Dealing With Infidelity In the Nursing Home

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couple(This was originally published on my own blog on 1/8/13.)  A year or so back, I remember there was some attention paid in the media to the case of the husband of Justice Sandra Day O’Connor, of the U.S. Supreme Court.  It seems that he was living in a nursing home due to dementia, and had a girlfriend.  There was some puzzlement in some facets of the media when it became clear that Justice O’Connor was not particularly upset by this situation.  She understood that it was the dementia which was prompting her husband to do things that he might not otherwise do, and chose to overlook his behavior.

This reminds me somewhat of a situation which occurred in a facility I was working in a couple of years ago.  The facility had a self-contained dementia unit.  There were three female residents of this unit who acted out sexually with a high level of frequency.  Most of this behavior manifested itself in verbal bantering with various male staff members and visitors, some of which got rather explicit.  And these men learned very early on how to avert any problems, either through ignoring the culprit or by re-directing her to some other, more appropriate, form of interaction.  But there was one male resident of the unit who often became the target of these women’s advances, and he was usually quite willing to respond in kind.  It was not unusual to see him sitting on the couch holding hands with one of these women, or with her leaning her head on his shoulder.  Sometimes two of the women were involved, one on each side, neither one exhibiting any kind of jealousy toward the other.

This was all really kind of cute to watch.  The staff carefully diverted those involved from taking their desires any further, smilingly suggesting that it was time for a snack or a trip to the bathroom.  One problem existed, though — the man in question was married.  But his wife wasn’t too concerned about the state of affairs, and more than once I would see her sitting in a chair across the public room from her husband who was holding hands with one of his “girlfriends.”  She told me, herself, that she knew it never went any further, and that her husband frankly didn’t even remember that he was married.  He was quite willing to spread his attentions around to anyone available, including staff members or his wife when she was present.  But he had also apparently forgotten how to take the relationship to the next step.

Earlier today, I came across a discussion of just such a “problem” in a publication called “Practical Ethics,” put out by the University of Oxford.  The paper describes the case of a man living in a Swedish nursing home, who has engaged in an on-going liaison with another of the home’s residents.  The man’s wife and children do not approve of this, and have asked the facility staff to keep them apart.  However, when the situation was brought up before the ethics committee of the National Board of Health and Welfare in Sweden, this body recommended that the staff not try to interfere in the relationship.  They stated that the man’s autonomy is more important than the wishes of his family.  In an earlier case, the same body ruled that it was inappropriate to medicate a man, and separate him from his girlfriend, despite his wife’s wishes.

One issue to be debated in such matters is whether these nursing home romances can be considered authentic, and whether they relate to desires expressed earlier in life.  The author makes it clear that he believes these residents do have autonomy, and are able to make choices for themselves.  However, can they be said to make the right choices if they consistently confuse another person with his/her spouse?

The question also arises as to whether a person with dementia can truly come to love a person, in a romantic sense.  Attraction from one person toward another can occur, certainly.  However, many believe that romantic love is an expression of the whole person, involving many levels.  And some will argue that a person at a certain level of dementia is not able to use his cognitive abilities at all possible levels.  And, there are recorded instances where a person’s affections and predilections are effected by neurological impairment.  For instance, there is a known case of a person with a brain tumor who showed pedophilic tendencies, which were eliminated once the tumor had been removed.

The point is made that some persons with dementia can be said to have regressed to an earlier stage of life.  If this is so, might not a person have also regressed to memories and personality traits from their youth, and act on these?  I’m going to quote a sentence from the original article, because it really made me think.  “If we cannot recall past promises (and cannot avoid forgetting them), we are not morally bound by them.”  Hmm, something to think about.  It is entirely probable that a person will have fallen in love and married, with every intention of remaining faithful to his/her spouse throughout life.  But, if people without dementia can change in this conviction, isn’t it all the more likely that those who are afflicted with the cognitive changes that take place in dementia might all the more discover that their prior determination toward marital fidelity might be altered?  And, is it really the place of a nursing home’s staff to enforce those marriage vows?

The issue was also raised of the possibility of making an advanced directive specifying that, for instance, we want the nursing home staff to ensure that we remain faithful to our spouses.  But can this carry the same kind of weight that an advanced directive has against a feeding tube, for example?  One thing about autonomy — it allows us room to change our minds.

I have to admit this article has caused me to think about some things, perhaps in a different way.  But, the fact remains that if the family of a nursing home resident — who has previously been determined to be mentally incompetent, requests that their father be discouraged from making romantic gestures toward a woman who is not his wife, there are some who will see it as their responsibility to do just that.  And I do feel it is the right of that same staff to take measures to prevent outward displays of sexual activity that might be upsetting to other residents.  (Like the woman I once knew who would often use her hand to pleasure her boyfriend, while sitting in the public areas of the facility.  In this case, the amorous couple was escorted to a room where the door could be closed to allow them some privacy.)

What do you think?  I’m curious to find out what others have experienced, or what opinions they hold on this matter.

Jami L. Hede,  M.S., CCC/SLP

3 responses »

  1. Relationships develop all of the time between individuals living in close proximity to one another. Dementia units are no exception. The challenge on these units is finding a balance between individual resident rights and ensuring that the rights of other residents are not infringed upon. It is most helpful when facilities have policies that address sexuality. For the most part, it seems as though families are pretty understanding of the relationships that develop. The matter becomes trickier when things begin to advance past sitting together all the time and holding hands. Staff generally are pretty good about redirection and a good facility will notify families as relationships develop so there are no surprises. In order to consent to sex in a facility the following must be present:

    1. It must be voluntary
    2. It must be safe
    3. There can be no exploitation
    4. There can be no abuse in the relationship
    5. The person must have the ability to say no
    6. They must be able to choose a socially appropriate time and place or be responsive to directives toward that end.

    Although the capacity to consent is a prerequisite for sexual activity, automatically excluding sex based on mental capacity is considered a violation of patient rights.

    What gets even trickier is when you have a patient with dementia that has a spouse that still wants to engage in intercourse. Is it automatically consensual because they are married?

    • Thank you for your input. Good points, all of them. Thankfully, the staff of most nursing homes I’ve been involved with are being trained as to the rights of residents regarding relationships and sexuality. Couples are being allowed to live in the same room, not just for companionship but for expression of their conjugal rights. And they are being accorded the privacy that any of us would expect. And this goes for same sex relationships as well.

      One of the big concerns regarding physical intimacy between residents centers around the issue of consensuality, as you mentioned. And that becomes even more of an issue when one or both of the residents has dementia. How do we determine whether an individual is able to make an informed consent, AND to express that consent or refusal? Matters of diminished reasoning/problem solving, as well as aphasia and other deficits come to mind. (Unfortunately, silence does not always imply agreement.) Then there is the right of other residents, as well as staff and visitors, not to be witness to such activities if they so choose. I have been pleased to see these, and other similar matters, being discussed by the public and by those responsible for the administration of nursing homes.

      Regarding your last question, I have to refer back to an issue that has been much discussed in the legal community with regards to the cognitively intact as well. Just because the person is married, that doesn’t assume that he/she consents — whether one or both parties has dementia, or not.

      Again, thanks for the thought-provoking dialogue.

  2. Nice reading about you

    Thanks for visiting my blog. Be in touch. Browse through the category sections, I feel you may find something of your interest.

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