RCSIsmj Ethics Challenge winner 2012/2013: Implementation of an advance directive in a case of dementia

Although there are many ethical reasons supporting possible decisions, in this case the most ethical decision is to uphold the AD of Mr R. The autonomous decision as outlined in the AD is of greater significance than the physician’s obligation of beneficence. The following criteria assess the validity of the AD: 1. The person must have been competent when he or she formulated the AD. 2. The refusal of treatment must have been made voluntarily, unequivocally, and without duress. 3. The refusal of treatment must represent a ‘firm and settled commitment’ rather than an offhand remark that informally expresses a reaction. 4. The advance decision must have been made with reference to and intended to cover the particular circumstances that subsequently occurred. 5. The person must have known in broad terms the nature and effect of the treatment to which he or she was refusing consent. It is clear that Mr R’s AD is perfectly legitimate and it must be upheld. The medical staff and family members should come to a consensus that Mr R should not be given antibiotics and should be allowed to die as he intended.