Society Recommends Comfort Feeding over SED by AD for Residents with Advanced Dementia

November 12, 2019

Although most conversations about stopping eating and drinking by advance directives (SED by AD) focus on patient autonomy and the right to determine one’s care, authors of a Society white paper in the November issue of JAMDA said that the ethical principle of justice is the decisive factor in this controversy. They noted: “We also suggest that implementing SED by AD can violate a physician’s obligation to beneficence and non-maleficence.”

The authors of Stopping Eating and Drinking by Advance Directives in Assisted Living and Nursing Homes, referred to discussions on this topic by AMDA – The Society for Post-Acute and Long-Term Care Medicine’s Ethics Subcommittee. They said, “The Society is convinced that no choice can be made here without practicing an injustice: if one refuses to implement SED by AD, one violates the autonomy of the person who drew up the advance directive.” In the end, the Society recommends against implementing SED by AD in residents who still accept food and fluids, implementing instead a policy of comfort feeding for those with advanced dementia.

While many lay people and some clinicians assume that SED by AD is identical to voluntarily stopping eating and drinking (VSED), the authors said, “the [Society] Ethics Subcommittee views the two as significantly different.” In VSED, they clarified, an individual with legal capacity will voluntarily stop all nutrition and hydration. Death generally occurs within several days to a few weeks after discontinuing intake. The authors stressed that SED by AD is not voluntary and that it “always entails stopping food and fluids for a person who is still accepting them.” The legality of VSED has been upheld in state and federal court, they explained, while SED by AD is “more fraught with legal, practical, and ethical complications.”

In summary, the authors said, “The Society affirms the right of all residents to receive comfort feeding until their behaviors indicates refusal or distress. We reject the notion that critical interests should be given more weight than experiential interests on the same grounds.” In addition, they stated, “We insist that staff in the homes in which we work should never be compelled to restrict a person’s access to food, a basic right for every human regardless of their physical or cognitive abilities.”

This paper was written by researchers at the SNF/LTC Partners of Virginia, Richmond, VA; Presbyterian Homes, Evanston, Illinois; Section of Geriatrics, Department of Medicine, NorthShore University Health System, Evanston, Illinois; and University of Rochester, Geriatric Medicine/Palliative Care, Rochester, NY.

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JAMDA is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. JAMDA publishes peer-reviewed articles including original studies, reviews, clinical experience articles, case reports, and more, on all topics more important to post-acute and long-term care medicine. Visit for more information.

About the Society for Post-Acute and Long-Term Care Medicine
AMDA – The Society for Post-Acute and Long-Term Care Medicine is the only medical specialty society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long-term care (PALTC) settings. Dedicated to defining and improving quality, we advance our mission through timely professional development, evidence-based clinical guidance, and tireless advocacy on behalf of members, patients, families, and staff. Visit for more information.