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The prevalence of dementia in the United States is increasing largely as a result of three factors: the number of elderly Americans is rising, the longevity of these elderly Americans is increasing, and the incidence of dementia increases with advancing age. [1] Because the prevalence of dementia is increasing, the medical and ethical problems of our demented elderly will rank among the most common issues faced in the future by American neurologists.
Ethical questions arising in the management of the demented patient vary as a function of the stage of dementia. In the early stages, issues of decision-making capacity and the execution of advance directives are paramount. In the middle and later stages, issues involving the appropriate level of medical treatment, decisions to restrain patients, and care-giver issues are most relevant. End-of-life treatment issues become the major ethical issues in the final stages of dementia. Problems resulting from impairments in the professional relationship between the neurologist and the demented patient can occur in all stages. [2]
The following statement summarizes the ethical issues arising in the management of the patient with dementia. It is intended to address how ethical considerations influence ideal patient management but is not intended to represent clinical practice guidelines.
Patient-physician relationship.
The neurologist's relationship with the demented patient can become impaired and thereby jeopardize its therapeutic potential for three reasons. Neurologists may unintentionally depersonalize demented patients because subconsciously they may equate the loss of intellect with the loss of personhood. Neurologists further may fear the loss of their own intellect and, in an attempt to maintain denial, avoid the patient and neglect the patient's medical problems. Finally, neurologists may feel an overwhelming sense of failure and therapeutic nihilism because of their belief that no therapy possibly can benefit a demented patient. If unchecked, these impairments may create a …
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