Members of AMDA–The Society for Post-Acute and Long-Term Care Medicine should adopt a policy of “comfort feeding” for certain assisted living and skilled nursing residents with dementia rather than honor advance directives that indicate criteria that otherwise would trigger an order to stop feeding them, recommends a resolution passed by the AMDA House of Delegates during the organization’s annual conference in Atlanta.
“We realize that many people will have a negative reaction to this,” James Wright, M.D., Ph.D., CMD, author of the resolution and vice chair of the AMDA Ethics Committee, told McKnight’s Senior Living. “Given the fact that healthcare providers typically view an advance directive as inviolable, this is a departure from our usual practice.”
Resolution A19, “Stopping Eating and Drinking by Advance Directives (SED by AD) in the ALF and PALTC Setting,” however, passed by “a wide margin” on Saturday, he said.
“SED by AD is a type of advance directive in which a person will direct his caregivers to stop offering food and fluids when he or she reaches a certain point of dementia,” Wright said. “The advance directive usually lists criteria that will trigger an order to stop feeding, such as ‘if I no longer recognize my spouse’ or ‘if I can no longer speak in legible sentences, I direct my caregivers to stop offering me food and fluids.’ ”
By offering comfort feeding instead, AMDA members would be “offering food and fluids to any resident who still accepts nutrition,” he said. “In essence, the healthcare providers of AMDA are urged never to force food on anyone, but also never to engage in forced nonfeeding.”
The committee’s recommendations are based on three considerations, related to justice, nonmaleficence and practicality, Wright said.
Violation of the principle of justice is the main issue, he said.
“We fully acknowledge that an injustice is performed when a provider refuses to implement SED by AD,” Wright said. “Advance directives, after all, are meant to direct the care of a person when they no longer are able to speak for themselves. To refuse to implement an advance directive is to practice an injustice against the person who wrote it.”
He and others who voted for the resolution, however, “strongly believe” that withholding food and fluids from someone who still shows interest in eating “is to perform a great injustice against that person, the patient for whom we are now caring,” he said. “After weighing the injustice of both approaches, we recommended that society members choose the injustice that does the least harm to our current patients by refusing to implement SED by AD.”
The resolution, Wright said, recognizes that those with advanced dementia have wishes and agency.
“Although much of the public tends to devalue the experience of a life lived with dementia, the providers of our society know that the people for whom we care, even those with advanced dementia, have lives of value, lives spent as part of a beloved community and lives worth sustaining,” he said. “If any professional group should stand up for and recognize the wishes and desires of those with dementia, it is the physicians, the physician assistants and the nurse practitioners of AMDA.”
Violation of the principle of nonmaleficence is a second consideration, he said.
“To implement SED by AD, the provider would be asked to not only write an order to deny one of his or her patients nutrition but could be asked to administer medications to decrease the anxiety and agitation associated with hunger and thirst,” Wright said. “This violates the physician’s duty to always work in the best interests of his or her patient.”
A third issue, he said, is impracticality.
“It is impractical to expect a facility to implement SED by AD, especially if the resident is actively seeking or showing interest in food,” Wright said.
For instance, he said, if a resident is still mobile, then a community would need to separate the resident from other residents during mealtimes and also watch other residents, staff members and visitors to ensure that the resident wasn’t given food by mistake.
“In a facility setting in which policies and procedures are in place to ensure that all residents are offered adequate nutrition, this would disrupt the typical processes to an extent that most facilities would find impractical or even impossible,” Wright said.