This was a long-nosed lie, and I knew that payback was coming. Several minutes earlier Ginny had bulldozed into my office with her walker. "Why the hell am I here? What's this all about?" I stared at her for a moment in silence. "All I want from you is my scooter!" she demanded. "Give it back!" The bare truth was that Ginny was moderately demented and perpetually hostile and paranoid. I was getting calls from nursing staff telling me that she had fixated on one particular chair on her unit and was forbidding anyone else to sit in it. It had even come to blows one day when she punched poor Victor, who had unknowingly sat in "her" chair, his deaf ears not hearing her stomping and curses from behind.
Fueling her anger was the fact that for several months Ginny had been demanding the return of her electric scooter. The nursing home administrator and I had recently made a decision to restrict her from using it for safety reasons, and I was supposed to inform her that day. However, given her demeanor and her hatred of psychiatrists, I feared an explosion.
"I'm one of your doctors," I stated, intentionally leaving out my specialty. She fired back, "Can I have my scooter?" I hesitated to answer. "Well, Ginny, we haven't yet decided,"
I lied. Ginny's angry face seemed to scrunch up into a single point that jabbed at the fragile bubble of my lie. She could be amazingly prescient even in the fog of dementia and paranoia. "Liar! Liar!" she accused, and then stood up and shrieked at me, "Go to hell!" I quickly opened the door and let her pass. I could hear her carrying on as she traversed the long hallway of the clinic. "That doctor can go to hell!" she called out repeatedly, her words echoing back to my office several times. "He can go to hell!" In her wrath she seemed to stretch my long-nosed lie past each office bay, around the front desk, and out into the courtyard in front of the clinic. Maybe it would have been better if I had simply told the truth.
Truthfulness is the foundation of the doctor-patient relationship, both as a method of discourse and as one of the "most widely praised character traits" of a doctor. Gone are the days when doctors withheld certain diagnoses or treatment details from patients. If anything, doctors today are often forced to disclose excess and sometimes unnecessary information due to concerns about liability or to patients who have already canvassed the Internet on their own and have pressing questions. The doctor's challenge is to present what he or she knows to be true about the diagnosis and its treatment options and to do so in a manner that truly informs the patient. But there are limitations and pitfalls to this process, as illustrated in the following paraphrased conversation I recently had with a seventy-five-year-old moderately demented patient and his wife:
Patient: Doctor, I know I can still drive. Just let me take a test.
Doctor A: I'm sorry, Mr. K, but I can't help you with that. As we discussed, your memory impairment makes it unsafe for you to drive.
Patient: Just let me take the test. I can drive just fine.
Doctor A: The memory testing tells us that you would not be a safe driver.
Patient: My memory is not that bad. I know I can drive.
Patient's wife: Honey, I told you that the car is not working now and needs to be fixed. Let's talk about it later.
Mr. K's wife did what caregivers for individuals with dementia often do -- she placated his concerns for the moment and then redirected him, in essence telling a lie. Should doctors ever do the same thing?