A programme of care for an individual living with dementia would have life history as need number one – this is your touchstone – know the persons linear history. What happened to this person on their life journey, and how does this help us to understand and help them in living with their dementia in the here and now. Alongside the therapeutic interrelation of the person’s history into the plan of care, you would also use these facts to design your programme of care to incorporate ‘personhood’ protective life story work.
So, someone is admitted to your care home, you fill out the patient history section of the admission documentation – then what?
These details are hugely significant
It is my experience across 100s of care sites and numerous care operators, that admission documentation is often viewed as the necessary safeguards for meeting the requirements for admission and these particular sets of information are either a) archived or b) sit at the front of the care plan and are rarely, if ever viewed again except perhaps to look at a family or GP contact number?
In actuality, for someone living with a dementia these details are hugely significant, therapeutic gold dust and a clinical absolute essential for any establishment claiming to be undertaking of a person centred approach to care.
Think about your care home, your care plans for a moment – where in these plans do you find constant references being made to the admission life history details? Which care plans are you currently using which indicate how life history is being incorporated into your daily therapeutic care regime? How are these facts being used by the activity co-ordinator and how are they being used to preserve personhood on a minute by minute basis – how indeed are they used to deescalate possible confrontational exchanges and how do you use these to support behaviours that challenge?
Let’s recap our ultimate goal – to preserve the personhood of the individual with personhood being described as:
‘Conferred condition’ which is: ‘A standing or status that is bestowed upon one human being, by others, in the context of relationship and social being. It implies recognition, respect and trust.’ Dementia Reconsidered (Kitwood, 1997).
From identity theory we understand that part of being a person is the realisation of our identity through our memories and the emotions associated with them. Many of the dementias destroy those structures of the brain responsible for not only the encoding of new memories and their transference into storage, but also the regions responsible for recall of these memories, including the memories associated with our senses.
Knowing who this person is
If a person cannot recall their relevance within a structured world or the meaning of the people, places or objects within their environment and how these relate to the persons construct of themselves as father, husband, brother, son, resident etc. how does that person navigate their world? In essence to preserve identity and to foster a sense of coherent personhood (a social being with relationships deserving of respect and trust and recognised for who they were, are and will be) you as carer become the person’s memories and emotional guardian.
How would you accomplish these goals without an intimate knowledge of the person’s factual life history?
It may not be practical that the person themselves realises they are aged 89 and three quarters however, what is relevant to you about knowing this person is almost 90 years old is a knowledge of the changes across society and technology in the years they were growing up, maturing and living their life to this point. What significant events will they have experienced – when were they married are they survived by a wife, if not, when deceased, where laid to rest – did they visit the graveside – how many children, relationships, what jobs did they have and what was their social standing within that context, where did they live, what significant social events will have shaped his thinking?
Remember we highlighted in our blog on life story working that the person has, or may create, a real identity that is separate from the facts of who they are? Well, how someone sees themselves as against the facts of their life is only visible to you should you work hard to learn about both – and then work harder again to synthesise the significance for your care programs of any discrepancies between the two: knowledge of both will be required for you to be successful in your role, as the person and their dementia progresses if they are to live well.
Using facts as opposed to beliefs and constructs
Why would you say to someone who has no current recall that they are 90 years old, are living in a care home and whose wife has been deceased for the last 20 years or so – when they are so obviously desperate for emotional security that they ask “where is my wife, she was with me a second ago, here in our sitting room?” the following “come on now, your wife is not here. How old are you then? Your 90, you live in this care home now, this is the lounge and your wife died 20 years ago”.
How does this preserve personhood, increase wellbeing and meet the emotional needs of the person? But we hear conversations – let me rephrase, we hear statements like this one from carers and often families on a very regular basis – just what are the carers or family trying to achieve?
Well it is likely they have heard a little about reality orientation – put the person ‘right’ by using facts time, date, person, and then the person will grasp the reality of their situation and ‘perform better’, or perhaps they simply think this is the correct approach when someone has ‘memory problems’ and it helps them therefore to feel productive, helpful, useful in an otherwise difficult and emotionally challenging situation?
We all want to be useful, helpful, we all want to care, but stop and think for a moment, is that why we are here to make ourselves feel better about doing this challenging work or are we here to therapeutically aid the resident – this person in front of us desperately needing the comfort a wife and a familiar environment will bring?
You will know from the facts where and when this gentleman married, the name of his wife, the children, their names, where they lived, went to school, built a home and lived together as a family?
This is the importance of life history – you share this as part of the care plan, other carers know these facts – an approach to comforting that is shared by all can now be used.
Validation
An arm linked gently between carer and resident, “I can’t see Lilly (name of wife) right now, perhaps she is with James (name of son) perhaps they nipped away for something to eat – just like you and she used to – did Lilly like cake? What kind of cake did you and Lilly have at your wedding in Ushaw Moor? Do you like cake – let’s have some cake and a cup of tea till Lilly comes back shall we – me and you – we know each other you know – let’s sit here and talk about Lilly……”
The above approach uses a therapeutic approach called validation and in our next blog we will look in some depth at validation.
Facts have their place, they allow us to use the fabric of someone’s life to support their personhood, confirm their identity and involve families, but when someone is living in an alternative reality due to the regions of neurological damage afforded by a process such as Alzheimers disease, then we need other modes of communication which allow facts and the recognising of the immediate needs of the person to facilitate each other – meeting the emotional need must, in all instances except the threat of direct physical harm, take precedence.
Some people worry when they are first introduced to someone using validation techniques – that’s lying they say. Next time we discuss this proposition.
Till next time
Paul Smith – Dementia Care Expert
