Avoiding Life with Advanced Dementia – Medical, Legal, and Ethical Analysis of Feeding Options

Abstract: Seven million Americans suffer from Alzheimer’s dementia. Many more are scared that they will, too. So, we must identify ethical obligations we owe patients who have irretrievably lost decisional capacity. Comfort feeding only (CFO) has appropriately become the standard of care in such situations, recognizing both the inevitable decline in swallowing function and the absence of benefit from medically administered nutrition and hydration.

CFO can sustain a patient for months or even years. That is bad news for those who do not want to be kept alive in a state of advanced dementia. These patients have two options. They can complete an advance directive specifying that food and drink should be entirely withheld. But that raises both ethical concerns (specifically, the “then-self/now-self” problem of a patient with dementia being willing to accept food and drink) and regulatory ones (given that many patients with dementia are residents of facilities).

The other option is Minimal Comfort Feeding (MCF), which replaces scheduled mealtimes with appropriate responses to hunger/thirst cues. This, in turn, may prompt concerns for unrecognized (and unrelieved) thirst and hunger, as well as similar regulatory concerns.

This panel of a legal scholar, ethicist, hospice medical director, and philosopher examines the legal, moral, and regulatory obligations toward providing nutrition and hydration to patients with advanced dementia. The panel reviews ethical consensus, statutory requirements, and advance directive tools to empower patients who are concerned about potential future incapacity.

Keywords: Dementia, Advance directive, Comfort feeding