Second, if the patient is not capable, who should make the decision This will depend on whether the patient has provided in advance for his or her own decision making; for example, by a lasting power of attorney (medical treatment) or by appointing an agent or a lasting guardian to make decisions when the patient is no longer able to do so. In some countries, a relative or caregiver is allowed to consent in certain circumstances (Skene, 2005).
Ethical issues begin immediately to arise at the time of diagnosis and may include whether to let the patients know the diagnosis. Giving a diagnosis can enable patients and families to plan for disability (including application for disability for those who are still employed), help ascertain patients' preferences about treatment and research participation, and facilitate support from family and community organisations (Weiner, 2004). However, this is best done in a supportive setting with adequate time to answer questions and deal with the patient's and family's emotional reaction (Post and Whitehouse, 1995). Many of the decision may include considerations of treatment, course of illness, the nature of the illness, and the availability of various options of support for the patient and family. Discussions of each person's values and preferences enable appropriate decision making in clinical situations that might arise later, such as the use of a feeding tube or resuscitative measures. On the other hand, conveying a definite diagnosis or discussing these issues may result in substantial uneasiness for patients and families alike, and such issues may need to be raised slowly over the course of continued visits--or be raised only with the family members responsible for patients' ongoing care (Weiner, 2004).
Decision-making capacity of the patient changes as the disease progresses. The capability of the patient with dementia to decide for himself should be respected in principle. Any evaluation of the patient must be made of both his capacities and incapabilities. A medically important area of decision making is that of accepting treatment with a cognitive enhancer or neuroprotective agent. These medications currently provide temporary slowing of progression and, in some cases, minimal cognitive improvement however they do not affect long-term outcome of the disease process. Considering the present level of effectiveness of these medications, it is suitable for patients to decide the desirability of taking them based on personal values or medication side effects (Weiner, 2004).
As dementing illnesses progresses further, decisions may need to be made by proxy decision-makers. In general, proxy decision-makers should be people who have knowledge and respect for the patient's values and opinions. When possible, proxy decision-makers should make decisions based on the patient's view, but there are times when decisions must be based on what the proxy decision-maker regards as best (Weiner, 2004). It is advantageous if the proxy decisio