Nursing Ethics: Truth Telling, Therapeutic Lying, and Patient Care

This case study examines the ethical dilemma of therapeutic lying in the context of nursing care for a 79-year-old patient with dementia, Mr. X. The presentation explores the case scenario, defining therapeutic lying and its prevalence, and analyzes the situation using an ethical framework. It delves into the decision-making process, relevant nursing legal ethics, and compares truth-telling with therapeutic lying, considering the outcomes and recommendations. The case highlights the challenges faced by nurses and family members in balancing patient well-being with ethical considerations, particularly when managing patients with cognitive impairments and mood disorders. The study emphasizes the use of therapeutic lies to prevent agitation and improve patient comfort, while acknowledging the ethical implications and potential for abuse.

TRUTH TELLING AND
THERAPEUTIC LYING
AN ETHICAL CASE STUDY
BY :
In the following presentation the presenter will look into the following sub-topics in
order to examine truth lying and therapeutic lying;
• A description of the case scenario
• Definition of the term therapeutic lie and its prevalence.
• Use of ethical framework in examining the case scenario
• Process of decision making
• Nursing legal ethics and a guidelines relevant to the case scenario
• Comparison between truth telling verses therapeutic lying
• Outcome and recommendations
• Conclusion .
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Mr. X case scenario
 A 79 year old.
 Has two daughters (the eldest has a son)
 Wife died 4 years ago
 Mood swings
 Physically functions well
 Hx of Hypertension and depression.
 Reasons for admission in the psychiatric hospital
This is a case study of a male patient Mr X and his family of two daughters and a grandson.
The eldest daughter has the power of attorney over his father Mr. X. He is considered
“incapacitated" as he cannot decide things for himself (Fetherstonhaugh. Et al. 2017;
Brinkman-Stoppelenburg. et al.,2014). This daughter by the name carol who has a son aged 2
years. Mr X is 79 years old with second stage dementia diagonized three years ago. He has
the following signs and symptoms; forgetting recent events and people's names, getting lost
at home and, increased difficulties in communication. His behaviour change is accompanied
by wandering and repeating questions that were asked before. Mr X is still well physically
and has long lucid periods. He can, therefore, follow a conversation and social cues at a high
standard. He usually wakes up while okay but mood changes along the way as the day
progresses, known as bipolar disorder. Mr .X starts the day while manic high then gets
depressed. He has a history of hypertension diagnosed five years ago. The hypertensive
condition has been managed by administration of amlodipine intravenously at a dosage of 10
mg once daily since for the time he has been in the psychiatry hospital., Alzheimer's disease
and depression. He is in a psychiatric hospital due to the daily conflicts that cause increased
blood pressure due to his hypertensive condition.
Mr X could wake up while okay take a substantial breakfast, however whenever it reaches
9:00 am he could lose track of time and starts calling his daughter as his wife. Whenever the
daughter reminds him that his wife passed some years back he could get agitated and kept
on forcing that she is her wife and the son she has is his only son He has, and he is soon
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taking him to school to learn and inherit him when he dies. He, therefore, keeps on asking
lunch whenever it reaches 9:00 am inconveniencing carol the daughter till she decided to
take him to a psychiatric hospital. The situation did not change while in the hospital despite
the management given b the nurses. Whenever his daughter, carol visited him kept on
insisting that she is his wife. It was at this point that the nurses and his daughter carol
decided to use the therapeutic lie to prevent him from exacerbating his hypertension
condition. The lying kept carol happy since she could barely see his father angry.
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Therapeutic lie and its prevalence.
 Therapeutic lie is when the nursing staff avoid an overt lie and instead, in
line with validation therapy, establish empathy with the feelings and
emotional content of patient’s conversation, but in so doing they deceive
the patient. (Hughes & Common, 2015).
 There are 4 main therapeutic lie categories according to Blum’s
categories of deception, 1994).
 (i) Going along the
 (ii)Not telling
 (iii)White lies
 (iv)Tricks
Sperber, (2015) defined therapeutic lying as “the practice of deliberately deceiving
patients for reasons considered in their best interest .” The scholarly literature
categorizes lying in dementia into four. These four categories include going along with
the reality of the patient, telling the truth inactively, white lies and lastly is the
outright deception. In our case with Mr X, it is evident that the daughter used white
lies and went along with the patient's reality by accepting that she is his wife. They
finally understood him and went with what he found pleasant to his heart.
