Ethical Issues

The implementation of advance directives to withhold food and water by mouth faces significantly more challenges than VSED by persons with decision-making capacity, though with sufficient care and attention, many of these can be resolved. Reduced awareness may leave the person with little understanding of her directive or no awareness at all. In severe dementia, is behavioral expression of a simple desire for food or drink a relevant change of mind about the directive, or by then does the person no longer have the capacity to make such a change? How relevant is the moral distress that caregivers and health care agents will often experience when implementing the person’s directive, or when they are unable to get it implemented? Patients in severe dementia also may be relatively content, with little pain and suffering—is the deterioration itself, without pain and suffering, a legitimate reason for implementing a VSED directive?