Neurofibrillary and Ethico-legal Tangles: In Search of Surrogates for Dementia Patients Lacking Decision-making Capacity and Relatives

Abstract

Singapore's greying population has led to an alarming increase in the prevalence of dementia, and inevitably to a rising number of dementia patients who lack competence and relatives. Although legislative provisions exist in the current Mental Disorders and Treatment Act (MDTA) for the appointment of committees of person and estate for incompetent patients, healthcare professionals continue to face challenging obstacles in their attempts to search for appropriate surrogate decision-makers for such patients. We illustrate, with 2 cases from our clinical experience, the ethical, legal and administrative tangles faced in our search for appropriate surrogate decision-makers. Specific problems, such as administrative ambiguities in applying the MDTA and the impracticalities of a rigorous judicial process in appointing surrogates, are discussed. We propose possible solutions how these obstacles can be effectively tackled, in particular adopting a radical shift from the present judiciary model to a clinical-based model of appointing surrogates for healthcare decisions. This clinical model is based on best interests considerations and emphasises peer review and a multidisciplinary consultative approach in determining the clinical merits of proposed treatment and its impact on quality of life. The ultimate aim of such a change is to facilitate timely medical care while ensuring ethical practices that respect the patient's dignity.