Alzheimer's Disease, Advance Directive and Feeding

Back on October 29, 2005, I wrote a post describing an elderly Alzheimer's patient with no other medical complications and who was aware of her environment but who years earlier when she had the mental capacity to make decision stated that she didn't want medical nutrition and hydration. A feeding tube was placed a few years earlier because of difficulty swallowing during a prolonged respiratory infection, with the intention that it would be temporary but the feeding tube still remained in the patient. The issue was whether removal of the tube now would contribute to her death and whether it should be removed.

On this current post, I would like my visitors to consider an elderly Alzheimer's disease patient who appeared to the caregivers that she was really not aware of her environment except when food or liquid is placed between her lips she appears to accept the feeding and swallows. The ethical issue is that years ago when she had capacity to make medical decisions she wrote in an advance directive that if she had an irreversible disorder that left her unaware of her family or others and couldn't care for herself, she would not want to be fed and should be allowed to die. She is tolerating oral feedings but should they be stopped in view of her past directive?

The ethical issue in both cases is whether if a patient rejects food and fluid by tube or even by mouth under some stated conditions in an earlier advance directive, should that request be followed? Should the patient's prior directive against being give nutrition be questioned either by trying to communicate with the demented person or by following the decision of a current legal surrogate? Should there be a difference between feeding a patient by tube or feeding the patient orally, if the patient doesn't resist the feeding? If a patient in end-stage Alzheimer's now appears to accept food and fluid orally, should that behavior trump any previous directive to the contrary? Is the currently demented person the same person (in terms of personhood) who signed the original advance directive? If not, should the advance directive be ignored?

Has any of my visitors had similar issues arise in the management of their own family member with Alzheimer's? ..Maurice.