Ethical issues raised in the cases
Much as declarations of advance directives have to be upheld, the nursing homes indulges the rule of Non Maleficence and patient autonomy to decline to honor Mrs. Bentley’s living will. The competent decision to deny self of any nutrition or water is respected by law. However when such decision is repatriated to a second party several ethical concerns come afore. Withholding of food and drink to an incompetent geriatric patient exacerbates adversity and suffering to the patient. Death by starving Mrs. Bentley would be perceived as too long and punitive to the patient.
Patient decision to die can only be upheld by medical practitioners if the patient is of sound mind, Bentley’s mental incapacitation impedes her from enjoying such privilege. During the early stages of dementia, patients are mentally competent enough to voluntarily ask for and be accorded with their demands. Wilkinson notes that with derailed mental capacity, characteristic of dementia, it is presumed that the patient may have a change in mind concerning the living will. Additionally the patient could in fact be comfortable with their current state of dementia (Wilkinson, 1997) a situation caregivers and family members could be uncomfortable with.
Which persona’s decision should reign supreme in case of derailed competence in the patient with dementia: competent Mrs. Bentley or the demented Mrs. Bentley. At the time of writing of the advance directive Mrs. Bentley was compos mentis and her wish could have been respected then. Often when patients make advance directives, they do not anticipate their future state of health (Wilkinson, 1997). The divide between what is expected of dementia and its actual effects on the patient causes a massive disconnect in the execution of advance directives. However, with reclined mental competence specialists argue that the patient could have recouped her initial decision (Mahieu, Anckaert, & Gastmans , 2017) and therefore a decision cannot be carried out based on their initial preclude.
If it were changed to meet the criteria for a model case, what ethical issues would come to the forefront?
Conflict between patient autonomy and the autonomy of the surrogate decision maker: Due to the derailed mental state of the demented patient, the appointed surrogate makes decisions on their behalf. The surrogate is bound to execute the wishes of the patient. However the patient’s inclination and wishes while demented cannot be readily determined (Yadav, et al., 2017). The decision to deny the patient of food when their actions vivify their desire for food is in contravention to the patient’s wishes. Therefore any undertakings by the surrogate towards the termination of the purported suffering by the patient do not meet the ethical threshold especially when these actions expose the patient to suffering.
Patient’ autonomy conflicts with beneficence and non-maleficence of the professional caregivers at the nursing home and family caregivers: there should exist equilibrium between those actions that keep the patient alive and the cost and risks involved in taking care of the patient. Withholding of food and medical intervention to incompetent patients works towards worsening their condition (Lee & Sommer, 2001). Administration of food prolongs the life of the patient, which could be perceived by the surrogate as prolonging the suffering of the patient (Rogers , et al., 2011). In such case withholding of food harms the patient bearing in mind they express the desire to eat either by reflex or by purpose.
Another pertinent issue that lays afore is the question of when should the medical practitioner consider euthanasia on geriatric patients with derailed competence. Derailed mental competence has debilitating effects on the patient and the family. It usurps legal competence necessary for decision-making. In such cases the medical practitioners have to make decision based on interests of the patient. Euthanasia, if necessary, also has to be carried out in a humane manner that would not cause harm to the patient.
Lambert , H. C., McColl, M. A., Gilbert , J., Wong , J., Murray, G., & Shortt, S. E. (2019). Factors Affecting Long-Term-Care Residents’ Decision-Making Processes as They Formulate Advance Directives. The Gerontologist , 45 (5), 626-633.
Mahieu, L., Anckaert, L., & Gastmans , C. (2017). Intimacy and Sexuality in Institutionalized Dementia Care: Clinical-Ethical Considerations. Health care analysis , 25, 52–71.
Wilkinson, J. (1997). Developing a concept analysis of autonomy in nursing practice. British Journal of Nursing, 6(12), 703.
Yadav, K. N., Gabler, N. B., Cooney, E., Kent, S., Kim, J., Herbst, N., et al. (2017). Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. ADVANCED ILLNESS & END-OF-LIFE CARE , 36 (7).