There was disagreement on social media recently after a story was published about an aged care provider creating “fake-away” burgers that mimicked those from a fast-food chain, to a resident living with dementia. The man had such strict food preferences he was refusing to eat anything at meals except a burger from the franchise. This dementia symptom risks malnutrition and social isolation.

But critics of the fake burger approach labelled it trickery and deception of a vulnerable person with cognitive impairment.

Dementia is an illness that progressively robs us of memories. Although it has many forms, it is typical for short-term recall – the memory of something that happened in recent hours or days – to be lost first. As the illness progresses, people may come to increasingly “live in the past”, as distant recall gradually becomes the only memories accessible to the person. So a person in the middle or later stages of the disease may relate to the world as it once was, not how it is today.

This can make ethical care very challenging.

Is it wrong to lie?

Ethical approaches classically hold that specific actions are moral certainties, regardless of the consequences. In line with this moral absolutism, it is always wrong to lie.

But this ethical approach would require an elderly woman with dementia who continually approaches care staff looking for their long-deceased spouse to be informed their husband has passed – the objective truth.

Distress is the likely outcome, possibly accompanied by behavioural disturbance that could endanger the person or others. The person’s memory has regressed to a point earlier in their life, when their partner was still alive. To inform such a person of the death of their spouse, however gently, is to traumatise them.

And with the memory of what they have just been told likely to quickly fade, and the questioning may resume soon after. If the truth is offered again, the cycle of re-traumatisation continues.

A different approach

Most laws are examples of absolutist ethics. One must obey the law at all times. Driving above the speed limit is likely to result in punishment regardless of whether one is in a hurry to pick their child up from kindergarten or not.

Pragmatic ethics rejects the notion certain acts are always morally right or wrong. Instead, acts are evaluated in terms of their “usefulness” and social benefit, humanity, compassion or intent.

The Aged Care Act is a set of laws intended to guide the actions of aged care providers. It says, for example, psychotropic drugs (medications that affect mind and mood) should be the “last resort” in managing the behaviours and psychological symptoms of dementia.

Instead, “best practice” involves preventing behaviour before it occurs. If one can reasonably foresee a caregiver action is likely to result in behavioural disturbance, it flies in the face of best practice.

What to say when you can’t avoid a lie?

What then, becomes the best response when approached by the lady looking for her husband?

Gentle inquiries may help uncover an underlying emotional need, and point caregivers in the right direction to meet that need. Perhaps she is feeling lonely or anxious and has become focused on her husband’s whereabouts? A skilled caregiver might tailor their response, connect with her, perhaps reminisce, and providing a sense of comfort in the process.

This approach aligns with Dementia Australia guidance that carers or loved ones can use four prompts in such scenarios:

• acknowledge concern (“I can tell you’d like him to be here.”)
• suggest an alternative (“He can’t visit right now.”)
• provide reassurance (“I’m here and lots of people care about you.”)
• redirect focus (“Perhaps a walk outside or a cup of tea?”)

These things may or may not work. So, in the face of repeated questions and escalating distress, a mistruth, such as “Don’t worry, he’ll be back soon,” may be the most humane response in the circumstances.

Different realities

It is often said you can never win an argument with a person living with dementia. A lot of time, different realities are being discussed.

So, providing someone who has dementia with a “pretend” burger may well satisfy their preferences, bring joy, mitigate the risk of malnutrition, improve social engagement, and prevent a behavioural disturbance without the use of medication. This seems like the correct approach in ethical terms. On occasion, the end justifies the means.

Steve Macfarlane, Head of Clinical Services, Dementia Support Australia, & Associate Professor of Psychiatry, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

As of January this year, Aotearoa New Zealand became just the second country (after Canada) to adopt a groundbreaking new procedure for patients experiencing cardiac arrest.

Known as “double sequential external defibrillation” (DSED), it will change initial emergency response strategies and potentially improve survival rates for some patients.

Surviving cardiac arrest hinges crucially on effective resuscitation. When the heart is working normally, electrical pulses travel through its muscular walls creating regular, co-ordinated contractions.

