Therapeutic Lying With Dementia Patients
The intended purpose of this article is to further explore the practice of therapeutic lying to demented patients.
Therapeutic lying is the practice of telling little 'white lies' or fibs to prevent from agitating the patient with dementia. Even though some of us were taught to never lie to any patient under any circumstances due to ethical issues, please realize that the truth often inflicts unreasonable pain and mental anguish upon the demented patient.
As caregivers, we want to be completely honest with our patients. However, when someone has dementia, honesty can lead to distress both for us and the one we are caring for (AGIS, 2009). For example, the 89-year-old female with mid-stage Alzheimer's disease asks about her husband on a daily basis because she has forgotten that he died more than twenty years ago.
The nurse has the option of reminding this lady that her husband is dead, but this will also remind her about the mental pain and profound grief associated with that loss. This female will likely ask the same question tomorrow because, due to her declining cognitive function, she cannot remember yesterday's events. The nurse may choose to provide these daily reminders of the spouse's death, which will only serve to reopen the demented lady's emotional wounds on a daily basis.
On the other hand, the nurse has the option of employing therapeutic lying to handle the situation. Instead of telling the demented patient repeatedly that her husband has died, the nurse reassures her by saying, "He has gone fishing with Uncle Bart." Uncle Bart also died many years ago, but the female patient has forgotten about that, too. Instead of collapsing to the floor in tears, our demented patient smiles and says, "I hope they catch some good ones!"
In most cases, telling the truth is the reasonable, moral, and ethical thing to do for all parties involved. The problem is that patients who are in the middle and late stages of dementia cannot be reasoned with. When someone is acting in ways that don't make sense, we tend to carefully explain the situation, calling on his or her sense of appropriateness to get compliance (AGIS, 2009). However, the demented patient has lost this sense of logic. Therapeutic lying works in these situations, whereas reasoning and logic fail miserably.
It is best to use therapeutic lying when the truth would incite mental anguish, anxiety, agitation, and confusion in the demented patient. Also use therapeutic lying when the demented patient is obviously not grounded in reality and is living in a different time than everyone else around him or her. People with dementia do not need to be grounded in reality (AGIS, 2009). If the 92-year-old gentleman believes that the year is 1962 and that John F. Kennedy is the president of the United States, what is wrong with allowing him to think it is 1962? Reality orientation would be more of a hindrance than a help in this situation. Instead of forcing him to live in the present day, the caregiver may wish to step into his world.
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About TheCommuter, BSN, RN Moderator
TheCommuter is a moderator of allnurses.com and has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a registered nurse.
Joined: Feb '05; Posts: 38,035; Likes: 69,254
CRRN, now a case management RN; from US
Specialty: 11 year(s) of experience in Case mgmt., rehab, (CRRN), LTC & psychJul 8, '12I learned to do this in school. My instructor explained it similarly. I couldn't imagine breaking a patients heart for no reason aside from it being truthful.
Oh, and you write the BEST articles!Jul 8, '12Excellent article. When I was in nursing school during the Jurassic age, we were being taught to re-orient, and sometimes it didn't seem right to me. But to get my grade, I went along. Later, I learned the art of being in their world.
Now I watch my MIL in her other world. Her son is heartbroken, but sees the point of not agitating.
It is sometimes just a matter of 'going along to get along'.Jul 8, '12I was just talking to my 12yo son about this last night. I don't remember how we got on the subject of Alzheimer's, but in the process of explaining the progression of the disease, I also explained the difference between being able to reorient someone in the early stages versus not causing further emotional anguish for someone in the later stages.
If an 80yo woman thinks she's pregnant with her husband's baby, what's wrong with saying, "Congratulations! I'm so happy for you!"??? It's different, of course, if she's wanting to eat the "chocolate candy" she retrieved from her brief -- then it's time to distract her and wash her hands. But if going along with her story doesn't cause any harm, you can bet your sweet bippy that I'm going to go along with her story.Jul 8, '12Wonderful article. Just the other day in memory care, nearing the dinner hour, perhaps 4:30p, I noticed two female residents whispering and clearly making "plans". I am charting at the computer during this time. After a few minutes, they leisurely stroll up to me in their sunhats and beads, and claim that they "need to make a reservation on the sundeck," and the ringleader tells me that I "need to have the boys pull the car around." She advises that they will also "need drinks." Clearly, these two lovely ladies were in high style on vacation (I like to imagine the 40's or 50's) with huge glasses and hats, perhaps a strapless glamourous white swimsuit, while the men were golfing. It was such a pleasant, happy thought for them, AND for me, after a long day, and I wouldn't dare take them out of that dream. I advised that dinner was being served in the "banquet" room, and that perhaps they should have a bite to eat first before heading into the hot sun. They went, they did, and unfortunately for me, their trip was over.
