Dementia: Legal and ethical dilemmas

Nursing in general presents us various ethical and legal challenges, and sometimes the

complications associated with medical care can produce some of the most difficult quandaries

imaginable. These dilemmas though, are magnified once we begin to consider patients who have

problems in terms of being able to provide consent. Even then though, the issues can be resolved if the

person is a persistent vegetative state, or some other non-responsive condition where consent, beyond

any written testaments, and the wishes of next of kin, is no longer necessary in order to render

treatment. But what happens when the person is responsive and conscious, yet their mental faculties are

such that they may be confused about their own memories. That is is exactly the situation facing the

nursing profession when it comes to caring for patients who have dementia, or Alzheimer's.

One of the characteristics of dementia, at least in the early to middle stages of the disease, are

the episodes of memory loss and disorientation which come and go, dependent on the severity of the

case. Sometimes the patient might be fully aware of their status, and recognize people in their lives

quite well, at other times though, they may be completely unable to recognize familiar faces(). Patients

experiencing either temporary or sustained episodes of memory loss may thus deal with any medical

professionals caring for them, with fear and even hostility. Such feelings can even be directed towards

friends and family, resulting in situations that could pose a danger to both the patient and others.

Further, patients who find themselves in unfamiliar locations, such as a residential treatment center at a

hospital, could decide to leave, and end up wandering alone in the streets without any idea of where

they are or even where home could be. Given that, some hospitals in Scotland have begun

contemplating using risk bands to track patients and make sure that those with serious mental

impairments such as dementia, do not leave the premises unattended(Peev, 2007). While that would

certainly help with protecting patients, it also raises the question of what sort of rights do dementia

patients have in terms of being able to make autonomous decisions. One of the fundamental qualities of

being an adult citizen, is being able to exercise ones rights in a variety of contexts, thus measures which
are highly restrictive in terms of personal freedom for dementia sufferers, could be considered counter

to the principles of a free society. Still, there are already precedents where dementia have been grounds

to deny certain legal rights in order to protect patients and the public at large. An example of this is the

rescinding of drivers licenses to those who suffer from alzheimer's (Grattan, 2003).

Additionally, it seems difficult, given the episodic nature of much of the disease symptoms, to

say for certain when a person is impaired, and when they are not(Monaghan, 2004). Thus maintaining a

clear line of legal authority when it comes to deciding on medical treatments can be quite problematic.

A patient might for example be coming into a hospital for dialysis treatment, without which they will

die, if they suddenly can't remember that, does the medical staff have authority to compel the patient to

undergo treatment, even though they are fully responsive? Such scenarios make it clear that there are

no easy answers when it comes to caring for patients suffering from dementia. Because of those

difficulties, it is necessary to maintain a good and open dialogue with those in the early stages of the

disease. Levels of care can be determined, and the family can be brought in to asses certain

responsibilities once the disease progresses to the point of causing severe disability(Australian

Government Department of Health and Aging, 2006). This approach has already been shown to be

useful in cases where the patient can no longer feed or drink for themselves(Eggenberger & Nelms,

2004). Therefore while the legal and ethical dilemmas that come with caring for dementia patients are

quite large, there are options which are available in order to help address those dilemmas in the most

just, compassionate, and practical way possible.

References

Australian Government Department of Health and Ageing. (2006). Guidelines for aPalliative Approach

in Residential Aged Care/Prepared by Edith Cowan University. Canberra: A.C.T. Retrieved October 29,

2007, from http://www.health.gov.au/internet/wcms/publishing.nsf/Content/palliativecare-pubs-workf-

guide.htm
Eggenberger, S., & Nelms, T. (2004). Artificial hydration and nutrition in advanced Alzheimer's

disease: facilitating family decision-making. Journal of Clinical Nursing, 13, 661 – 667.

Grattan, M. (November 3, 2003). Hazel Hawke: I have Alzheimer's. The Age [Electronic Version].

Retrieved October 29, 2007 from http://www.theage.com.au/articles/2003/11/02/1067708071324.html

Monaghan, C., & Begley, A. (2004). Dementia diagnosis and disclosure: a dilemma in practice.

International Journal of Older people Nursing, 13(3a), 22-29.

Peev, G. (2007, Friday 20 April). Elderly dementia clients could be tagged. The Scotsman [Electronic

Version], Retrieved June 17, 2007, from http://news.scotsman.com/health.cfm?id=606882007