Dementia: Ethical Issues

Patient autonomy (i.e., self-determination) cannot exist without truth. Autonomy can be extended through advance directives (i.e., living wills and durable power of attorney for health care), and few question the importance of such documents. The durable power of attorney for health care allows the person, while still competent, to designate a trusted individual (usually a family member with whom he or she has had ample conversation) who will make medical treatment decisions once the person becomes unable to do so. This allows the surrogate decision maker to be attentive to the person's values and wishes, and to make decisions as needed. A living will, coupled with the durable power of attorney for health care, is usually recommended by lawyers. In the absence of legal documentation, all states allow the surrogate decision maker to proceed de facto, based on the sate statutes, although some states may try to interfere with surrogate control in designated areas, such as the refusal of a feeding tube.

The still competent self may not know what the experience of moderate dementia is like, nor be privy to the forms of well-being to be facilitated for such a self, but he or she surely knows the meaning of incontinence of bowel or bladder, repeated majors infections, and severe dysfunction. The best mechanism for empowering the intact self is the implementation of a durable power of attorney for health care, which is, paradoxically, the act of relinquishing control by placing oneself in the loving hands of another, with certain broad parameters spelled out as desired.