Still the same person?

Jake wrote an advance directive years ago that stated he would not want to receive life-sustaining treatments if he were to be diagnosed with dementia or another type of permanent cognitive impairment. He had many conversations with his family and friends over the years, stressing to them how a life of complete dependency would be intolerable to him, and he would rather die than live like that.

When he started having memory problems, and was diagnosed with Alzheimer’s disease, Jake contacted the Medical Assistance in Dying team and began the process of requesting an assisted death. Because the criteria included having the capacity to consent at the time of the procedure, he was prepared to die before he became incapable of providing an informed consent. This meant that Jake would likely die while he still had some time left before his cognitive impairments became so profound that he could no longer recognize his family, but he felt so strongly about it that he was prepared to forego some time in order to avoid that state of dependency.

Fortunately for Jake, however, the Canadian government passed* an amendment to the MAID legislation, permitting advance requests for assisted death. This meant that Jake could specify the point at which he wanted to die, and his substitute decision maker could provide the final consent at that time, even if Jake was no longer capable. In his new advance directive, Jake stated that he would like to receive an assisted death once he no longer recognized his wife. He went through the process of eligibility assessments and was provisionally approved by the team, for a time when his condition met the criteria set out in his directive.

Now, Jake is at that point. He lives in a personal care home and his wife and son visit frequently. He is still physically fit, able to walk around the unit and feed himself, but his family members are strangers to him. He is pleasant and friendly, and seems happy to sit and visit with anyone who wants to chat with him, even though most of what he says is gibberish. He likes to be busy, so the nurses often give him piles of washcloths to fold, and he seems to take great pleasure in stacking columns of tidy folded cloths for hours on end.

Lately, Jake’s wife and son have been discussing whether it is time to contact the assisted dying team again. Jake’s clinical condition certainly meets the criteria he set out in his directive. The problem is that he seems happy, not at all like he always believed he would feel if he was this dependent on care. But his substitute decision makers are torn between what they know of Jake’s wishes when he was well, and the man he has become.

*As of this writing, Parliament is still debating the exact wording of the amendment to this Act, but it is widely assumed that incapacity at the time of a scheduled assisted death will no longer strictly prohibit the provision, should the patient meet all other criteria.

Questions for discussion and consideration:

1. Can we consider Jake to be the same person he was when he made his advance directive? Why or why not? How does this affect the status of his request for an assisted death?
2. How might his current level of apparent contentment affect his eligibility for MAID?
3. What would you do you were the substitute decision maker in this situation?
4. What would you do if you were a MAID provider in this situation? Would you be comfortable going ahead with it? Why or why not?