tell a 4 year old on September 11, 2001 that we don't know what is going on and that terrorists are trying to kill us. You would tell that 4 year old that she is safe and mommy will take care of her. I see the same treatment intent and goal with the dementia patients.

    Only one who lacks an understanding of what dementia is - would say orienting is the goal. It isn't possible in the later stages.
    Last edit by Multicollinearity on Aug 31, '06
  4. by   indigo girl
    Quote from multicollinarity
    How we make children feel safe comes to mind. We don't always answer their questions truthfully. We answer what they can handle as age appropriate. I think our approach would be similar with those in the stages of moderate to severe dementia. The aim is the same with a small child. Keep them feeling safe. Keep them feeling secure. Both little children and moderate/severe dementia patients lack the mental capacity to handle (and/or remember) all of the truth. Comfort is the goal.

    Someday when I'm a little old lady - if I have dementia...I hope my nurses will shield me from the truth. Because I would just want comfort and I'd lack the mental capacity to fully understand and remember. But what do I know. I'm just a pre-BSN student. I do know that if my grandmother's nurse had attempted to orient her to reality every time she had asked for her sister or husband (both deceased) it would have been an agonizing scene. You wouldn't tell a 4 year old on September 11, 2001 that we don't know what is going on and that terrorists are trying to kill us. You would tell that 4 year old that she is safe and mommy will take care of her. I see the same treatment intent and goal with the dementia patients.

    Only one who lacks an understanding of what dementia is - would say orienting is the goal. It isn't possible in the later stages.
    You show good sense and compassion. Your future patients will be blessed to have you as a nurse.

    indigo
  5. by   Multicollinearity
    Actually, as I think about it, I'm sure that there are certain treatment techniques that academics would be loathe to put in print even though they know sometimes it must be done. This is where experience comes in. I'm sure 'therapeutic lying' is one of them.

    I do know that my BSN program cannot possibly teach me everything I need to know. It will only provide a foundation. I imagine you learn the basics, and hone the critical thinking skills necessary to keep on learning for the rest of your career. I like the phrase "license to learn" that I have heard here. I'd listen to those who have decades of actual experience, add that to my college education, and come to a common sense conclusion. Oh, and once in a blue-moon academia is wrong.
  6. by   Multicollinearity
    Quote from indigo girl
    You show good sense and compassion. Your future patients will be blessed to have you as a nurse.

    indigo
    :icon_hug:
  7. by   OneChattyNurse
    Quote from jesskanurse
    yes, it may be unethical in your opinion to tell her that... but any ethics board would tell you that you are wrong. as for your last sentence: how do you know what will damage your resident and what wont?? you dont. you are just using your own feelings and displacing them on the patient. you think it will damage her. who are you to decide this? that is why it is unethical. what if there is a stage of the grieving process that she hasn't gotten through just because nurses are uncomfortable seeing her in anguish? i think that is what is happening. you cant have peachy happy patients all the time. sometimes that anguish is therapeutic for them.

    [font="comic sans ms"]reminding a dementia patient that her husband is dead several times a day and watching her horror and shock (because to her this is the first time she has heard it) is not only wrong, it is mean, cruel and inhumane.

    we had a husband and wife that shared a room they had been married for over 60 years. the first few times she asked about him she was reminded that he had passed away. if you could have seen the absolute horror in this womans face each time she was told this you would realize what everyone is trying to tell you. she was never going to get through the grieving process because she could not remember long enough to get through the denial and shock let alone the rest of the steps. from that point on i instructed my staff to not tell her again that her husband had died. in their younger years her husband was an avid fisherman. from then on we reminded her that he was "up north on a fishing trip" never again did she have to grieve for him.

    treating a patient/resident with respect is about more that being truthful. it is about treating them in a kind, compassionate, humane manner.
  8. by   rn/writer
    Quote from Jesskanurse
    Yes, It may be unethical in YOUR OPINION to tell her that... but any ethics board would tell you that you are wrong. As for your last sentence: How do you know what will damage your resident and what wont?? You dont. You are just using your own feelings and displacing them on the patient. You think it will damage her. Who are you to decide this? THAT is why it is unethical. What if there is a stage of the grieving process that she hasn't gotten through just because nurses are uncomfortable seeing her in anguish? I think that is what is happening. You cant have peachy happy patients all the time. Sometimes that anguish is therapeutic for them.
    please keep in mind, that much of the grief work has already been done by the pt.
    There is a difference between grief--pain that serves a purpose--and suffering that accomplishes nothing EXCEPT the infliction of pain. Even if a resident was able to "work through" something from her past, the Magic Slate would lift in short order and the hard-earned results would disappear. Each fresh encounter with a painful reality is like experiencing it again for the first time with all the resulting anguish and confusion. Why would we put a resident through something so traumatic when there is nothing good to be gained from it?

    We re-orient people for the same purpose that we put some bed-ridden patients through physical therapy--TO PRESERVE A FUNCTIONAL STATE FOR THEM TO RETURN TO. Dementia patients serious enough to warrant LTC aren't coming back. Continual re-orienting of these patients, especially if it renders them emotionally upset and frustrated, is akin to performing PT on someone with end-stage cancer. It causes pain for no good reason in the name of accomplishing a task (preserving function) that is no longer a reasonable expectation.

