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While truth should always be the starting point, some lies – or ‘untruths’ – can minimise distress, although they can raise ethical concerns for nurses and carers
For many nurses working with people who have dementia, lying – or at least not telling the whole truth – is almost part of the job.
Nursing Older People. 35, 5, 10-11. doi: 10.7748/nop.35.5.10.s3
Published: 03 October 2023
As many as 96% of care staff in dementia settings say they use lies while caring for their patients, according to a 2006 paper, with most doing so to ease residents’ distress. So it seems most believe that, when there is a therapeutic reason, there are times when choosing to lie to people with dementia is justified.
‘People with dementia often ask questions that are hard to answer due to cognitive decline and memory loss,’ says Stephanie Craig, registered nurse in the School of Nursing and Midwifery at Queen’s University Belfast where she is undertaking PhD research on this topic.
Ms Craig suggests ‘difficult’ questions include those about loved ones who have died, the patient’s current situation or their past.
Questions about the whereabouts of deceased loved ones can be particularly thorny, says Northumbria University assistant professor in nursing, midwifery and health Jane Murray, who is a mental health nurse and a member of the RCN’s older people’s forum. ‘Every time a person is told that a relative is no longer here, it is like starting the grief process again,’ she says. The Nursing and Midwifery Council code instructs nurses to ‘act with honesty… at all times’. This can create a dilemma when a nurse is trying to do what is best for a patient or resident, argues Ms Craig.
‘As a nurse working with people with dementia this is often a delicate balance between being truthful or being tactful,’ she says. ‘This complexity makes us consider the factual accuracy of our words – but also the emotional impact.’
A 2016 Mental Health Foundation report drew a practical distinction. It defined ‘lies’ as blatant falsehoods initiated by a nurse or carer and ‘untruths’ as attempts to meet the person with dementia in their reality by conveying less than the full or whole truth.
A truth-lies axis highlights different levels of ‘truth’ and can provide a useful guide for nurses who are trying to give appropriate responses (see Box).
‘While truth should always be the starting point, there is no point repeating the truth if it is causing distress,’ argues Dr Murray.
The Mental Health Foundation report presents a truth-lies axis for evaluating communication with people with dementia. It is a five-part spectrum with ‘telling the whole truth’ at one end, moving through ‘looking for alternative meaning’, ‘distracting’, and ‘going along with’, and ‘lying’ at the opposite extreme.
Northumbria University assistant professor in nursing, midwifery and health Jane Murray, however, believes there are more useful ways to look at the issue. She prefers an approach that takes into account the motivation for, and effect of, a lie, and she has developed an affective reflective model for lying (see right).
‘This can help staff to reflect on why the lie did or did not have a positive outcome – or predict whether a lie is likely to meet the needs of the person with dementia.’
For a lie to be effective or therapeutic, it must be ‘genuine’ and in the patient’s interests, she argues, and validate their emotions.
Dr Murray offers the example of a patient with dementia becoming distressed and banging on a door, yelling: ‘Where’s my mum? She’ll be worrying where I am!’ Knowing the patient’s mother is dead, their nurse carer responds: ‘Your mum just telephoned. She is running late and asked you to have a cup of tea and she will be as quick as she can.’
This is a lie, but if it is said with kindness and compassion in a reassuring tone, it can be effective or therapeutic. The nurse genuinely wants to reduce the person’s distress. They are validating what the person said by referring to their mum and there is an emotional element to the interaction.
However, if the same words are said with indifference – perhaps when the nurse is tired and the main motivation is to disengage – they are meeting the needs of the carer not the patient and are unlikely to have a positive impact on the person with dementia.
Ms Craig details other factors nurses should reflect on before deciding not to be wholly truthful with a person with dementia. These include:
» Cognitive and emotional state.
» Potential impact on well-being.
» Coping mechanisms.
» Ethical and legal considerations.
» Input from family and care givers.
» Respecting autonomy.
» Context and timing.
» Availability of alternative approaches.
Dr Murray highlights ‘genuineness’ as another factor, arguing that how something is said is as important as what is said. ‘If communication is kind and reassuring, it is more likely to have a positive outcome,’ she says.
Dr Murray says the stress nurses can face when navigating dilemmas over telling a truth that might cause distress heightens the need for reflective practice.
‘Telling lies is an emotionally laden and contentious area, so it is important that all staff have an opportunity to discuss and reflect on an intervention, particularly in the case of planned lies, where consistency across the team is a factor that may be considered.’
Ms Craig says: ‘When nurses and the patient’s family are aligned on truth-telling and compassionate communication strategies, it helps create a supportive and stable environment for the patient.’
Certain types of lies may never be acceptable, however. ‘While therapeutic fibs may be used to prevent unneeded tension or discomfort, certain sorts of lies should be avoided to retain professional integrity,’ argues Ms Craig. ‘Falsifying medical information or withholding information relevant to consent are two types of lies that are not acceptable.’
Lying to a patient with dementia may also be considered a restrictive intervention. ‘Particularly when it entails withholding crucial information or making up stories to control the person’s behaviour or emotions,’ says Ms Craig. ‘When using lies as an intervention in dementia care, use caution due to the possible ethical, emotional, and legal repercussions.’
Ultimately, what supports the well-being of a person with dementia is paramount. ‘While truth should always be the starting point, telling lies to patients with dementia can be a kind and effective intervention to support their personhood and reduce distress,’ concludes Dr Murray.