Trust me, I am a liar

I was discussing lies in medicine with the team yesterday.

Let’s face-it, some of us working in health and social care lie more than others;

I have written before about false-promises – in other words, ‘I’ll be back in a minute, Mrs MacPherson,’ as you leave the ward for the weekend, and, therapeutic-lies, ‘You will be going home soon,’ when, there is no likelihood of a return, with, ‘soon’ to someone with advanced dementia, who has perhaps lost touch with the essence of this theoretical framework, a frequent balm.

Within this context, part of the language of working with those who have dementia is diversion and distraction, such that, when John B is worried about getting home in time for the football, you respond, ‘Don’t worry John, it will be fine, we can always watch a recording,’ or, something along those lines.

It is now well established within the worlds of dementia and delirium that like the first principle of medicine – primum non-nocere, first, tell no lies (primum dicite absque dolo).

Most of us know this from our family and social lives – one lie begets ten more and on and on, yet, the multiplication of lying is dependent on the person you are talking with having the capacity to hold-on to the matter of your conversation.

And, this is where it gets difficult; this is where the lies and false-promises can become unstuck.

Clearly, there is no ‘person with dementia’ only, people – each individual is unique, with their own abilities and challenges, no one size can ever fit all.

Yet, when we speak with another, when we connect, communicate in the true sense of the word, it is not only information which is exchanged, but feeling.

Feelings are frequently more concrete than thoughts; if I offer a person who is confused, hope, they will potentially attach a positive significance to that communication and, despite the subject matter of the hope fading, the essence can remain. I become identified perhaps with hope and, when a patient sees me, they feel the hope and, what if that hope is frustrated; it is translated into my rushing past, eyes down, focused on other things? Where is the person?

Those who have dementia pass through different phases, with the loss of insight being both the most feared as well as perhaps most supportive aspects of the condition. Lack of awareness – or, insight, is be a blessing and a curse.

When one of my patients is starting to lose insight, this is often the most difficult time for them and for those providing care – when, they are aware that they are in hospital but unaware or unable to recall the events that brought them in – the fall, becoming lost at night, or the delirium.

‘I have been on this ward for ten days, I want to go home now,’ is often expressed by patients who can tell they are not at home, can tell that the people around them are doctors and nurses and can also identify the door which is locked.

‘We are sorting-out your care at home,’ is a frequent response, which is often met with, ‘I am fine, I don’t need help,’ and, so it goes, round in circles, with mounting pressure on the nurse or healthcare assistant to resort to lying.

In biblical times lying was considered one of the greatest sins – punishable by death – with repercussions more severe than blasphemy, theft or adultery. The reason for this is that honesty and truth are so fundamental to society, so essential to people being able to get along, coordinate, build, support, care, that without it, the fabric breaks-down and chaos potentially ensues.

Yes, I lie. Often, frequently.

God, forgive me – I do it for the best, I do it because I am unable to think-up an alternative strategy, and, I only do it when absolutely necessary, when there are no alternatives.

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