Introduction

In excess of 850,000 people live with dementia in the UK. This statistic, in conjunction with dementia’s detrimental impact on cognition, demonstrates it to be a prominent and important topic.1 The cognitive impairment accompanying dementia may result in patients holding beliefs that fail to reflect reality, causing individuals to have a distorted understanding of the world around them.2

These patients may believe that deceased parents or spouses are still alive, or that other aspects of their lives are as they once were. For example, a patient in a care environment may not recognise their surroundings and may wish to return home to their past residence. How best to respond to these situations may prove to be a challenge for those caring for these patients.

Correction may lead to further patient distress, whilst dishonesty raises a number of ethical dilemmas.This paper aims to look at the advantages of therapeutic lying, as well as the possible issues raised, in order to conclude whether it has a place in dementia care.

What is a therapeutic lie?

The term “therapeutic lie” was first used in the context of geriatric care by James et al in 2003. Their definition incorporated various behaviours, not limited to verbal deception. These included manipulation of a patient’s surroundings, small falsifications of facts and omission of the truth during patient communication.4

This paper will focus on verbal communication rather than environmental manipulation, for the purposes of emphasising various impacts on patient relations. Arguments surround the phrase “therapeutic lie” as some dispute that dishonesty can ever be in a patient’s best interest, thus rendering the term self-contradictory, the therapeutic nature of such lies are formally determined by their underlying intent, rather than their magnitude.6

Method

A primary search was conducted through Plymouth University’s online library, Primo, using the search term “therapeutic lying AND dementia AND care.” This search was also carried out using Google Scholar and PubMed. The search term “therapeutic lying AND ethics OR morals OR morality” was also used in each of the above. The search was narrowed down by adding filters such as “peer reviewed” to increase the reliability of included literature. Google searches were conducted to find information from reliable sources such as the Alzheimer’s Society.

Positive aspects of therapeutic lying

The majority of arguments in favour of therapeutic lying centre around a pragmatic approach to each patient’s situation. Arguments exist to show that lies told in a patients’ best interest are among the most acceptable, in addition to lies that prevent patients from coming to harm.7

For example, therapeutic lying is deemed more acceptable in cases where a patient is being recurrently retraumatised by the truth. In the later stages of dementia, it is common for patients to become mentally ‘time-shifted.’ In cases such as these, patients may believe themselves to be living in the past.Repetitive correction may be distressing and considered cruel, especially in cases where confusion centres around the deceased. Revealing to a person with dementia that their loved one has passed away can lead to severe bereavement reactions, which are upsetting for both the individual and those in charge of their care.9

There are also concerns surrounding the impacts of constant correction on patients with dementia. These include feelings of anxiety and reluctance to express thoughts and emotions in the future.10,11 Thus, therapeutic lying may be considered beneficial in maintaining valuable communication between patients with dementia and those caring for them, whilst also allowing patients to remain social and content.

The scale of the lie being told also contributes to its perceived acceptability. Studies show that patients with dementia feel more comfortable being told smaller lies, rather than a ‘blatant’ falsification of facts. These lies were deemed less hurtful if told by clinicians and carers, as patients expected a higher level of truthfulness from their friends or family. They also felt that therapeutic lying was more acceptable in the later stages of dementia, when the possibility of identification of lies was considerably lower. Individuals also found lies respecting their dignity and feeling of self-worth acceptable, in addition to lies that reduce the emotional turmoil that may accompany the truth. Overall, the most important factor for patients with dementia was whether the lie told was in their best interest.12

Some of these arguments in favour of therapeutic lying were very similar to arguments raised by nurses. One study found that some nurses believed lying to be most acceptable when trying to prevent periods of aggression and to deescalate these situations should they arise.13 Their arguments also included the possibility for patients to experience increased happiness and decreased discomfort.14

A number of psychiatrists shared this view, admitting that therapeutic lying could lead to an increase in treatment adherence, as well as improved communication between patients and those in charge of their care.3,15 A common theme can be seen across most opinions; therapeutic lies are more acceptable when told with the patient’s best interest in mind.

The estimated frequency of therapeutic lying must be considered in conjunction with other arguments. One study found that 69% of psychiatrists admit to having resorted to lying to their patients with dementia, providing they lacked capacity.

