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University Hospital
Advance
Directives in
Dementia:
An argument
Iraklis Pantelidakis
9-03-2015
La vie, Pablo Picasso,1903
Stages of Dementia
Predement
ia
Mild
dement
ia
Severe
Dement
ia
End
stage
dement
ia
Self
Agent:
Active partinitiating actions
Subject:
Passive partemotions and
experiences
Korsgaard, Christine. 1989. Personal identity and the unity of agency:
A Kantian response to Parfit. Philosophy and Public Affairs 18, no. 2: 101-132.
Stage 2
Stage 3
Pre-dementia
Mild Dementia
Severe Dementia
Stage 4
End stage
dementia
-Minimal remaining
consciousness
-Sense of self
partially
fragmented both
atomistically and
relationally
-Sense of self
completely
fragmented
atomistically and
relationally
- A functioning
agent
-Episodically
compromised
agency
- Permanently
compromised
agency
-Not functioning
agent
-A consciously
aware subject of
experience
-Consciously aware
subject of
experience
-Consciously aware
subject of
experience
-Not a consciously
aware subject of
experience
- - No remaining
sense of self
Bes
t
inte
rest
s
(pri
nci
ple
of
Surrogate
ben
decision-making
efic
enc
Advancee)
directives
Substitute decision-making
(precedent autonomy)
Informed Consent
The principle of autonomy
Buchanan and Brock (1990) Deciding for Others: The Ethics of Surrogate Decision Making
Cambridge University Pres
Bioethical question
In
The conflict
Critical
interests of
the agencys
precedent
state
Experiential
interests of
the current
state
Current
interest
Two rival philosophical
camps
view
(Dresser)
Extension View
(Dworkin)
The dominant tendency,
both
in
recent
legal
doctrine
and
in
the
bioethics literature, has
been to view the rights of
incompetent
individuals
as an extension of the
rights
of
competent
individual
Buchanan and Brock
The remaining
autonomy of the
current state
She gives weight to the
capacity to value as the
core feature of autonomy
and she propagates the
fact
that
certain
dementia patients hold
this capacity, at least in
an
elementary
form,
through
the
severe
stages of the disease
The integrity
view of
autonomy
The
integrity
autonomy
holds
view
a
of
basic
1.
2.
it
Balance
Subjective
value of
human life
Objective value
of human life
Intuitive truths:
.
There is always some connection with the past
self that is critical to the current state and provides
hints of the value load of the person and this is
obvious even in the posthumous state.
364
The argument
We
McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR Jr, Kawas CH,
et al. The diagnosis of dementia due to Alzheimer's disease:
recommendations from the National Institute on AgingAlzheimer's
Association workgroups on diagnostic guidelines for Alzheimer's disease.
Alzheimers Dement. 2011; 7:2639.
Biomarkers of AD
Biomarkers
even
asymptomatic
patients
with
positive biomarkers!
In the minimally symptomatic MCI (Mild
Cognitive Impairment) biomarkers are
used in order to individualize the future
risk to Alzheimers disease.
In dementia patients biomarkers are
used mainly to unravel and identify if
AD is the cause of the cognitive
disorder.
The converters
1996-1997