Bioethical implications of end-of-life decision-making in patients with dementia: a tale of two societies

Abstract

End-of-life decision-making in patients with dementia is a complex topic. Belgium and the Netherlands have been at the forefront of legislative advancement and progressive societal changes concerning the perspectives toward physician-assisted death (PAD). Careful consideration of clinical and social aspects is essential during the end-of-life decision-making process in patients with dementia. Geriatric assent provides the physician, the patient and his family the opportunity to end life with dignity. Unbearable suffering, decisional competence, and awareness of memory deficits are among the clinical considerations that physicians should incorporate during the end-of-life decision-making process. However, as other societies introduce legislature granting the right of PAD, new social determinants should be considered; Mexico City is an example. Current perspectives regarding advance euthanasia directives (AED) and PAD in patients with dementia are evolving. A new perspective that hinges on the role of the family and geriatric assent should help culturally heterogeneous societies in the transition of their public health care policies regarding end-of-life choices.

Euthanasia in Dementia: A Narrative Review of Legislation and Practices in the Netherlands and Belgium

“…The Dutch Alzheimer's Society 9 and the Flemish Federation of Palliative Care ( www.palliatief.be ) recommend that the (im)possibility of euthanasia be discussed as soon as possible after dementia is diagnosed, in the broader context of ACP, meaning of life, palliative care and end-of-life care, to create the possibility for the patient and physician to share the process. A geriatric assessment can provide a good basis for a shared decision process ( 57 ), considering the preferences of the patient with cognitive impairment in decision making ( 58 ). In patients with advanced dementia, ACP should consider the wishes of the “then self” written in the ACP at the time the person had actually decisional capacity and the actual wishes of the “now self,” expressed non-verbally by the patient and interpreted by relatives and professionals ( 36 ).…”

Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence

“…Advocates of PAS in dementia could credibly respond to the three preceding sections by suggesting that the practice should be confined to patients with severe or “terminal” dementia, where the patient’s life expectancy is already low and there is little or no scope for improvement ( Mondragón et al, 2020 ). The typical case scenario discussed in this context is that of a patient with advanced dementia who has difficulties in feeding himself, has limited or no mobility, and has developed (or is at risk of developing) complications such as decubitus ulcers or aspiration pneumonia ( Cohen-Mansfield and Brill, 2020 ).…”

Advanced Requests for MAID: Are They Compatible with Canadian Medical Practice?

“…The changes to identity, preferences, cognitive function, and experience seen with dementia pose a further challenge: how should physicians and families decide on the appropriate time to execute an ARM? While a patient may specify in their ARM a threshold of quality of life at which they would like to receive MAID, providing MAID once the patient meets this threshold may still prove ethically challenging (15,18). For example, the patient's preferences may have changed, they may be inaccessible, they may not exist, or the patient, on the whole, may not demonstrate signs of significant physical or existential suffering.…”