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?

[RNinRubySlippers, BSN, RN]

No, I fortunately do not have any family members or close people dealing with this disease. I just happen to take mental health seriously and as a healthcare professional, I am bothered when other Nurses think it's acceptable to lie to patients. I only wish other Nurses had a great psych instructor like I had in school.

I must ask-how long have you been practicing? JMHO but "new" nurses who preach the textbook are more difficult to deal with than dementia pts! I am myself a new RN, and it amazes me how some folks just dont get the real world of nursing. I trust in all the posters that they all care for thier patients. No doubt in my mind-so I find it difficult to swallow that you have the odasity to insult seasoned nurses and thier ethics. You have a lot to learn and much growing and evolving to do yet (judging from your posts). I applaud you for trying to be professional, but somehow, your posts tell me otherwise. Maybe you need more life experience. I feel there is 2 schools of thought on this subject, and the experience of MANY of the nurses here wins. Sorry. Have a great next day at work! :)

[romie]

In my experience as an Alzheimer's Director managing a 50 + bed unit and all of its residents and staff, the nurses don't actually spend much time with the residents at all--they are too busy passing meds. They hardly interract at all with the residents and I can tell you that the quality of their interactions are severely lacking. Most of the MEANINGFUL interactions I observe are between the CNA's and residents and Activity personnel and the residents.

Let me ask all of you this--- how would you talk to a resident if you knew a surveyor was observing you? I thought so!

The title of the thread is "Pacify or orient [orientate]? I think most people agree that orienting a very disoriented person whose perception of reality is off is a losing battle. Lying, whether it be "therapuetic lying" or whatever PC term we come up with, is NOT the default. You can speak honestly to a resident in a way that meets their needs for recognition and helps them maintain their dignity and preserve their safety without outright lying to them. Understanding and practicing this communication modality is not the sole province of nursing-- my housekeepers, laundry aides and other staff all understand and practice this daily with my residents.

In short you don't have to lie to them. It is not an either/or issue.

[leslie :-D]

In my experience as an Alzheimer's Director managing a 50 + bed unit and all of its residents and staff, the nurses don't actually spend much time with the residents at all--they are too busy passing meds. They hardly interract at all with the residents and I can tell you that the quality of their interactions are severely lacking. Most of the MEANINGFUL interactions I observe are between the CNA's and residents and Activity personnel and the residents.

Let me ask all of you this--- how would you talk to a resident if you knew a surveyor was observing you? I thought so!

The title of the thread is "Pacify or orient [orientate]? I think most people agree that orienting a very disoriented person whose perception of reality is off is a losing battle. Lying, whether it be "therapuetic lying" or whatever PC term we come up with, is NOT the default. You can speak honestly to a resident in a way that meets their needs for recognition and helps them maintain their dignity and preserve their safety without outright lying to them. Understanding and practicing this communication modality is not the sole province of nursing-- my housekeepers, laundry aides and other staff all understand and practice this daily with my residents.

In short you don't have to lie to them. It is not an either/or issue.

what strikes me first and foremost about your post, is the minimal communication between the nurses and the residents.

despite the clinical aspects of any medical facility, the bottom line is this is their home.

and a home should be filled with warmth, security, interaction and appreciation of its' residents.

for the nurses to "hardly interact at all with the residents" is just sad.

sad for the residents and nurses both.

no matter how busy nsg got where i worked, there was always a sense of belonging and comfort.

and speaking of surveyors?

one yr the state and feds were at my facility.

not only did we get a deficiency-free survey, we also received commendations for the excellence in providing therapeutic care to our residents.

and there were residents where therapeutic lying was the only way to pacify them, in the absence of chemical sedation.

i can assure you, we did not behave any differently w/the state & feds present.

it's plain for me to see that the surveyors looked at the bottom line: and focused on the total well-being of the residents.

it's not as if (therapeutic) lying is the norm.

but when all other interventions do not work, and your late-stage alzheimers' resident has lost his capacity to speak, therefore, having him talk about "whatever" is totally unrealistic, then you do whatever it takes to bring him to peace and safety.