A study carried out by James et al showed this number to rise to 96% among carers and nursing staff. Here, only two of the 112 staff interviewed stated that neither they nor their colleagues had employed lying as a technique whilst caring for patients with dementia. In addition to these findings, 66% of psychiatrics admitted to having authorised the use of therapeutic lies by carers of patients with dementia.16

These figures suggest that therapeutic lying is already prominent in dementia care. If the majority of healthcare professionals are employing this technique, discouraging its use entirely may be futile. Rather, strict guidelines for its use should be implemented. A set of such guidelines was produced by James et al following a study investigating the opinions and experiences of healthcare professions regarding therapeutic lying. The guidelines included the importance of documentation, consent and acting in the best interests of patients.16

These guidelines were then revised by Culley et al and reviewed by psychiatrists, in order to evaluate their practicality. The majority of respondents believed that such guidelines would improve patient communication, but fears arose regarding the ethics of the guidelines’ implementation.15 It is clear that therapeutic lying is present in modern dementia care and despite proposed guidelines for its use, healthcare professionals still lack much needed official advice.

Limitations of therapeutic lies

When the notion of therapeutic lies was first introduced, experts such as Blum were entirely opposed to it, concluding that deceiving patients with dementia would allow healthcare professionals to manipulate their thoughts and actions. This early opinion determined that lying to dementia patients was a violation of the assumed trust between patients and their carers.17 If this point of view is taken, a potential risk of paternalistic medicine can be seen, where the opinion of healthcare professionals is indisputable, and patients are obliged to comply.

Another concern surrounding the use of therapeutic lying is the potential for recognition of lies.18 Kitwood, the founder of person centred dementia care, believed lying to be part of malignant social psychology, behaviours that undermine the wellbeing of a patient. Treachery, one part of malignant social psychology, is described as deceptive behaviours used to manipulate a patient’s actions. Kitwood’s work argues that lying to a patient with dementia depersonalises them, as the person telling the lie has dominance over the situation.19 Thus, the literature shows a reoccurring fear that lying to a patient represses their social control. If this view is taken, even lies told therapeutically are inappropriate.

There are also concerns about individuals who have periods of lucid thoughts accompanied by periods of confusion. Fears exist surrounding the potential for patients to identify lies once clarity has returned. This situation jeopardises the relationship between the patient and the healthcare professional caring for them, as the patient’s trust may be damaged. 

Day et al found that some patients with dementia share this view, agreeing that therapeutic lies were inappropriate if detection was possible at any point. Patients perceived the act of lying to be derogatory, “patronising,” and detrimental to their power in these situations.12 Patients’ level of insight into their health is also deemed important whilst caring for individuals who experience visual hallucinations as a part of their dementia.

In patients who have a less significant cognitive impairment, informal caregivers have been shown to prefer using truthful communication to offer individuals a better insight into their visual hallucinations, rather than being dishonest and confirming hallucinations are real. Here, the truth is thought reduce distress and intimidation. However, insights decreases as cognitive impairment decreases, often causing dilemmas for caregivers regarding how best to respond to visual hallucinations.20,21

Alternatives to therapeutic lying

The relative effectiveness of therapeutic lying may be evaluated in comparison to alternative responses to confused or distressed individuals. One such alternative approach is distraction. This involves diverting a patient’s attention away from misunderstandings, in order to avoid lies or further patient distress as a result of correction. Distraction is often used alongside transformation of questions, thus answering as if the patient had asked another question.22 This method could be effective in reducing escalation of situations, whilst still assuring patient’s feel valued and considered. However, this technique raises its own ethical dilemmas and can be criticised for its inability to meet patients’ underlying needs.

Some professionals prefer to address the emotion behind their patient’s words rather than employing techniques such as lying or distraction. This theory believes that statements made by patients with dementia can give healthcare professionals an insight into their needs. For example, anxiety may be expressed through questions about a patient’s deceased parents, showing an internal desire for comfort.

This technique is encouraged by the head of policy of the Alzheimer’s Society, George McNamara, who notes that “knowing, observing and listening to the person allows a carer to see what a particular behaviour means.”23 This would suggest therapeutic lies are not in fact in a patient’s best interest. Though lies may reduce distress and agitation, they do not address the patient’s potential underlying emotional turmoil. 