Different scholars have researched therapeutic lie in dementia patient and presented
their findings in different literature books and journals. The studies aimed at
determining the prevalence of therapeutic lie incidences and the nurses' perception
concerning the issue arising. Tuckett (2012), conducted qualitative research on the
experience of lying in dementia care. In these, 96% of the people taking care of
dementia patients, including nurses and psychologists admitted to being involved in
lying the patients with dementia. From these respondents, some are oka with it while
a smaller percentage of less than 10% said they were not okay with it. Whatever is
done by the nurses, therefore, is in contrast to what the nurses' code of ethics
states.(Cantone et al. 2019)
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Therapeutic lie and its prevalence
continuation..
 It is evident that of the 95% of the nursing stuffs who acted as respondents
in the research that was conducted by Tuckett (2012), 81% acknowledged
to have been involved in therapeutic lying.
 Less than 10% claim that it is not okay with lying patients withdementia.
According to Culley et al. (2013), “nurses are not encouraged to
practise therapeutic lying because of the potential legal implications that could arise."
The literature findings, therefore, outlines that the prevalence is very, surprisingly,
there is no training conducted for the nurses concerning therapeutic lying. According
to Cantone et al. (2019), A more significant percentage of, the healthcare providers
89.6% are okay with so-called therapeutic lying as a way of alleviating vulnerability in
uncooperative patients. , the nursing, legal ethics does not consider therapeutic lying
as one of the means of managing patients with dementia.
4

Ethical framework
 The ethical framework that is used in examining the case scenario is
adapted from The Ethox Entre, 2004
 A description of what Truth telling is verses Therapeutic lying.
The ethinox framework cheaps in this case scenario as it is an ethical framework,
usually working in a clinical case scenario where there is a dilemma. In our case
scenario, the nurses in difficulty between telling the patient Mr X the truth and
continue with our therapeutic lies. With Mr X at the centre, in the case scenario, the
ethical issue is whether telling a therapeutic lie more beneficial than telling Him the
truth. The more significant percentage of the nurses are involved in therapeutic lying.
Most of then have reasons behind lying to the patient. Elvish et al. (2010), outlined
the primary reasons as to why nurses may find themselves lying to dementia patients.
A therapeutic lie is more comfortable. It is distressful thus saves time. In doing this,
they prevent themselves from stress as well. The other reason is coercing the patient
into doing something that hesitates to do. Telling lie also ensures compliance with
the treatments and nursing management (Seaman et al., 2017). The following
reasons give the practising nurses a reason to lie to their patients even if it is against
their legal, ethical code of conduct fr them who are registered by the board. Nurses
are supposed to work as per the guidelines to provide adequate nursing management
to their patients. However, this is not the case in reality. Some nurses are involved in
therapeutic lying because they consider patient wellbeing. Others can lie for their
benefits, such as avoiding stress and avoiding time wastage.
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The decision making process
 Consider competence and the capacity
 Involve the family
 Outline the members of the inter-disciplinary team to be involved
 Describe the care planning of Mr. X
 All of the people mentioned above will take part in planning the care for
Mr. X
The ethox centre (2004) framework helps in analyzing the ethical dilemma case
scenarios from a legal point of view (Lohse et al., 2015). The framework gives an
opportunity for the patient to experience what is right and what is wrong. One can,
therefore, plan on what is to be done when the clinicians find themselves in such
dilemma case scenarios. It is legal for a patient that is considered "anticipated" to
have someone who has power of attorney over his decision. This person is allowed to
decide on behalf of the patient and can determine the type of management to do on
the dementia patient. In the case scenario, Mr X's power of attorney is his daughter
Carol. Carol is in a position of making patient's decision. The decisions made should
work in the patient’s interest in regardless of her own beliefs or opinion (Garrido et
al., 2015).
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Nursing legal ethics and a guidelines
relevant to the case scenario
 Newzealand legal nursing code of ethics
 An overview of the 7th code.
 A description of ethical principles of Non-Maleficence or Beneficence
 An overview of definition of power of Attorney
The nurses of New Zealand are governed by the legal code of ethics made by their
board. Nursing Council Board of New Zealand. According to these ethics we find that
the seven code of ethics states that any nurse practising should prove care to the
patient with integrity and honest (Woods et al., 2015) Considering that the high
prevalence of dementia is in the aged, an emphasis of protecting the vulnerable adult
under the Crimes Act 1961 (Nursing Council of New Zealand, 2012).
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Comparison between truth telling
verses therapeutic lying
 Positives of therapeutic lying.
 Positivity to the patient maintained
 Working relationships can be maintained
 Positives of truth telling.
