Annals of Long Term Care

Michael D. Cantor, MD, JD, Special Assistant to the Director, National Center for Ethics, Department of Veterans Affairs, Washington, DC, discussed when and if food and water can be withheld from a nursing home resident. There are three important considerations when making this determination: autonomy, surrogate decision-making, and the best-interest approach.

Dr. Cantor used a case discussion to illustrate a person who fits the common profile of someone who resides in a nursing home. Mr. Smith is an 89-year-old resident with advanced Alzheimer’s disease (AD) who is dependent for all of his activities of daily living (ADLs) and requires assistance with eating and drinking. His wife of 60 years is his health care proxy and surrogate. She has recently asked staff members if they would stop feeding Mr. Smith as “he would not want to live like this.”

The first question to be answered, according to Dr. Cantor, is regarding a patient’s autonomy and the authority of his family members to make this decision. The basic definition of autonomy is the concept that people have the right to make their own decisions. The idea of autonomy stresses that each person knows what is best for him or her as an individual, and under American medical practice and the law, it is recognized that patients have the right to choose what health care they do and do not accept, even when this decision can impact their length of life.

The above-mentioned case brings into question whether someone who has a terminal illness—in this instance,  advanced AD—can decide to stop eating and drinking, especially since this patient clearly lacks decisional capacity and does not have insight into the risks, benefits, or alternatives to his decision. Does this patient lose his autonomy to make this decision, or does someone else make that decision on his behalf?

The choice to eat and drink, unlike other decisions that health care proxies are usually asked to make, is not really a medical decision, according to Dr. Cantor. These actions fall into basic activities of living, aspects that are needed to continue to live, but are not necessarily technical or medically- directed. Therefore, the speaker asked, can people decide to have this nonmedical care withheld? Law and medical practice dictate that people have absolute power to make decisions about what medical treatments they choose or reject. In addition, it must be determined how much importance should be placed on a person’s previous wishes regarding eating and drinking. “Can we be sure that the person who now has dementia would have been able to predict  what he really would want in this condition?” questioned Dr. Cantor.

Generally speaking, surrogates are the best determinants for assessing what the patient would want; for example, in the case study, this person would be Mrs. Smith. However, the speaker stressed that the question remains as to whether some decisions are so fundamental to the care provided that others should not be allowed to make them. Mrs. Smith may not truly be capable of ascertaining whether Mr. Smith is being overburdened by eating and drinking and if he would really want to be “put out of his misery.”

When it becomes impossible to determine what someone would have wanted based on his or her prior decision, the “best-interest analysis” is employed by looking at this particular patient in the context of other patients who have received similar care or experienced similar circumstances and determining what the best outcome was for them. Dr. Cantor noted that,  generally speaking, it is difficult to argue that it is not in someone’s best interest to eat and drink, although there are exceptions to this likelihood.