New VSED Advance Directive — Progress, but Problems Persist

Abstract In their article, Pope and colleagues examine the ethical, legal, and practical complexities associated with the use of advance directives (ADs) to pursue voluntarily stopping eating and drinking (VSED) in the context of patients with advanced dementia. The authors detail the shortcomings of current VSED ADs, and they review a new VSED AD that they argue addresses these shortcomings and provides a better solution to the complexities associated with implementing VSED ADs. While the authors make a robust argument for the overall need and supportability of VSED ADs, this commentary highlights a problem that still persists even with the new VSED AD, specifically the absence of a robust ethical justification for continuing to honor the VSED AD even when the advanced dementia patient is requesting to eat or drink in the context of distress and suffering. Without this robust ethical justification, moral distress of family and caregivers is likely to occur, which could jeopardize the larger implementation of the VSED AD. Rather than pursue this more extreme measure without robust ethical justification, the commentary argues that the authors’ alternative proposal of minimal comfort feeding is the more practical and ethical strategy that best balances the patient’s longer- and shorter-term interests.