Whether, When, and How to Honor Advance VSED Requests for End-Stage Dementia Patients

Pope, Thaddeus Mason

doi:10.1080/15265161.2018.1544309

Cited by 6 publications

(6 citation statements)

References 4 publications

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“…But after she presented it to Kendal’s administrators and they consulted their legal team, they refused to comply. They may have incorrectly believed institutions are required to assist oral feeding—even if patients legally memorialized their specific request to refuse such assistance [ 59 ].…”

Section: Part Two: Common Flaws When Implementing Completed Directive...mentioning

confidence: 99%

Flaws in advance directives that request withdrawing assisted feeding in late-stage dementia may cause premature or prolonged dying

2022

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Background The terminal illness of late-stage (advanced) Alzheimer’s and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die—which many advance directives cannot provide. Proxies/agents’ substituted judgment may not be concordant with patients’ requests. While advance directives can be patients’ last resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive’s requests to cease assisted feeding. Aim This article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters’ selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are implemented. The article includes excerpts from “dementia-specific” directives or supplements that exemplify each flaw—mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests “Cease assisted feeding” but the incapacitated patient apparently expresses the desire to “Continue assisted feeding.” Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities’ additional clinical criteria as a prerequisite to honor the requests in patients directives. Conclusion This critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients’ wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care?

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Section: Part Two: Common Flaws When Implementing Completed Directive...mentioning

confidence: 99%

Flaws in advance directives that request withdrawing assisted feeding in late-stage dementia may cause premature or prolonged dying

2022

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“…If a competent individual has the right to stop eating and drinking, proponents argue, then the same right should be guaranteed to incapacitated individuals through a legally recognized instrument, such as an advance directive. 6,10,18 Thus, decisions about refusing food and fluids would be governed by the same rules as decisions to forgo ANH and other medical treatments, and the same rules for advance directives would apply. Honoring such requests respects an individual's autonomy and right to decide what constitutes an acceptable quality of life.…”

Section: Can a Decision About Stopping Eating And Drinking Be Made Bymentioning

confidence: 99%

“…Honoring such requests respects an individual's autonomy and right to decide what constitutes an acceptable quality of life. 10 In the case of Mr S, the family strongly feels that the patient, when competent, held values that did not support the use of assisted feeding if it would prolong a life of severe cognitive debility and physical dependence, and he would want such feedings to be discontinued.…”

Section: Can a Decision About Stopping Eating And Drinking Be Made Bymentioning

confidence: 99%

“…Sometimes called "voluntary dehydration," VSED is a practice in which a competent person deliberately stops eating and drinking in order to hasten death. 7,8 Some have proposed that an incapacitated individual has the same right, through an advance directive, to request that oral hydration and nutrition be withheld, [9][10][11] the so-called Stopping of Eating and Drinking by Advance Directive (SED by AD). 4,12 Most recently, this practice has been recognized in Nevada, amending the state's statute governing Durable Power of Attorney for Health Care Decisions (DPAHC) to include a section that focuses specifically on treatment choices for persons with dementia.…”

Section: Introductionmentioning

confidence: 99%

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Advance Directive as Ulysses Contract: The Application of Stopping of Eating and Drinking by Advance Directive

Marks

Ahronheim

2020

Am J Hosp Palliat Care

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Increased attention is being paid to “dementia directives,” advance directives tailored to persons with dementia that outline what treatments an individual with dementia might wish to receive or forgo should they lose capacity. Particular focus has been placed on the request to have assisted oral feedings withheld, the so-called Stopping of Eating and Drinking by Advance Directive (SED by AD), the purpose of which is to hasten death. This article reviews the available literature regarding the practice of SED by AD and explores the clinical and ethical aspects as they present at the bedside. Our review aims to show that practical, clinically applicable ways to approach such requests must be developed in order to balance the fundamental principles at play.

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“…However, interdisciplinary there is no consensus on whether VSED is suicide, physician-assisted suicide, passive euthanasia or an intentional natural death (Simon, 2018) and the discussions about that remains ongoing (Stängle, 2021) Against this background, often inhibitions arise among FC and professionals in accompanying someone who (wants to) carry out VSED (Fringer et al, 2018), but there is consensus that support of a person who is willing to die through VSED may only be offered if there is no doubt about the ability to make independent decisions (Walther, 2015). Discussions about this are increasingly taking place in the context of people with dementia (Marks, 2016;Pope, 2019;Trowse, 2019;Wright et al, 2019) and with regard to inclusion in living wills (Christenson, 2019;Chuang & Flicker, 2018;Menzel, 2017). However, the German Association for Palliative Medicine states that assistance during VSED can be differentiated as assistance in dying and not as assistance to die .…”

Section: Introductionmentioning

confidence: 99%

Family caregivers' advocacy in voluntary stopping of eating and drinking: A holistic multiple case study

et al. 2021

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Whether, When, and How to Honor Advance VSED Requests for End-Stage Dementia Patients

Cited by 6 publications

References 4 publications

Flaws in advance directives that request withdrawing assisted feeding in late-stage dementia may cause premature or prolonged dying

Flaws in advance directives that request withdrawing assisted feeding in late-stage dementia may cause premature or prolonged dying

Advance Directive as Ulysses Contract: The Application of Stopping of Eating and Drinking by Advance Directive

Family caregivers' advocacy in voluntary stopping of eating and drinking: A holistic multiple case study

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