anyway romie, you have my condolences.

i mean that sincerely.

i hope that the nurses and the residents find ea other.

both are missing out on opportunities for human bonding.

at the very least, the alzheimers' population deserves that.

leslie

[romie]

Perhaps you failed to read the rest of my post while you were writing you reply Leslie. My residents have a rich plethora of meaningful experiences and interactions with all of the staff, including my CNAs, Laundry Aides, dietary aides, activity aides. It is with the nurses with whom I seem to have the most resistance, both in person during my staff education sessions and on this board. I nor my residents do not need your condolences.

Lying is a cop-out. It indicates a general lack of creativity and lack of interest in the resident. "Just say something quick to shut them up so you don't have to deal with this behavior" Instead, I enter the residents' world, recognize their fears and worries, reassure them and redirect them by using validation therapy techniques. I do not attempt to orient them to reality nor do I lie. I have never told a resident that their dead mother is coming to see them or that someone will be taking them home or any of the other classic lies.

My unit has also recieved deficency free surveys and I personally have been complimented by surveyors on my therapuetic communication techniques and the therapuetic care that my residents have recieved.

[rn/writer, RN]

Please, watch the tone of your posts, folks. This doesn't need to become a battleground or a sniping arena.

We should all be aiming for the same goal--residents that are as calm and content as they can be during a period of decreasing cognition. There may be more than one way to accomplish this task. We don't need to get edgy with each other or make derogatory comments to endorse a method that we've found to work.

I applaud anyone who has taken the time to converse with a dementia patient and give effective reassurance in whatever form it takes to help that person connect and settle. This is no mean feat. The biggest requirement, one I hope we can agree on, is the caring it takes to make the effort in the first place.

In the end, it may not be the words so much as the kindness, patience, and compassion shown by the caregivers that the patients respond to. Seems like those qualities have universal application that benefit givers and receivers alike.

[leslie :-D]

Perhaps you failed to read the rest of my post while you were writing you reply Leslie. My residents have a rich plethora of meaningful experiences and interactions with all of the staff, including my CNAs, Laundry Aides, dietary aides, activity aides. It is with the nurses with whom I seem to have the most resistance, both in person during my staff education sessions and on this board. I nor my residents do not need your condolences.

Lying is a cop-out. It indicates a general lack of creativity and lack of interest in the resident. "Just say something quick to shut them up so you don't have to deal with this behavior" Instead, I enter the residents' world, recognize their fears and worries, reassure them and redirect them by using validation therapy techniques. I do not attempt to orient them to reality nor do I lie. I have never told a resident that their dead mother is coming to see them or that someone will be taking them home or any of the other classic lies.

My unit has also recieved deficency free surveys and I personally have been complimented by surveyors on my therapuetic communication techniques and the therapuetic care that my residents have recieved.

no romie, i read about the other staff interaction w/the residents.

i guess i'm not understanding the lack of interaction between nurse/resident.

to randomly say that lying indicates a lack of interest in the resident and "just say something quick to shut them up...", leaves me speechless.

clearly you have not been reading the evident devotion and commitment of everyone who has posted on this thread.

best of luck, to you, the nurses and the residents.

leslie

[ktwlpn, LPN]

In my experience as an Alzheimer's Director managing a 50 + bed unit and all of its residents and staff, the nurses don't actually spend much time with the residents at all--they are too busy passing meds. They hardly interract at all with the residents and I can tell you that the quality of their interactions are severely lacking. Most of the MEANINGFUL interactions I observe are between the CNA's and residents and Activity personnel and the residents.

Let me ask all of you this--- how would you talk to a resident if you knew a surveyor was observing you? I thought so!