 Honesty between the nurse and the patient is maintained
 Consistency between all haelcare professionals and disciplines.
While using the Ethox centre(2004) framework, a debate on both sides should be
considered. Both truths telling and the therapeutic lying has some positivity and
negativity World Health Organization. (2017). Analyzing the dilemma scenario will,
therefore, involve a vivid comparison of the positivity and negativity of both sides. In
truth-telling, there is continuous honesty relationship between the patient and the
caregiver. This trust is consistent, and there is no room for confusing information that
can bring an alteration in history taking. On the other hand, therapeutic lying as well
as positives. These include maintaining a positivity to the patient and sustaining
working relationships between the nurse and the patient. When Carol, the daughter
accepted that she is her wife, she rarely started seeing her dad angry, and this, in
return, reduces the incidences of hypertension episodes. A therapeutic lie can help
the uncooperative patient become calm and cooperates while management of his
needs is ongoing.
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Comparison between truth telling
verses therapeutic lying continuation
 Negatives of therapeutic lying.
 It is unregulated
 It can lead to harm to the patient during lucidity
 There is potential for abuse of position of the patient.
 Negatives of truth telling.
 Potential distress to the patient
 May appear as un-caring to the patient
 Can have a negative effect on working relationships.
The next point on morally significant features of the two is comparing their negativity.
From the positivity, it is found that both two have positive features that are helpful
and work for the good of the client in question. The debate can, therefore, be based
on analyzing the negatives of the therapeutic lying and negatives of truth-telling. The
negatives of truth-telling are potential distress to the patient; the effect on working
relationships and truth lying can also appear as "un-caring." When Carol, the
daughter declined that she is not her wife, Mr X seemed to be agitated and angry
every day. When carol accepted everything that her dad was saying, he started seeing
his father not angry any more, and this reduces his hypertension episodes. In
affecting working relationships, truth-telling leads to uncooperating and
incoordination of the patient. Truth lying can also appear as "un-caring." When the
truth is said, it may appear as someone is not really caring as such, this may be
interpreted as the caregiver is happy seeing the patient angry and distressed.
Negatives of the therapeutic lying may include harm during lucidity, the potential for
abuse of the position of the client, and finally, it could be unregulated (Cantone et al.,
2019). This is simply using therapeutic lies to dismiss the patient’s needs instead of a
thorough investigation of what is causing the hallucinations and the forgetfulness.
Knowing the truth concerning the cause of the patient's confusion and the short
memory can help in coming up with management strategies to help curb the arising
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signs and symptoms.
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Outcome and recommendations.
 Evidence from the case scenario and different scholars has shown that
therapeutic lying is an individual decision and there is no enough evidence to
be declined or legalized.
 Before embarking on therapeutic lying the following should be put into
consideration.
 Whether the competency, capacity have been tested
 The family should be involved in decision making establishing a clear care plan
 Education done to the family and the nursing staff
 validation of the person’s feelings be done
 caregivers are recommended to respect the integrity of a person with
dementia by accepting his or her reality
Therapeutic lying is simply using therapeutic lies to dismiss the patient’s needs
instead of a thorough investigation of what is causing the hallucinations and the
forgetfulness. Knowing the truth concerning the cause of the patient's confusion and
the short memory can help in coming up with management strategies to help curb
the arising signs and symptoms.
Recommendations should be made such that when such a dilemma case scenario
happens in future, the healthcare providers will choose the most appropriate care for
the patient. Instead of lying, it is therefore recommended that a validation of the
person's feelings be done. In doing this may allow the patient to share his underlying
opinions. Redirection can also be helpful, and it is therefore recommended. This will
work by diverting the patient's attention to something pleasant. Lastly, the caregivers
are recommended to respect the integrity of a person with dementia by accepting his
or her reality, and this will help the caregivers to understand better what the patient
is experiencing.
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Conclusion
 Therapeutic lying is an ongoing issue in the healthcare sector
 legal nursing codes of ethics of the NewZealand nurses have been
reviewed.
 More research is therefore required to check on the views from the patient
and healthcare givers as well.
Concluding, therapeutic lying is an ongoing issue in the healthcare sector. Some of
the healthcare professionals, such as the nurses are for the idea of applying
therapeutic lying in patients with dementia. However, the legal nursing codes of
ethics of the NewZealand nurses is against the idea. The essay has included a
comparison between truth-telling and therapeutic lying. It was observed that both
have the positives and the negatives as well. More research is therefore required to
check on the views from the patient and healthcare givers as well.
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