End-of-Life Decisions and Demented Patients.

What to Do if the Patient’s Current and Past Wishes Are in Conflict with Each Other?

in European Journal of Health Law
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In this article different approaches are distinguished in order to solve the question of what has to be done if a demented patient behaves in a manner which is found to be inconsistent with his previously expressed wishes. Positions vary, from implementing the advance directive to not implementing the advance directive. The article defends a compromise position by holding that the exact circumstances of each case should be weighed against each other to determine the outcome and to provide an answer to the research question.

End-of-Life Decisions and Demented Patients.

What to Do if the Patient’s Current and Past Wishes Are in Conflict with Each Other?

in European Journal of Health Law




S. Fazel T. Hope and R. Jacoby“Dementia, intelligence, and the competence to complete advance directives”Lancet 354 (1999) 48.


Fellowssupra note 7 922; S.S. Richards and H.C. Hendrie “Diagnosis management and treatment of Alzheimer disease. A guide for the internist” Arch. Intern. Med. 159 (1999) 792; M.A. Drickamer and M.S. Lachs “Should patients with Alzheimer’s disease be told their diagnosis?” N.Eng. J. Med. 326 (1992) 948.


Fellowssupra note 7 924.


See for instance M.R. Tonelli“Pulling the plug on living wills. A critical analysis of advance directives”Chest 110 (1996) 816-822; T.S. Drought B.A. Koenig and T.A. Raffin “Advance directives. Changing our expectations” Chest 110 (1996) 589-591 and A.J. Block “Living wills are overrated” Chest 104 (1993) 1645-1646.


Deliens et al. (2009) Advance Care Planning supra note 7 13 f.f.


R. DworkinLife’s Dominion. An Argument about Abortion Euthanasia and Individual Freedom (New York: Vintage Books1994) 226.


C.M.P.M. Hertogh“The role of advance euthanasia directives as an aid to communication and shared decision-making in dementia”J.Med.Ethics 35 (2009) 100; S. Fazel T. Hope and R. Jacoby “Effect of cognitive impairment and premorbid intelligence on treatment preferences for life-sustaining medical therapy” Am. J. Psychiatry 157 (2000) 1009-1011 (the authors show that patients with limited mental capacities are inclined to choose life prolonging treatments. This could mean a conflict with an advance refusal); E.L. Diamond J.A. Jernigan R.A. Moseley et al. “Decision-making ability and advance directive preferences in nursing home patients and proxies” Gerontologist 29 (1989) 625.


Dworkinsupra note 22 199 f.f. See also N.L. Cantor “Prospective autonomy: on the limits of shaping one’s postcompetence medical fate” J. Contemp. Health L. & Pol’y 8 (1992) 13-48 (the author places great value on precedent autonomy but at the same time admits that in some exceptional cases precedent autonomy can be overridden namely if human dignity is in danger: 40-43); and S. Michalowski “Advance refusals of life-sustaining treatment: the relativity of an absolute right” Mod. L. Rev. 68 (2005) 974-977.


R. Dresser“Life, death, and incompetent patients: conceptual infirmities and hidden values in the law”Ariz. L. Rev. 28 (1986) 379-381 and 394; and R. Dresser “Dworkin on dementia: elegant theory questionable policy” Hastings Center Report 25 (1995) 32-38. See also A. Fang “The living will of dementia patients: an exercise of autonomy and maximisation of utility?” UCL Juris. Rev. 4 (1997) 156. The patient is not a person: D.W. Brock “Justice and the severely demented elderly” Journal of Medicine and Philosophy 13 (1988) 73-99 and J.D. Arras “The severely demented minimally functional patient: an ethical analysis” J. Am .Geriatr. Soc. 36 (1988) 940-941. The concept of precedent autonomy can still be useful: A. Buchanan “Advance directives and the personal identity problem” Philosophy and Public Affairs 17 (1988) 280 f.f.; H. Kuhse “Some reflections on the problem of advance directives personhood and personal identity” Kennedy Institute of Ethics Journal 9 (1999) 347-364; L.L. Emanuel “What makes a directive valid?” Hastings Center Report 24 (1994) S27; and A.R. Maclean “Advance directives future selves and decision-making” Med.L.Rev. 14 (2006) 295 f.f.


R.S. Dresser and J.A. Robertson“Quality of life and non-treatment decisions for incompetent patients: a critique of the orthodox approach”Law Medicine & Health Care 17 (1989) 234-244; Dresser 1986 ibid. 373-405; R. Dresser “Missing persons: legal perceptions of incompetent patients” Rutgers L. Rev. 46 (1994) 609-719; Dresser 1995 ibid. 32-38 and R. Dresser “Relitigating life and death” Ohio St. L. J. 51 (1990) 425-437. See also the following authors who attach more value to a contemporaneous decision than to an advance decision: N.K. Rhoden “The limits of legal objectivity” N.C.L.Rev. 68 (1990) 845-865 (the author places great value on precedent autonomy but at the same time is of the opinion that the patient’s current and future interests can override an advance directive); S.H. Kadish “Letting patients die: Legal and moral reflections” Cal.L.Rev. 80 (1992) 871-878 (a wish to live has to be respected because of human compassion which is essential); Fang ibid. 148 f.f. (same opinion as S.H. Kadish); and S.G. Post “Alzheimer disease and the ‘then’ self” Kennedy Institute of Ethics Journal 5 (1995) 313-314 (human compassion).


See also M. Donnelly“Best interests, patient participation and the Mental Capacity Act 2005”Med. L. Rev. 17 (2009) 25-29; and J. Samanta “Lasting powers of attorney for healthcare under the Mental Capacity Act 2005: enhanced prospective self-determination for future incapacity or a simulacrum?” Med. L. Rev. 17 (2009) 385.


Meisel and Cerminarasupra note 23 7 119-121.


E.g. Meisel and. Cerminarasupra note 23 7-121; Articles 13 § 2 and 14 § 3 Belgian Patient’s Rights Act and Article 7: 465 § 5 and 6 Dutch Civil Code.


In the same sense: Cantorsupra note 27 36-39; Fang supra note 29 at 160; Michalowski supra note 27 at 981.


In the same sense: Francissupra note 7 591-592; and Donnelly supra note 31 at 27.


Dutch Health Councilsupra note 4 19 (the importance of nonverbal communication).


In the same sense: Cantorsupra note 27 41-42; R.S. Olick Taking advance directives seriously. Prospective autonomy and decisions near the end-of-life (Washington: Georgetown University Press 2001) 192-194; 559- Francis supra note 7 560; and Michalowski supra note 27 at 980.


In the same sense: Francissupra note 7 591-592; and Maclean supra note 29 at 292.


In the same sense: Cantorsupra note 27 41-42 (dependent on the degree of the dementia); Fang supra note 29 at 155; and Post supra note 30 at 313.


Cantorsupra note 27 at 43; Olick supra note 39 192-194; and Post ibid. at 313.


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