pacify or orientate? Alzheimers...

[Lfransis]

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?

[tryingtomakeit, RN]

Oh, I bet you could write a book about her...:beer:

Once during a staff meeting, she pulled a chair in front of us, sat down and proceeded to tell us that our "intake of money" was down, so we were going to have to look at ways to generate more "interest". She told us that the way we dressed really wasn't fitting for our line of work, then she looked at our DON, who was in her early sixties, and told her that she really needed to consider "throwing in the towel"! LOLOL

[leslie :-D]

Once during a staff meeting, she pulled a chair in front of us, sat down and proceeded to tell us that our "intake of money" was down, so we were going to have to look at ways to generate more "interest". She told us that the way we dressed really wasn't fitting for our line of work, then she looked at our DON, who was in her early sixties, and told her that she really needed to consider "throwing in the towel"! LOLOL

:rotfl: :rotfl: :rotfl:

[ragingmomster, BSN, MSN, RN]

I would like to politely ask Jesskanurse if she can understand the opinion that is opposite of hers that is being discussed.

I see we haven't heard from Jess in several days on this topic and am wondering if she is still keeping up with this thread.

No ill will intended, just wondering if Jess can understand both sides of the discussion on this matter.

[rn/writer, RN]

Maybe lying isn't the right word. Lying implies an intent to deceive on our part and the possibility of understanding the truth on the part of the resident.

Maybe a better name for what we sometimes do would be patient-guided connection. We attempt to meet them where they are.

When we reorient psych patients, we begin by meeting them where they are, but then we encourage them to move to a heathier place and a more coherent sense of reality. When this is not possible, as in a dementia patient for whom our current reality means little, we can meet them where they are, join them for a bit of warmth, reassurance, and human contact, and help them to live out their days with settled spirits and calm hearts.

Look at it this way. When you enter a foreign land, you have to learn to trade in their currency. It's a form of respect, and it's what you need to do to accomplish your goals. So too, when we enter the foreign land of the deteriorating mind, out of respect and a desire to be effective, we need to trade in whatever currency has value for these residents.

Patient-guided connection should be just that--directed by the patient. We shouldn't be initiating delusions or even bringing up things that have been common (things can change from hour to hour). Instead, we need to ascertain how that patient sees herself and what is happening to her in the moment. This evaluation should be a regular and ongoing part of our mental status assessment, not because it will help us "fix" what ails her, but because it will map the course of her disease AND it can help us calm her and give her those few moments of connection she is still capable of experiencing.

If this kind of interaction is patient guided, I believe strongly that we can operate well within ethical and therapeutic boundaries and give the patients a better quality of the life they have left. We can also show them kindness, compassion, and respect for the reality they are living in. Remember, they are different from other disoriented folks in one essential aspect. They aren't coming back. Can we at least make their gradual departure a gentler passage?

[RebeccaJeanRN]

Maybe lying isn't the right word. Lying implies an intent to deceive on our part and the possibility of understanding the truth on the part of the resident...we can meet them where they are, join them for a bit of warmth, reassurance, and human contact, and help them to live out their days with settled spirits and calm hearts.

Well said!

[jetscreamer101]

Once during a staff meeting, she pulled a chair in front of us, sat down and proceeded to tell us that our "intake of money" was down, so we were going to have to look at ways to generate more "interest". She told us that the way we dressed really wasn't fitting for our line of work, then she looked at our DON, who was in her early sixties, and told her that she really needed to consider "throwing in the towel"! LOLOL

That's too funny.

I've worked in LTC about 12 years. For awhile, I couln't bring myself to "lie" to my patients. I had taken care of a couple for about a year. He had alhzeimers, she could no longer care for herself, so family did a "dump and run". Sad, but it happens. Her condition declined and she eventually died. He husband held her hand as she passed. Everyday he would look for her and I would tell him that she died, you were with her, etc. EVERY time he would start to cry and say "I would remember that if it happened". I got to the point that I would ask him to tell me about his wife, and he would (every day he told me the same things!)but it was enough to distract him, and it seemed to help.

I have several residents that just get a little confused sometimes and reorienting them is therapudic. You know "the suns still out, what makes you think its 2am?" But trying to orient a person in the later stages of alhzeimers is cruel. I don't do it to make my job easier, it actually takes more of my time to get them engaged and talking about something else.

