Dementia and the Advance Directive by Marcia Sokolowski

Author:Marcia Sokolowski
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Concluding Remarks

Let us return now to how we might continue to understand what to do, if anything, with Mrs. Black’s advance directive. I would look to the advance directive not as the sole determinant in terms of what action to take, but rather as a particular tool. There is no value in choosing an approach that privileges the “then” person over the “now” person or vice versa. Both the autonomy and best interest standards have strengths and limits, so perhaps there is merit in using the advance directive to guide decision-making, but not in its usual way.54

Before I explore this idea more fully, let us review some important points. First of all, I have noted a number of problems that surround an advance directive : prediction problems, irreversibility, and both insufficient knowledge and insufficient appreciation of the pitfalls of having an advance directive. While some of these problems occur in everyday kinds of decision-making, there are particular degrees and types of problems that occur with advance directives that make them more problematic. Despite their limitations, I suggest we can still look to them not so much as an act of will that specifies what specific action to take, but rather as a piece of personal information that hopefully tells us something about Mrs. Black’s values and wishes, as expressed at a certain time in a particular context. Clearly, we can tell from her advance directive that there were certain values that she was expressing. For me, one important question is similar to what Davis was getting at, and I state it as “what does Mrs. Black value about her existence today?” And when that question is pondered and responded to, by those in the best situation to draw inferences from her current behavior, then I would ask, “Is there anything in what Mrs. Black wrote in her advance directive that could help us better understand and appreciate her wishes and values now?” An advance directive might also prove useful when we are really in the dark about what a patient’s values and best interests might be. A situation as such would probably be limited to very end stage dementia where the patient is close to being in a coma or near death.55

Prior to the very end, however, we have a person whose interests probably are either quite evident or potentially could be, if we take the time to get to know them as much as we can from this particular person’s perspective of being in the world. This is a tall task undoubtedly, and not without its challenges, but it should be attempted. We start with the wishes we see being exhibited and look as well to this person’s best interests.56 This will be challenging because we then move into the subjective interpretation territory again and we know the limitations of such a world already. It is also perhaps an impossible task to calculate a balancing of risks and benefits because again these will be subjective in nature and also

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