I have both Alz/Dem organic cognitive decline as well as behvaioral/mental health on my lockdown unit. Some require reorientation, and some do not. The two lovely ladies were just FINE where they were.Jul 8, '12I've found theraputic fibbing to be helpful sometimes. I've had patients think I am their mother. It came in very handy if they didn't want to bathe or eat. Why put a LOL through the pain of her mother saying she's not her mother or that her husband is really dead?Jul 8, '12I don't look upon it as lying, per se, but entering into that patient's reality, which is probably much more pleasant to them than the present. AD is such a cruel disease, dismantling the personality and memories a bit at a time. Hope they find the cure soon!Jul 8, '12I try and tell people... Imagine the pain of finding out your husband is dead. Now, imagine reliving that ever 10 minutes, every hour, or daily depending on how often they ask. They grieve all over again. Stress level increases... stress can lead to sickness.
We were taught a long time ago to re-orient as well. I saw way to many tears.Jul 8, '12If someone wants to wander out in a storm, I tell them the truth. If what they are doing will harm them, I reorient, or at least spin their ideas into something safe. If it doesn't hurt to let them stay in their own, safe, comfortable, or at least non-terrifying reality where they are younger, healthier, or in a happier time and place, why drag them back to ours, where they are sick, helpless, vulnerable, and living in a nursing home? If it hurts nothing, let them stay happy where they are! Good article!Jul 8, '12"Lying" has such a negative connotation for many of us that it's just too darn difficult to give it the stamp of approval. Instead, we need to look at this therapeutic connection as meeting our patients where they are.
Who are we caring for if we tell a woman she retired from a job she loved twenty years ago, or we say to a man that the cows he wants to go milk have been dead and gone for decades?
Here are a couple of strategies to keep ourselves honest while not clubbing these tender souls with unwanted truth.
Let the fabrication be mostly theirs. Work with the names and places and situations they supply. One of the very best pieces of advice I have ever heard on this subject is to ask the patient how old he or she is. The answer will tell you a lot about where they are in their own heads.
Address the emotions at hand without dwelling on the details. Mid-stage dementia patients can't identify that they're losing their minds, but they can convert that anxiety into other feelings and attach the tension to the people and places they still have left. One patient's agitation over feeling out of control becomes worry that her husband won't know where to pick her up. You deal with the concern by saying that you'll be sure he gets the message and encourage her to have a light meal while she's waiting. Chances are she'll be distracted enough by the normal routine (and by her feeble short-term memory) that she'll move on to something else before too long.
Ask open-ended questions about the people and things they talk about. This can come in handy later when some of the details begin to slip away. "You're worried about your car, Ed? Are you talking about the old Chevvy? The red one you told me about?" If he had indeed talked about such vehicle, your words--your connection--may help settle him or at least get him talking about something less stressful.
Mostly, just put the patients' needs before your own. Join them wherever they happen to be and only attempt to re-orient if they're in harm's way. And even then, try to do it in such a manner that it's more of a gentle redirection than a harsh slap of reality.
Thanks, Commuter, for this article on such an important subject.Last edit by rn/writer on Jul 9, '12Jul 8, '12This article is extremely poignant and realistic. I agree with all the other posters who find reality orientation generally useless and distressful for the confused pt. I esp agree with rn/writer that 'lying' is just too negative for healthcare workers to really feel comfortable using.
I try my best to avoid fibs and/or little white lies; I just try to turn the conversation around to myself and I feign lack of information or the time, etc. I think I'd feel more comfortable if we could call it 'therapeutic aternative communication' techniques. I don't know that I'd like to write 'therapeutic lying' on a pt care plan!
One other point of the article, I know what frustrates me most with pts having advancing dementia is their increasing aggresion and the loss of 'polite society social skills'. Gracious, mild mannered people who in days past would NEVER have struck out to hit, kick, bite, claw, spit, etc. Or use language that would make the devil blush. Or inappropriate toilet habits and sexual behaviours that would be arrest-able offences.
There's NO amount of 'therapeutic lying' or 'therpeutic alternative communication' that will really help the situation much. If it's frustrating for me I can only multiply it exponentially for the pt. And as the population of dementia/Alzheimers pts increase in numbers and severitiy with the increasing longevity of this population, I remain troubled. I don't really see a good outcome.Jul 8, '12Thanks for this and the tips.. They will come in handy. Nice to have new "tricks" in my bag.
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