Stan Terman MD PhD psychiatrist and bioethicist Advance directives for dementia

May 07, 2025 -- Today, my friend Stan Terman MD PhD psychiatrist and bioethicist is presenting to the Network for End-of-Life Care. In his work, he is refining the language and procedures surrounding Advance Directives. As these documents are commonly written today, there are few provisions for the subtleties demanded by dementias. In that context, families must often struggle with healthcare decision-making. Often, patients don't get what they would have chosen. Stan is fixing that. He calls his solution a Natural Dying Living Will and you can create your own on-line.

Here are examples of issues that are often not well resolved by conventional Advance Directives:

  • Often, dementia sufferers cannot express to us what treatments they want (or don't).
  • High-tech health care may not be the issue; there might be no "plug to pull". Yet the wish might be to withhold interventions and let the disease run its course.

Stan identifies fifty specific dementia-related conditions to enable sufferers to specify their wishes with regard to each. These include:

  • serious medical illness causing severe pain
  • serious medical illness for which treatment provides little or no benefit
  • strokes
  • locked-in state
  • Lou Gehrig's disease
  • brain cancer
  • Persistent Vegetative State
  • disease that weakens swallowing such that thickened nourishment is needed to prevent pneumonia from aspiration
  • no longer able to toilet so that clothes become soiled and others must change diapers
  • many more

Using Stan's NOW Care Planning (for patients who are in an advanced stage of dementia and have no effective living will) for each of the fifty, the patient can choose one of:

  • CPRL -- one last CPR resuscitation attempt but if that fails, stop.
  • SLT -- "Selective, Limited Treatment" with or without a ventilator, dialysis, parenteral (tube) feeding, as I may choose.
  • "Natural Dying" -- don't spoon-feed me but leave food and fluids within reach.
  • Moderate anesthesia -- give me sedatives to calm me or make me unconscious of my suffering.

This approach also addresses such subtleties as:

  • Distinguishing "comfort feeding" from "comfort care" -- a patient may want the latter without the former, thus not prolonging dying and suffering.
  • The exigencies of different religions may be a factor in these decisions yet conventional Advance Directives often leave it to the patient to identify and plan for them. Stan offers language that helps with these.

Here is Stan's Effective Advance Care Planning for Late-Stage (Advanced) Dementia presentation. This is important work and addresses many of the flaws in the way we die today. Check it out!