But if normal electrical rhythms are disrupted, heartbeats can become unco-ordinated and ineffective, or cease entirely, leading to cardiac arrest.

Defibrillation is a cornerstone resuscitation method. It gives the heart a powerful electric shock to terminate the abnormal electrical activity. This allows the heart to re-establish its regular rhythm.

Its success hinges on the underlying dysfunctional heart rhythm and the proper positioning of the defibrillation pads that deliver the shock. The new procedure will provide a second option when standard positioning is not effective.

Using two defibrillators

During standard defibrillation, one pad is placed on the right side of the chest just below the collarbone. A second pad is placed below the left armpit. Shocks are given every two minutes.

Early defibrillation can dramatically improve the likelihood of surviving a cardiac arrest. However, around 20% of patients whose cardiac arrest is caused by “ventricular fibrillation” or “pulseless ventricular tachycardia” do not respond to the standard defibrillation approach. Both conditions are characterised by abnormal activity in the heart ventricles.

DSED is a novel method that provides rapid sequential shocks to the heart using two defibrillators. The pads are attached in two different locations: one on the front and side of the chest, the other on the front and back.

A single operator activates the defibrillators in sequence, with one hand moving from the first to the second. According to a recent randomised trial in Canada, this approach could more than double the chances of survival for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard shocks.

The second shock is thought to improve the chances of eliminating persistent abnormal electrical activity. It delivers more total energy to the heart, travelling along a different pathway closer to the heart’s left ventricle.

Evidence of success

New Zealand ambulance data from 2020 to 2023 identified about 1,390 people who could potentially benefit from novel defibrillation methods. This group has a current survival rate of only 14%.

Recognising the potential for DSED to dramatically improve survival for these patients, the National Ambulance Sector Clinical Working Group updated the clinical procedures and guidelines for emergency medical services personnel.

The guidelines now specify that if ventricular fibrillation or pulseless ventricular tachycardia persist after two shocks with standard defibrillation, the DSED method should be administered. Two defibrillators need to be available, and staff must be trained in the new approach.

Though the existing evidence for DSED is compelling, until recently it was based on theory and a small number of potentially biased observational studies. The Canadian trial was the first to directly compare DSED to standard treatment.

From a total of 261 patients, 30.4% treated with this strategy survived, compared to 13.3% when standard resuscitation protocols were followed.

The design of the trial minimised the risk of other factors confounding results. It provides confidence that survival improvements were due to the defibrillation approach and not regional differences in resources and training.

The study also corroborates and builds on existing theoretical and clinical scientific evidence. As the trial was stopped early due to the COVID-19 pandemic, however, the researchers could recruit fewer than half of the numbers planned for the study.

Despite these and other limitations, the international group of experts that advises on best practice for resuscitation updated its recommendations in 2023 in response to the trial results. It suggested (with caution) that emergency medical services consider DSED for patients with ventricular fibrillation or pulseless ventricular tachycardia who are not responding to standard treatment.

Training and implementation

Although the evidence is still emerging, implementation of DSED by emergency services in New Zealand has implications beyond the care of patients nationally. It is also a key step in advancing knowledge about optimal resuscitation strategies globally.

There are always concerns when translating an intervention from a controlled research environment to the relative disorder of the real world. But the balance of evidence was carefully considered before making the decision to change procedures for a group of patients who have a low likelihood of survival with current treatment.

Before using DSED, emergency medical personnel undergo mandatory education, simulation and training. Implementation is closely monitored to determine its impact.

Hospitals and emergency departments have been informed of the protocol changes and been given opportunities to ask questions and give feedback. As part of the implementation, the St John ambulance service will perform case reviews in addition to wider monitoring to ensure patient safety is prioritised.

Ultimately, those involved are optimistic this change to cardiac arrest management in New Zealand will have a positive impact on survival for affected patients.

Vinuli Withanarachchie, PhD candidate, College of Health, Massey University; Bridget Dicker, Associate Professor of Paramedicine, Auckland University of Technology, and Sarah Maessen, Research Associate, Auckland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.