SNF/LTC Partners of Virginia, Richmond, VA.
Presbyterian Homes, Illinois, Section of Geriatrics, Department of Medicine, NorthShore University Health System, Evanston, IL.
J Am Med Dir Assoc. 2019 Nov;20(11):1362-1366. doi: 10.1016/j.jamda.2019.07.026. Epub 2019 Oct 3.
The Ethics Subcommittee of AMDA-The Society for Post-Acute and Long-Term Care Medicine ("The Society") presents arguments for and against Stopping Eating and Drinking by Advance Directives (SED by AD). SED by AD is a type of advance directive in which a proxy is instructed to stop offering food and fluids to a person when they reach a certain stage of dementia. Although most conversations regarding SED by AD focus on patient autonomy and the right to determine one's care, we propose that the ethical principle of justice-the obligation to treat all individuals equally regardless of race, gender, and physical or cognitive ability-is the decisive principle in this controversy. We also suggest that implementing SED by AD can violate a physician's obligation to beneficence and nonmaleficence. On the other hand, we identify with the families of our patients who see the refusal to follow an advance directive as an injustice of the highest order. In the end, 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. If, on the other hand, one refuses food and fluid to a resident who still accepts food, one risks practicing an injustice against that person as they are now. Recognizing that we have the greatest responsibility to our patients as they present to us in the residential setting, 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.
AMDA-The Society for Post-Acute and Long-Term Care Medicine（“协会”）的伦理小组提出了支持和反对通过预先指示停止进食和饮水（SED by AD）的论点。SED by AD 是一种预先指示，其中代理人被指示在患者达到一定痴呆阶段时停止为其提供食物和液体。尽管关于 SED by AD 的大多数讨论都集中在患者自主权和决定自己护理的权利上，但我们认为，正义原则——即平等对待所有个体，无论其种族、性别以及身体或认知能力如何——是这场争议中的决定性原则。我们还认为，实施 SED by AD 可能违反医生的行善和不伤害义务。另一方面，我们认同我们的患者的家属，他们认为拒绝遵守预先指示是最高级别的不公正。最终，协会确信，在不实施不公正的情况下，这里无法做出任何选择：如果拒绝实施 SED by AD，就会侵犯制定预先指示的人的自主权。另一方面，如果拒绝向仍接受食物的居民提供食物和液体，就有可能对他们实施不公正待遇，因为他们现在已经这样了。协会认识到，作为在居住环境中为患者提供服务的专业人士，我们对患者负有最大的责任，因此协会建议在那些仍接受食物和液体的居民中不实施 SED by AD，而是为那些患有晚期痴呆症的患者实施舒适喂养政策。
