An Open Letter to Norman Cantor Regarding Dementia and Physician‐Assisted Suicide

Sulmasy, Daniel P.

doi:10.1002/hast.868

Cited by 17 publications

(5 citation statements)

References 12 publications

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“…There is conflict in the literature regarding the ethics and legality of ACDs that request the cessation of handfeeding in progressive dementia. 5,[9][10][11] In our patient's case, although the directives were not legally binding, the health care team felt that the ACD, along with his wife's input, was the best guide to appropriate care provision, particularly when it became increasingly likely that he would not regain his previous cognitive abilities. Ultimately, regardless of the instructional or values-based designation of his written instructions, there was uniform agreement that he could not have made his wishes any clearer, and accordingly this was respected.…”

Section: Author Manuscriptmentioning

confidence: 84%

Challenges in advance care planning: the interface between explicit instructional directives and palliative care

Eastman

2020

Medical Journal of Australia

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Section: Author Manuscriptmentioning

confidence: 84%

Challenges in advance care planning: the interface between explicit instructional directives and palliative care

Eastman

2020

Medical Journal of Australia

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“…Many moral leaders consider it wrong for one human being to judge whether the life of another human being is worth living. Implementing this practice could start a “slippery slope” that could (again) end in a humanitarian disaster [ 86 ]. 29…”

Section: Type IV Flaws Omit Strategies Designed To...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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“…If so, his suffering could decrease from moderate to mild. If Cantor's designated “resolute health care agent” did persuade his future provider to honor his requests by writing an order to cease assisted feeding, others could judge this order as clinically inappropriate since it caused premature dying, which is immoral, unethical, and illegal (euthanasia)—especially if the planning principal had asked his future providers to prescribe sedation for discomfort from not eating and drinking 20 …”

Section: Section 2 Difficulty In Assessing Patients’ Contemporaneous ...mentioning

confidence: 99%

“…If Cantor's designated "resolute health care agent" did persuade his future provider to honor his requests by writing an order to cease assisted feeding, others could judge this order as clinically inappropriate since it caused premature dying, which is immoral, unethical, and illegal (euthanasia)especially if the planning principal had asked his future providers to prescribe sedation for discomfort from not eating and drinking. 20 Providers are not obligated to honor all directives. Consider California's statute: "A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that [is] .…”

Section: Some Plads Manifest Agitation Because They Have No Othermentioning

confidence: 99%

Timely dying in dementia: Use patients' judgments and broaden the concept of suffering

Terman,

Steinberg,

Hinerman

2024

Alz & Dem Diag Ass & Dis Mo

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Patients living with advanced dementia (PLADs) face several challenges to attain the goal of avoiding prolonged dying with severe suffering. One is how to determine when PLADs’ current suffering becomes severe enough to cease all life‐sustaining treatments, including withdrawing assistance with oral feeding and hydrating, a controversial order. This article broadens the concept of suffering by including suffering that cannot be observed contemporaneously and the suffering of loved ones. Four paradigm shifts operationalize these concepts. During advance care planning, patients can judge which future clinical conditions would cause severe suffering. To decide when to allow patients to die, treating physicians/providers only need to assess if patients have reached patients' previously judged, qualifying conditions. Questions: Will this protocol prevent PLADs’ prolonged dying with suffering? Deter early‐stage dementia patients from committing preemptive suicide? Sway decision‐making surrogates from withholding life‐sustaining treatments from patients with middle‐stage dementia? Provoke providers’ resistance to relinquish their traditional, unilateral authority to determine patients’ suffering?

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An Open Letter to Norman Cantor Regarding Dementia and Physician‐Assisted Suicide

Cited by 17 publications

References 12 publications

Challenges in advance care planning: the interface between explicit instructional directives and palliative care

Challenges in advance care planning: the interface between explicit instructional directives and palliative care

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

Timely dying in dementia: Use patients' judgments and broaden the concept of suffering

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