The best of your ability

As regular readers of this blog will know, I am very candid about dementia and the experiences my dad had during his 19 years with this disease. It should come as no surprise then that this post is on one of the most sensitive subjects in dementia care, and one that has polarised opinions amongst many people that I know. Indeed the merits or otherwise of it divide clinicians, therapists and relatives alike – everyone searching for the ‘right’ answer.

As human beings most of us are conditioned from a very young age to answer questions 'as is' and as so many application forms tell us in our adult life, ‘To the best of your ability’. So when you are faced with a relative who has dementia and is asking you a particularly sensitive question, what do you do?

This conundrum is one that most people who have a loved one with dementia will face at some point. In that moment you have to decide whether you should answer as the current reality demands, even if you face bringing upset, disappointment, pain and anguish to someone you love very dearly, or whether you should in some way manoeuvre yourself around the subject by either avoiding an answer or answering in a way that does not involve direct facts - in other words, you validate the person's beliefs rather than enforcing their orientation into the current reality.

How you approach this situation depends on some key considerations. Firstly your knowledge of your loved one is vital – there is no greater moment for personalisation than this one. Secondly your understanding of their dementia – if you have been with the person throughout their journey with this disease you will have become accustomed to their reactions (even if sometimes this proves to be completely irrelevant when their dementia surprises you). Thirdly your views - instinct is very important, but it has to be measured against the situation you are in.

Many people wrongly approach this subject from a viewpoint established within their world - reality orientation - completely forgetting that the person with dementia is living their life is a world that is very different, and you should be aiming to support them there, not try to drag them into your reality. This approach is a vital part of reminiscence therapy, something that I wrote about here, and whilst pursuing memories of the past can occasionally lead into difficult enquiries, do not be put off from exploring the benefits reminiscence can have just because you want to avoid any possibility of having to negotiate awkward issues. In my experience those moments come around regardless of whether you are actively reminiscing or not, therefore it is far better to simply be prepared.

When it comes to answering sensitive questions, that timeless ‘To the best of your ability’ phrase says it all. You may have the ability to answer an enquiry on the whereabouts of a parent, partner or sibling who passed away many years ago, but for me the decision on whether you should do that rests on what is in the best interests of your loved one. Will answering this question in the current reality give the person peace and reassurance, or will they be asking the same question repeatedly, and in doing so and hearing the same news every time, just relive that grief-stricken moment over and over again.

Enquiries about deceased relatives may not be the only obstacle you have to overcome either. Equally awkward candid moments can come from questions such as, ‘Am I losing my mind?’ ‘Am I dying?’ ‘Why am I here?’ Answering yes to the first two could again create huge distress, and in answering the last one, telling your relative repeatedly that they have dementia when they may be from a generation that associates that word with very negative images of asylums and appalling treatment, is going to create fear in someone who may not have the ability to articulate that emotional response and feel inwardly wretched as a result.

Pure reality orientation can be a very brutal business, and in dementia care, where gauging the person’s understanding can be such a tricky task, it is a bit like roulette – you just never know how the information will be received, the implications of it, and whether you will be asked to supply it frequently thereafter. These dilemmas do not end with having to deal with difficult questions either. Making a judgement about passing on emotionally-charged information can be similarly challenging.

During my father’s dementia both of his sisters passed away. On each occasion we received the news, we had to make a decision about whether to tell dad. On both occasions we never told him. Whether that was the right decision or not we will never know, but I do know that it saved him unnecessary heartache. 

We had some old sepia photos of dad and his siblings when they were in their early 20’s, and those pictures always brought a positive reaction from dad. Realistically, he remembered his sisters as those vibrant young women with their lives ahead of them. He lived out memories of growing up with them, taking them to the theatre, and being their protective brother. News of their passing would have been, for him, about those young women dying, not the reality of elderly ladies passing away having had families, lived their lives and been happy. So we spoke of his sisters in the context of dad’s world, reminiscing about the things that they had done together, smiling and laughing as we recalled events.

Ultimately no one can tell you whether validation or reality orientation is the right choice for your loved one in any given situation. What I can tell you is that while some people view the validation approach as lying, I never once felt that in sidestepping my father’s questions or not imparting information that I was lying to him. Protecting someone you love from the harsh realities of your world so that they can remain as comfortable as possible in theirs is, in my opinion, never about lying.

Until next time...

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