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 New Recommendations Out on Comfort Feeding for Residents with Advanced Dementia

A new white paper in the November issue of JAMDA said even though much of the discussion about stopping eating and drinking by advance directives (SED by AD) focus on patient autonomy, the ethical principle of justice is the decisive factor in this controversy, according to the report’s authors. 

Inside the article, researchers also suggested that implementing SED by AD “can violate a physician’s obligation to beneficence and non-maleficence.”

The authors of “Stopping Eating and Drinking by Advance Directives in Assisted Living and Nursing Homes,” referred to discussions on this issue by AMDA – The Society for Post-Acute and Long-Term Care Medicine’s Ethics Subcommittee. 

“The Society is convinced that no choice can be made here without practicing an injustice: if one refuses to implement SED by AD, one violates the autonomy of the person who drew up the advance directive,” the white paper said.

At its conclusion, the Society recommends against implementing SED by AD in residents who still accept food and fluids, implementing instead a policy of comfort feeding for those with advanced dementia.

Even though many lay people and some clinicians assume that SED by AD is identical to voluntarily stopping eating and drinking (VSED), the white paper’s authors said, “the [Society] Ethics Subcommittee views the two as significantly different.” 

In VSED, for instance, an individual with legal capacity will voluntarily stop all nutrition and hydration. Death generally occurs within several days to a few weeks after discontinuing intake. The authors said on the other hand SED by AD is not voluntary and that it “always entails stopping food and fluids for a person who is still accepting them.”

The legality of VSED has been upheld in state and federal court, they explained, while SED by AD is “more fraught with legal, practical, and ethical complications.”

The authors said in summary that the Society affirms the right of all residents to receive comfort feeding until their behaviors indicates refusal or distress. 

“We reject the notion that critical interests should be given more weight than experiential interests on the same grounds,” the white paper said. “We insist that staff in the homes in which we work should never be compelled to restrict a person’s access to food, a basic right for every human regardless of their physical or cognitive abilities.”

The white paper was written by researchers at the SNF/LTC Partners of Virginia, Richmond, Va.; Presbyterian Homes, Evanston, Ill.; Section of Geriatrics, Department of Medicine, NorthShore University Health System, Evanston, Ill.; and University of Rochester, Geriatric Medicine/Palliative Care, Rochester, N.Y. 

JAMDA is the official journal of AMDA and publishes peer-reviewed articles including original studies, reviews, clinical experience articles, and case reports. See www.jamda.com for more details. 
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