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Whether, When, and How to Honor Advance VSED Requests for End-Stage Dementia Patients

The Director of Nursing at the Pleasant Valley Nursing Home has requested an ethics consultation for guidance on whether the staff should follow the directions of a resident’s health care agent. Rhea, the agent, has asked the staff to stop spoon feeding Gertrude. Gertrude has end-stage dementia. Rhea explains that Gertrude did not want any orally or artificially ingested food or fluids under those circumstances. She wanted to voluntarily stop eating and drinking (VSED). 
 
The ethics consultant should ask (and answer) at least six questions: 
1. Is the advance directive valid? 
2. Who is the decision maker? 
3. Has Gertrude, in fact, requested forgoing spoon feeding? 
4. Does Rhea have authority to direct forgoing spoon feeding? 
5. Is Rhea complying with applicable decision-making standards? 
6. Does Gertrude’s opening and swallowing trump contrary instructions?