dealing with confused patients

sunnycalifRN · Nov 17, 2010

It depends on the cause of the "confusion". If it's "garden-variety" sundown'ing, then I would usually try to re-orient the patient. However, if it's Alzheimer's or schizophrenia, then the RN's approach sounds reasonable. Then, I'd go check the MAR . . .

Forever Sunshine, ASN, RN · Nov 17, 2010

Most of the time we "play along". If we try to re-orient some of the dementia patients they go up the wall crazy or it would just be useless because their mind is so far gone.

Davey Do · Nov 17, 2010

Yeah, well, this is a very gray area. And I'm not 100% sure it's THE appropriate approach. But I have fed into a confused patient's delusion in order to calm them down.

I think the first time I did this was in my first job in a LTC Facility. A woman in her 80's was concerned about her parents. I was relatively sure they were no longer living. So, I said, "Your parents are taken care of." It calmed her down.

As time past, and when other confused Patients brought unfounded concerns to me, I would often give the pat answer of: "Everything's taken care of." Like most of us, confused Patients just want to be sure they, and their loved ones, are safe.

I've even applied a name to this technique. It's called "Poetic License". Manipulating one's media in order to achieve a desired affect.

I think this is a case where the method is justified by the end result.

Dave

JB2007, ASN, RN · Nov 17, 2010

Do not argue with a demented resident or patient. In their mind they are right and you will not change their mind no matter what. In fact, you will probably cause them to become more agitated the more you try to reorientate them. Your best bet is to play along with them so that they are more agreeable to do the things that you need them to do to keep them safe.

JB2007, ASN, RN · Nov 17, 2010

Yeah, well, this is a very gray area. And I'm not 100% sure it's THE appropriate approach. But I have fed into a confused patient's delusion in order to calm them down.
I think the first time I did this was in my first job in a LTC Facility. A woman in her 80's was concerned about her parents. I was relatively sure they were no longer living. So, I said, "Your parents are taken care of." It calmed her down.
As time past, and when other confused Patients brought unfounded concerns to me, I would often give the pat answer of: "Everything's taken care of." Like most of us, confused Patients just want to be sure they, and their loved ones, are safe.
I've even applied a name to this technique. It's called "Poetic License". Manipulating one's media in order to achieve a desired affect.
I think this is a case where the method is justified by the end result.
Dave

I call them therapeutic lies. I even had a resident's family tell me I was going to hell one day because I told a resident so many lies.

Nascar nurse, ASN, RN · Nov 17, 2010

I call them therapeutic lies. I even had a resident's family tell me I was going to hell one day because I told a resident so many lies.

I got "beat up" and flamed several years back for using the term therapeutic lies.

OP, you will probably get many different opinions on this topic and it can get pretty heated. After 25+ years of working with the geriatric population I'm here to tell ya - reorientation does not work and at times can be out right cruel. Why would I tell this sweet little ole lady that is looking for her husband that he has been dead for 10 years? Her reaction will be the same as the very first time she heard this...repeated every hour on the hour. All the initial pain & agony of this loss played out in her mind over and over. Easier on her to tell her if I see him I'll bring him right to her. (Now you and I both know I won't be seeing him anytime soon - but I don't need for her to know that).

tyvin, BSN, RN · Nov 17, 2010

I've had em all from the gentleman who would pack his bags every morning without fail and it was when he was exiting the building I would send a nurse down to him to advise him he had a phone call. Worked every time. By the time he got to me about the phone call he couldn't remember why he was leaving or that he was leaving. I then would play the welcome this is your room number please unpack part. He never got violent or sad he just played along admitting himself daily and exiting the next morning. Alzheimer's can be cruel and I'm glad when a resident can enjoy themselves even in the throes of late stage Alzheimer's.

Now there's the other fellow who's s/p mva and has permanent brain injury that insists he's going home every night. Now this guy gets violent. There's a certain amount of truth to what he rants which brings me to believe he could be regaining memory but everyone including his wife has given up any hope for recovery. It's impossible to talk to him so he is usually medicated with IM Ativan for the safety of the other residents, the staff and himself. I don't play games with him.

So in your nurses case, she did just fine. At first when you do it you feel like your somehow betraying them by lying but in the end you are making there life just a little bit easier. Imagine if you would confront an Alzheimer's patient whose in the late stages and try to take them to a place of reality when they are clearly not there; usually ends up in a fiasco as I've seen nurses and family try. Let them enjoy; there's nothing wrong with it.

NurseKatie08, MSN · Nov 17, 2010

Reorientation is almost never best practice for Alzheimer's/dementia patients in my experience.

When I was an aide on an Alzheimer's unit, we made use of a bench with signage from our local public transit (familiar to the residents) as a "bus stop". Had a lady (100years old) who would tell me every day that she needed to take the "bus down to (blank) to see my mother". I'd wheel her over to the bus stop and tell her the bus would be there soon. By the time several minutes passed she'd forget all about it.

Davey Do · Nov 17, 2010

I call them therapeutic lies. I even had a resident's family tell me I was going to hell one day because I told a resident so many lies.

"I'll meet you in Hell!" Gene Hackman to Clint Eastwood in "The Unforgiven"

Yeah. Well, if telling little therapeutic lies is a pre requsite for entry into Hell, I guess I'll meet you there, JB2007.

The DSMIV defines a delusion as a false fixed belief in spite of evidence to the contrary. However, in spite of this definition, I've seen many Nurses attempt to show psychotic delusional Patients "The Way". It makes me wonder- who's MORE delusional? Which one of you are running the train? And, who's shovelling the coal?

Dave

rn/writer, RN · Nov 17, 2010

You decide what to do based on what is best for the patient.

In the case of a dementia patient, you accord them the respect due an adult, but you filter and adjust information the way you would with a young child. If they supply characters and situations, so much the better. Work with what they give you. Meet them where they are and tell them what will ease their hearts and minds.

Previous posters gave wonderful examples of working within the patient's frame of reference.

It may help to rethink what you are doing and recognizing that you are connecting in order to comfort rather than lying in order to deceive.

Practitioners who insist on telling and re-telling unpleasant truths to ease their own conscience are taking care of themselves at their patients' expense.

86toronado, BSN, RN · Nov 17, 2010

I've got to agree with the nurse you work with. Going along with the patient's delusions can be a whole lot better for them (and you as their nurse) in the long run. I've seen too many elderly dementia patients get combative, and eventually need to be sedated just because some nurse insisted on "re-orienting" them, when in fact they probably haven't been "oriented" in years. My approach of playing along with them usually results in a pleasantly confused elderly person enjoying a "cocktail" (cranberry juice and ginger ale) before "heading out to dinner" (at four in the morning).