    I've read about alternative treatments--validating and such--and, excuse my negativity, but they come across as coldly professional and sterile, more about protecting the practitioner than meeting the resident's needs. I do think we need to be careful to let the patient tell us where she is and not initiate any delusional conversation. (I really liked one poster's suggestion to ask the resident how old she is.) But, as another poster mentioned, the "lying" aspect of this can be tempered with the compassion we show young children whose minds are not capable of processing certain types of information without causing them great disturbance.

    Jesskanurse, advanced dementia patients can't stay very long in our reality, but we can join them for brief moments of connection in theirs. If your conscience will not allow you to do that, this is probably a population you should not work with.

    I'm sorry people have been so hard on you. I think you mean well. But this is one of those areas where so much devastation has already taken place that it seems any small kindness that can be offered ought to overrule the technically correct "solution."
    Last edit by rn/writer on Aug 31, '06
  9. by   RebeccaJeanRN
    Quote from sanctuary
    When we concentrated on the patient, and their level of comfort, and made it the primary goal, we worked (sometimes with other family members) to find the path of most comfort. Women looking for children were asked where they went when they tried to get out of chores...Then we used the story from the patient's life. Husbands were frequently "helping a neighbor." Wives were "putting up food." There was an immediate improvement in the energy level on the units. Staff stopped getting screamed at, or slapped, and patients could join in activities if the demons were temporarily at rest.
    Sanctuary- I liked your phrase about putting 'the demons temporarily at rest'...good analogy between these patients' distressing and compelling thoughts, which are not even related to the present time and environment, and 'demons' . These patients are haunted by worries that prevent their enjoyment of the present (a movie, a meal, visitors, etc.). Helping to push away these imaginary worries for a while, so they can be mentally at peace enough to take enjoyment in something could only be considered a kindness. I doubt that making the attempt to re-orient them to hard facts, like the fact that the patient's husband has been dead a while, serves that same purpose. A poster above mentioned that anguish may actually be therapeutic and that we are not to decide what truths our patients can handle (I'm paraphrasing here), and that our obligation is to provide real information. Well that may be what the Ethics boards still say, but I say this: Unlike mental illness, where re-orienting a patient may help them to live in the real world, Alzheimers is progressive and unrelenting and nobody with an advanced case currently has the hope of being cured or helped to live independently again. When we insist on re-delivering a painful truth to a person who's brain neurons are being affected by Alzheimers, we simply doom them to suffer the same anguish over and over and over again because that is the nature of the illness. Will any nurse out there, who is working with an Alzheimer patient say this: that insisting that the patient's husband/child is dead has EVER resulted in the patient completing the grieving process and moving on? That the nurses and staff enjoy peace by utilizing whatever kindly method provides the greatest comfort for the longest time, is just a double benefit- not a reason to rebuff the concept of 'therapeutic lying' (although I'd like to call it something else...how about "pretend therapy"?).
  10. by   topkat
    My Dad is in the early stages of Alzheimer disease. My Mother suffered a mild stroke and has been in a nsg home for the past couple of weeks. He has done a couple of things that made absolutely no sense, but he does know where she is and he's trying to take care of himself the best he can. I check on him every day and he's actually doing pretty well. I hope that when he gets to the stage where he isn't doing so well that I will remember what I've learned from this post and help to make him feel safe and loved instead of more confused and frightened. thanks for a great post.....I believe that we're never too old to learn something new.....topkat
  11. by   redwinggirlie
    Two things: There is no such word as orientate. It's orient, or oriented...
    Sorry, big pet peeve I hear allllllll the time.

    Sometimes just saying ok and moving on to something else helps. In many Alzheimer's patients, once an idea gets in their head, it's hard for them to let go.
    Similar situation: A patient wanted to call her daughter to check when she was coming to get her to go home. Well, I'd call and give the phone to her.... only I called the number I was calling from and she always got a busy signal. Then she'd hear that, and say, well, maybe I'll try tomorrow.

    All the best to you.
  12. by   santhony44
    Will any nurse out there, who is working with an Alzheimer patient say this: that insisting that the patient's husband/child is dead has EVER resulted in the patient completing the grieving process and moving on?

    Wouldn't you say that there's a great likelihood that the patient in question actually did work through the stages of grief, but that this has been "lost" in the process of dementia? Then, because of the same process of dementia, the patient cannot successfully "work through the stages" again; their brains simply cannot function that way. Every time the person is reminded that the loved one is gone, the grief is new and fresh all over again.

    It's one thing to tell a mentally competent terminally ill patient that she is going to get better; it's quite another to remind someone who cannot properly process the information that her husband is dead.
  13. by   PANurseRN1
    Quote from KScott
    I love this thread. One, for the great information regarding dementia and two, for the wonderfully explicit example of bullheadedness. Brain anomalies are so fascinating to me! :wink2:
    It also is an excellent study on why some new nurses have such a difficult time with their co-workers.

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