pacify or orientate? Alzheimers...

Specialties Geriatric

Published

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 far. (should I be?)

Mrs. X is driving me crazy. For my three days she has asked to call her daughter to come get her.She is going home, looking for her car, easily agitated,etc.

The aides pacify her: "Mrs. X your daughter is at work, you can call her when she gets home from work" " your going home after lunch" This goes on all day.

I am new with Alzheimers behavior. I am new at being a nurse.

I don't feel good about telling her she can call her daughter to get her

"after she gets off work" , or that she is going home.

Is this not implanting the idea even futher, possibly even creating a cycle?

Any advice/ suggestion?

Specializes in LTC, MDS/careplans, Unit Manager.
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.

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.

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."

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"?).

Specializes in NICU, DC planning, Neurosurgery, Inf Dis.

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

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.

Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

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.

Specializes in Day Surgery/Infusion/ED.
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.

"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."

If I knew that every time the boy told the truth, that it would upset and agitate the person he was telling it to, (thereby making their lives more difficult and stressful) --then I advocate for therapeutic lying. I dunno, I just think that orienTATING a patient should be done if it is in the best interests of the patient...If it isn't in the best interest of that patient, then why be so anal and force your take on reality on to them?? Plus, forcing the patient to face "reality" could be worse than your idea of what is proper...Who knows what these people have been through that they cannot tell us?

Think about this: That 12 yo boy has done something stupid and almost got hurt. He's normally a well behaved conscientious young man but this time he made a big mistake that would worry and upset his Mom to no end. Would he need to tell her? I think that if he DID tell her, it would be more to assauge his own guilt than for his Mom and her own good because he knows how upset she would be......Sometimes we need to know how to roll with the punches, go with the flow, or whatever other cliche we can think of....Therapeutic lying is for the good of the patient.....I think that what you're advocating would be for your own good, so that you could tell yourself that you did all the right things today, in view of your morals...Your version of crossing your T's and dotting your i's....Sometimes we need to cross our i's and dot our t's....

"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.'

Just for the record: BOTH orientate and orient are actual words and both can mean the same thing. Look up 'orientate' in Merriam-Webster's paper dictionary (yes, paper dictionaries still exist), and you will see 'orient' for the definition (because it means the same thing). Dictionary.com lists 'orientate' the same way (says it means 'to orient'). Compact Oxford English dictionary states that "orientate is another word for orient". Must I go on? The American Heritage Dictionary of the English Language, fourth edition, says the transitive verb form of orient is orientate and it means 'to orient'. Orientate has another meaning, which is to turn someone toward the East, but its more well-known meaning is 'to orient'. So can we agree to end the discussion of whether orient or orientate is the proper word? Geesh.

You say to-may-to and I say to-mAH-to...

[And we wonder why the world can't solve the Arab-Israeli conflict...]

i just googled "therapeutic lying" and received many favorable responses.

the only ramification mentioned, was if the pt remembers what you said, and so, remembers you lying.

but this would have obviously taken place in its' early stages, where this intervention should almost never be used.

but we knew that already, yes? :)

leslie

I work as a CNA in a LTC facility, so that experience is what I draw from. I prefer to go with whatever works. As nurses we asses and treat and evaluate the response to said treatment. Maybe I have a simplistic view of the world, but when we discover that reality will not work on a pt living with dementia, why keep on trying. We don't keep feeding the depressed psych patient the same med that turns him/her suicidal just because the med is the current "right" treatment. We advocate for a different type of med, right? We don't give out antihistamine-sulfonomide cocktails to pt's with UTIs when they are allergic to sulfa drugs, do we? So when reality does more harm than good, why would we insist on inflicting that treatment repeatedly?

Anyone remember ADPIE? Assess, Diagnose, Plan, Implement, Evaluate. I like to think that a happy and calm patient is less of a danger to themselves and others, than one in distress or anxious. I've only had three patients that genuinely scare me, and that was because their behavior would change rapidly, without any obvious triggers.

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

Stay the course friends. Good healthy debate.

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