The title of the thread is "Pacify or orient [orientate]? I think most people agree that orienting a very disoriented person whose perception of reality is off is a losing battle. Lying, whether it be "therapuetic lying" or whatever PC term we come up with, is NOT the default. You can speak honestly to a resident in a way that meets their needs for recognition and helps them maintain their dignity and preserve their safety without outright lying to them. Understanding and practicing this communication modality is not the sole province of nursing-- my housekeepers, laundry aides and other staff all understand and practice this daily with my residents.

In short you don't have to lie to them. It is not an either/or issue.

I think 50+ is way TOO many residents for a true Alzheimer's unit.I have worked in "secure " units with census of 40 to 50 and it was awful. It also was not a true "dementia" unit-there were no special programs in place for the residents,no additional training for the staff.....We usually staffed 3 nurses-6 to 8 cna's...Med pass was awful-you could end up fighting for your med cart.Residents hung all over it,put their fingers in the pudding,drank from the juice/water pitchers,ate tissues.Once the meds were out we still had to do everything else we were responsible for and anything else that came up so,yes we seldom had time to practice our re-assurance and validation communication skills..However I was the charge nurse in a real Alzheimer's unit-census was 21.We all (housekeepers and dietary included) had additional training and the daily routine was geared to the residents.Had lots of time to interact with them then....It's sad that adminisration does not always recognize the importance of staffing the nurses in a way as to enable them to interact more with the residents,monitor the cna's communication techniques and the resident's moods and behaviors.That kind of staffing can really make a positive impact on the behaviors of these residents.I've seen it myself...Maybe you can do something similar on your large unit? Also-I think the term 'therapeutic lying" has maybe been misused or misunderstood in this thread.No one is saying to tell a resident who is crying for their mother that she is on her way or at work or whatever....We are talking about re-directing their attention to something else.We are not going to say "You are 95-your mother is dead" but rather.-for example-My mother makes the best cookies-let's have a drink and a few" and presenting the snack...Or offering the resident an arm and saying " My mom LOVES lilacs ,what's your favorite flower? " And proceeding to take a walk......Or saying" I need some help with *fill in the blank* ....

[Pedi-ER-RN, RN]

As a former LPN in LTC I always would try to orient first, but if that didn't work I chose to pacify!! If it were me with Alzheimers, I would want the staff to do whatever kept me happy (even if it was playing along with my delusions!)

[lvs2nrs3535]

As a new nurse working in LTC, I have already had to use therapuetic "lying". My patient passed away last Friday, but in my first week with him, he got dressed and ready to go to church. I had had no experience with him, but something told me not to argue. I just told him that church wasnt for another two hours, and he should have some breakfast first. Mission accomplished. The resident calmed down, ate breakfast, and never tried again to "go to church". It was actually kind of sad, for the nurses who have been working with him for two years told me stories of his getting ready for church, suit, tie, hat, ect. the man I saw was a wasted skeleton of a human being, getting ready to pass on. Perhaps at that point I should have told him that he wasnt going to church, he was getting ready to DIE, he weighed 67 pounds, and he just needed to come back to reality and accept it?

I dunno, but with my (extremely short, 3 weeks to be exact) experience in LTC, I would NEVER demand that my patient accept my reality. This is the longest and most interesting thread I have ever read, and I want to commend the patience of the experienced nurses. I have kept my opinions to myself, and I appreciate all the input and advice from my seasoned peers. Keep up the good work guys! And to the moderators, thanks for not closing this thread down. As frustrating as it was, there was so much excellent advice and experience to glean from this. Jesskanurse, good luck with your career. I hope you can step back from this and learn. It doesnt look like it, but..........you never know. I hope that God doesnt grant you with dementia. Karma isnt an easy thing to deal with, and you are in my prayers tonight.

Thanks again everybody!

[lvs2nrs3535]

Thanks Romie! I was beginning to get worried. :)

Re: pacify or orientate? Alzheimers...

