Clarifying the limits of advance directive in decision-making around food and nutrition in patients with dementia

This short piece is a reply to the response Professor Menzel made to the Shelton and Geppert paper, <i>The Limits of Advance Directives in Decision Making Around Food and Nutrition in Patients with Dementia</i>, which appeared in the January 2024 issue of the <i>Journal of Medical Ethics</i> We disagree with Professor Menzel's response to our paper that we fail to address situations at the heart of the Dworkin/Dresser debate regarding the tension between critical and experimental interests. The purpose of our paper was very practical: to delineate the types of situations in the progression of dementia when advance directives can be acted on and when they should not be acted on. Given that most patients, including many individuals with dementia, do not have advance directives, it is important for both healthcare providers and surrogate decision-makers to be keenly aware of their options for decision-making throughout the trajectory of dementia, especially if there is no advance directive. It is also important for all patients, especially ageing individuals, to understand the points at which advance directives are most important to have, as well as when they are less important, indeed sometimes how they are just not relevant to sound, ethical decision-making during the progression of dementia. Based on this analysis, it is important for individuals completing advance directives to know those limits and the stages of dementia at which they can and cannot be followed.