[leslie :-D]

i'm not sure whether changing the name of the intervention will truly make a difference.

for those who are opposed to the 'therapeutic lying', will probably refer to the new & improved 'patiented-guided connection' as still, lying.

for those who are proponents of this intervention, probably don't care what it's called.

afterall, we're going to use this intervention either way.

i am reminded of the ethics in administering morphine at end of life.

we know that morphine can hasten death.

but as long as the intent is to relieve suffering, there are no legal or ethical implications.

such is the case of therapeutic lying.

it is clear that our intent is to relieve the anguish of our debilitated and terminal, alzheimers' population.

let their remaining time be filled with a sense of belonging, of being cherished, and of being understood.

to me, these are the most basic of human needs.

leslie

[rn/writer, RN]

I like the term patient-guided (or patient-directed) connection for three reasons. One is that it may help some who aren't put off by the practice so much as by the terminology. Two is that the lying term sounds unnecessarily offensive to the general public who may not take the time to find out the particulars. And three, it can be a reminder for US that the patient (or resident) ought to be the one telling us who she is and what she needs in that particular moment.

At the opposite extreme of those who would use aggressive and relentless reorientation techniques despite negative effects on the patients are others whose good intentions might lead them in the direction of anticipating certain delusional reactions and running ahead of the game. In the name of being kind, they could easily "lead" the delusions and, while probably less traumatic, this is not what we should be doing.

I do like the suggestions that several have made encouraging caregivers to ask the patient to talk about a person or event they have mentioned. A patient who is waiting to see her sister (when that sister died twenty years earlier) might simply be asked to "tell me about your sister." It's amazing how detailed and fresh some of those ancient memories can be.

You know, there are common themes to many dementia delusions. Waiting for someone/something, looking for something that has been lost, fear of an impending bad event. They KNOW on some level that all is not right. We need to address that unrest and deep soul disturbance. They are telling us about it but so much of their sense of self and so many of their communication tools have been stolen from them. It's like trying to build a house using shoes and dinner forks.

Let's go beyond the surface meanings of their words and connect with the urgency and agitation of these fading souls. But first, let's put their hearts at ease with connection that will let them know that whatever else is happening, they are not alone.

[old rural nurse, RN]

Wow, I just read thru this whole thread, but now wish it was longer!!!!!!! I am the DON at our facility, and wholeheartedly agree that "therapeutic lying" is best for both the resident themself as well as the staff, and often the other residents, who are worried or concerned when one of their friends is upset or crying.

Try thinking of the "lying" part of it in this way, like a little white lie you tell your friends etc, the reason you are lying is to save the other person's feelings and emotions. If you were really "lying", you are trying to prevent yourself being "found out", or saving face. I think it is a matter of intent, who are you concerned with here, yourself, or your resident? I do believe the easy/lazy way out is to ask them to believe in your reality, pretty soon they won't ask you, they will go to someone who will take the time to respond to them and help them feel a little less lost!:thankya:

[santhony44, MSN, RN, NP]

They KNOW on some level that all is not right. We need to address that unrest and deep soul disturbance. They are telling us about it but so much of their sense of self and so many of their communication tools have been stolen from them.

The first Alzheimer's patient I ever encountered was in her mid-50's. She couldn't remember how to feed herself, drink from a water fountain, etc. She would, however, get flashes when she knew that something was terribly wrong. She'd say that: "Somthing is wrong, something is wrong!" with an intensely distressed look on her face. Then it would go- but I think you're right, they are trying to make sense of what's not right with their lives.

[TracyB,RN, RN]

Originally Posted by Jesskanurse

"Experience isn't everything. I just know how to use my resources and happen to find this topic interesting. My resources include include a 4 year college degree, great psych nurses, and friends with masters degrees in psychology."

NOT IMPRESSED....

So, Jesskanurse, I still didn't see you mention how much experience you have in dealing with advanced stages of dementia. Your 4 yr degree, great psych nurses & friends with their masters obviously have not worked with this population, either.

Any kind of a degree just means you have a degree. It doesn't make you a caring or compassionate care-giver. To constantly remind an advanced dementia patient of grief, making them re-live that misery over & over again, b/c you "have great psych nurses & friends with masters" is just cruel & heartless.

After you & your buddies have some experience, please let the rest of us know how re-orienting a patient with ADVANCED dementia works.

[fleur-de-lis, BSN, RN]

Originally Posted by Jesskanurse

"Experience isn't everything. I just know how to use my resources and happen to find this topic interesting. My resources include include a 4 year college degree, great psych nurses, and friends with masters degrees in psychology."

NOT IMPRESSED....

So, Jesskanurse, I still didn't see you mention how much experience you have in dealing with advanced stages of dementia. Your 4 yr degree, great psych nurses & friends with their masters obviously have not worked with this population, either...

After you & your buddies have some experience, please let the rest of us know how re-orienting a patient with ADVANCED dementia works.

:yeahthat: Just what I was thinking!