--------------------------------------------------------------------------------

""Quote:

Originally Posted by romie

Validation therapy is the best approach. I am the Dementia Care Coordinator in my facility and am constantly in-servicing staff and family members about the best approach to communicating with individuals with dementia. Sure, "therapuetic lying" is very easy if you're rushed and can get you short term results, but I believe that it is unethical and bases the relationship on deciet. It indicates a lack of respect for others and doesn't address the real issue--the resident who is looking for her mother or wants to go home to make dinner is feeling something; scared, abandoned, worried, lonely. Validation therapy explores this and validates a resident's feelings.

An anecdote: A resident named "Betty" gets anxious and agitated in the late afternoon and attempts to leave the activity group and try to go down the elevator to "get a recipe from her aunt". This behavior is dangerous because she usually falls right around the same time and is difficult to monitor outside of the activity group. I spent five minutes talking to "Betty" about the recipe, the aunt, reminiscing until somehow the conversation got to how "Betty" used to be a phone operator. By using validation techniques on her, "Betty" was left feeling validated, sat back and relaxed and exhibited no further behaviors for the rest of the evening.

I am sure most of you will say, "But I don't have time to talk to her for five minutes!" I will say that that staff don't have time to drag her wheelchair back to the activity every two minutes for 3 hours while she anxiously calls out and cries. The nurse doesn't have time to fill out the incident report when she falls which requires a call to the MD and family. Then I don't have time to fill out the incident investigation and interview everyone involved, update care plans, ect.. It only took five minutes to make the resident feel better and save everyone else a lot of work.

As far as reality orientation, I will just say that it might work for some early stage dementia if the resident asks for it, "what time is it? where am I?" Subtle cues like calendars, clocks on the wall might have meaning for some early stage people.

Great thread!""

BTW Jesska,

I think you missed Romies point entirely. I believe that the point was that you do try it reality orientation with early stage dementia, but it is better not to push it with the later stages. You might want to reread this one.

[leslie :-D]

i'm talked out so i will summarize w/this:

nobody can rubberstamp any one therapy as an absolute solution.

i think we all agree that unless someone is in the early stages of alzheimers, reality orientation is futile and even cruel.

i have researched all of the behavioral interventions used.

therapeutic lying is indeed widely used and accepted.

i cannot speak for anyone else, but i utilize therapeutic lying as a last resort.

validation therapy does not work, even most times.

it is a viable and realistic intervention but certainly not even nearly, always effective.

a nurses' interventions should be as unique as are the needs and personality of ea resident.

what works for one, will not necessarily work for the next.

i know what my goals are with every single patient i care for.

and i feel good about myself.

i can sleep at noc, knowing i gave my personal best.

as long as i treat ea pt with integrity and respect, knowing that i want to and need to abate any type of suffering, then i've done my job.

whether we are nsg students or experienced nurses, this is a profession where learning is perpetual.

the science of nursing is concrete but filled w/new and changing data that commands us to keep up.

but it's the art of nsg that presents the real challenges, for there are no absolutes.

when dealing with the ilk of human nature, we try and apply what we were taught.

most often, this is not sufficient.

we know that we must treat ea and every pt with benificence and dignity, but no one really ever taught us how.

that's where the artform comes in.

our own personal contribution that defines what works and what doesn't.

as long as my intent remains in parallel with the grace of God, i will continue to do as i do.

as long as i combine my knowledge base w/literally, my hearts' desire, then my pts and i will both be fine.

leslie

[grentea]

When I was in nursing school I met a resident who was rather pleasantly confused. When I would ask her the standard orientation questions, she said that she was on a cruise ship with some friends. She even remarked about how wonderful the food was and how she was treated so nicely by all of the "workers" (her nurses and aides). And this made me think for a minute.....it would be almost cruel for me to assert, "No, you're in a nursing home." So we started talking about this and that and she told me about how she had travelled around the world and taken some cruises in the South Pacific. I will never re-orient a sick elderly person who thinks that their nursing home is a really nice cruise ship. Think about it...that's just awesome! I wouldn't ever take that away from someone. The subject of those who are not quite so pleasantly confused is an entirely different matter which I would certainly handle differently, but in the case of those who are happy in their realities, so long as they're safe, I say let them be. :)