Point–Counterpoint: Are Dementia vsed Advance Directives Ethical, and Should Clinicians Honor Them?

Sponsored by the Ethics Committee

Moderator: Ursula K. Braun, MD, MPH

Voluntarily stopping eating and drinking (VSED) is increasingly discussed as a patient-directed option to hasten death in the context of serious illness. Dementia-specific advance directives that instruct proxies and clinicians to withhold or stop assisted feeding and drinking once an individual reaches moderate or severe dementia aim to avoid years of life in a condition the authors of such directives view as inconsistent with their core values and identity.​ Clinicians in geriatrics and long-term care may increasingly encounter such documents, yet may express ethical unease and uncertainty about whether and how to honor them. Concerns include whether assisted hand-feeding constitutes basic care rather than medical treatment, the moral weight of the “current” experiential interests of a content but severely demented person, and regulatory fears related to survey citations or allegations of neglect. At the same time, ethicists and legal scholars argue that clear dementia VSED directives may fall within established rights to refuse life-sustaining interventions and can be implemented within a robust palliative framework.​ In this point–counterpoint session, two experts will debate whether dementia-specific VSED advance directives are ethically justifiable and whether physicians and interdisciplinary teams should assist in drafting, interpreting, and operationalizing them in clinical and long-term care settings. Using a case-based format, speakers will explore conceptual, clinical, legal, and systems-level implications and identify practical strategies for counseling patients and families who bring these directives to the clinical encounter.​ Learning Objectives: (1) describe key ethical arguments for and against honoring dementia-specific advance directives that request voluntarily stopping eating and drinking (VSED)​; (2) differentiate between contemporaneous VSED by a capacitated patient and VSED implemented later by an advance directive in the context of moderate to severe dementia; (3) identify practical and regulatory challenges clinicians and long-term care facilities face when asked to honor dementia VSED directives and potential strategies to address them; and (4) formulate an approach to counseling patients and families who request or present dementia-specific VSED directives, including communication about goals of care and palliative support.​

Voluntarily Stopping Eating and Drinking in Dementia by Advance Directive: A Case Report
Ursula K. Braun, MD, MPH 

Are Dementia-Specific Advance Directives that Request Voluntarily Stopping Eating and Drinking Ethically Acceptable and Should Physicians Actively Support and Implement Them?
Pro: Thaddeus M. Pope, JD, PhD
Con: Farr A. Curlin, MD