Comment on: Stopping Eating and Drinking by Advance Directives: Choose Your Injustice

      Editor’s Note

      This case is not an ambiguous one. I think that in real life very few physicians would implement an order to withhold food and sedate someone who still appears to want food, can still feed himself, and is able to swallow safely like Bill in this vignette. That would probably be a criminal act. But it gets a lot more complicated when the person does not appear to desire food and is unable to put food or fluids into his own mouth, even when it is offered by being placed on a tray in front of him. And the situation becomes more complicated still when the person appears to be experiencing severe suffering in other ways or is having severe difficulties swallowing. We should not be placing value judgments on other people’s quality of life, but there does come a point for almost everyone where the burdens of sustaining life — or as others might say, prolonging the dying process — outweigh any perceptible benefit beyond biological functioning. This is especially true when there is severe apparent suffering in a patient with profound dementia or in someone for whom virtually everything going into the mouth is going to wind up in the airway. Electing not to hand-feed selected patients under these circumstances when it is in accordance with their previously expressed wishes seems much less ethically fraught. We equate feeding with nurturance and love, but it may not always work out that way. Nursing homes will probably never be a place where SED by AD will be practicable or permissible, but other care settings may be. There will be much more discussion on this topic in the bioethics community and beyond, in the years to come.

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      • Stopping Eating and Drinking by Advance Directives: Choose Your Injustice
        Caring for the AgesVol. 20Issue 3
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          Jim, I have a hypothetical case for you. One of my residents with dementia, let’s call him Bill, has an advance directive stating that when he no longer has meaningful social interaction, his caregivers should stop giving him food or water. He is now mostly mute, though rarely he may say a word or two. He still eats reasonably well and seems to enjoy mealtimes, occasionally saying “That’s good” when eating ice cream. His agent with POAHC [power of attorney for health care] is his wife, Alice, who also has advanced dementia and can no longer function as his decision-maker but is more verbal than Bill.
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