Have you ever wondered what it means to be a person, what it means to be you? And who really are you?

A cornerstone of modern medical ethics is the right to self-determination, the right to autonomy. Patients should be allowed to make their own medical decisions, which means a person should be allowed to make their own medical decisions. But how do you define what a person is?

This may seem overly philosophical and with no real application to the real world, but with situations such as cognitive decline in patients and dementia, this can have a real impact. Take this scenario:

A patient had been recently diagnosed with dementia and, also recently, lost her husband. She was following an advance care plan, had signed an advance directive, and had said that she would not want any medical interventions if a situation were to come where she needed to be hospitalized or intubated. She would rather just be made comfortable and allowed to pass. Naturally, she would not want any aggressive measures.

This was documented, but during the conversation she had made statements such as, “I don’t really understand why we’re doing this, I don’t really want to live, and I don’t see the purpose of all this.” At the time, she was grieving the loss of her husband.

Now several years later, this patient had been living in a nursing facility with assisted care and has completely lost capacity. Her dementia has grown, and she is essentially at this point a different person. She does not have the same memories or same medical preferences. While at this nursing facility, she found another resident and they have fallen in love together.

She recently had a fall and broke her hip. She comes to our hospital and when we’re talking to her, she says things like “I want to live, I love my life, I am so happy now. I would want you to do everything.” But she doesn’t have capacity due to her dementia. And we have an advance directive on document that says, “don’t do any medical interventions.”

The question was proposed to the ethics team: Do we honor the previous advance directive and allow that patient to naturally pass, or do we do what the patient who is looking us in the eye wants and save her life? Was this even the same person, the same patient that had signed that advance directive in the past?

These were very challenging, complicated questions regarding the nature of personhood, the nature of who we are and how we make medical decisions for ourselves, and also how we make medical decisions for ourselves in the future.

These can all be complicated and very challenging, but there’s something that we need to reflect on. These situations are going to continue to increase as recent studies show that dementia and other cognitive decline diseases are going to severely impact more and more patients. Are we as a healthcare system prepared to address these situations as we have more patients who may not even have the opportunity to have their wishes expressed or understood due to their dementia, and dementia cannot be perfectly managed with advance directives?

These situations are going to continue to get worse and become more prevalent, and we as a society, and as a country, and as a healthcare culture need to be ready to address this. We need to come together to discuss and solve situations like this. Maybe we won’t be able to define what a person is, but we can at least come with a plan to show these patients dignity and respect through all ways.