Alternative approaches have been praised and are often preferred over the use of therapeutic lying due to their potential ability to prioritise patient well-being.24 Mackenzie argues that therapeutic lies should be used as a last resort following a number of alternative approaches. Her argument centres around the “time machine” hypothesis of dementia, wherein patients initially lose more recently obtained memories and become progressively mentally shifted back time.

Mackenzie states that primarily, attempts should be made to reorient the patient, thus bringing them back to clarity. However, success is reliant on the severity and stage of a patient’s dementia. Distraction techniques are then recommended, such as engaging the patient in gratifying activity. Following the failure of these alternative techniques, the professional can identify the time that the person with dementia is time shifted to in order to devise the most appropriate intervention for that particular stage of memory loss.

This requires the compilation of a timeline of life experiences, including those of great emotional significance. In doing so, the professional is able to consider the best approach to the patient’s care, which may involve assenting to a patient’s current beliefs. Here, there is a reduced risk of the lie being detected or further escalation of the situation.

This alternative approach prevents the necessity for rapid formulation of therapeutic lies, and once again the importance of pragmatism is highlighted. Whilst this approach is extremely time intensive, it could potentially have higher efficacy than more impersonal care.

Ethical and moral considerations

The ethics and morality of therapeutic lying are key when discussing its place in dementia care. Currently, no official UK healthcare guideline justifies lying to patients.15 For example, the General Medical Council states that doctors “must be honest and trustworthy in all […] communication with patients.”25 These guidelines are based on fundamental elements of modern medical ethics. An example of one such principle is the patient’s right to autonomy, their right to make informed decisions regarding their care.26

This principle would seem to require total veracity with patients regarding their care and situation. However, autonomy is complicated in the case of dementia patients as it assumes competency. Competency requires the capacity to evaluate the risks and benefits of treatment, an ability often lost in later stage dementia. The ethical principles of non-maleficence, the duty to do no harm, and beneficence, the duty to do good, are also paramount in ethical debates surrounding therapeutic lying. However, these principles often conflict with autonomy, as the necessity to minimise patient confusion or distress is often antagonised by the moral obligation to tell the truth.27

In this case, the ethical tradition of consequentialism may decide if the use of therapeutic lying is appropriate. Consequentialism believes that the moral value of one’s actions is based solely on the consequence they have. This would suggest that therapeutic lying is justifiable providing the patient outcome is better than if other techniques, such as honesty were chosen.28 Ethically, the majority of professionals approach this question with a great deal of pragmatism. Deceiving a patient may be justified if telling the truth would result in more harm than good.

Conclusion and discussion

A potential professional dilemma may arise when caring for confused or disorientated patients with dementia. Therapeutic lying may be advantageous when attempting to avoid patient harm and potential psychological damage from consistent correction or distress. The majority of arguments in favour of therapeutic lying centre around acting in a patient’s best interest. However, a pragmatic approach should be taken if this technique is used, as the scale of the lie, the intent behind the lie and the patient’s individual situation must be considered carefully. Most arguments against therapeutic lying concern the implications that lying to a patient has on their relationship with those in charge of their care. In addition, there are numerous ethical considerations to be made when debating the use of therapeutic lying and these require an extremely individualistic approach to each situation. Research shows that therapeutic lying is prominent in modern healthcare, despite current guidelines demanding truthfulness.

These guidelines should be amended to consider patients with severe cognitive impairment from dementia, promoting the use of distraction techniques and attempts to empathise with patients’ inner feelings. Guidelines such as those proposed by James et al could also be implemented, offering advice on the use of therapeutic lies failing the success of alternative techniques. Such guidelines would promote consistency and ethical consideration when therapeutically lying, as well as removing some of the evident shame and taboo surrounding the use of lies in dementia care.

 


Miriam Smith  2nd year medical student, Peninsula Medical School

Allison O’Kelly DipHE, BSc (Hons), MSc, Queen’s Nurse, Winston Churchill Fellow, Clinical Lead East Cornwall Memory Services, Cornwall Foundation Trust 

Dr Giles Richards MB, BS, FRCPsych. Consultant Psychiatrist (Honorary), Cornwall Foundation Trust

 


 

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