Loss of capacity and requests for meat

What does dementia mean for people on special diets, and those who cater for them?

The decision to be vegetarian or vegan often reflects deeply-held ethical, environmental, or religious convictions. But V for Life is currently only aware of two fully vegetarian care homes in the UK, offering Indian/Gujarati food. This means that people with vegetarian or vegan philosophical beliefs are likely to be a minority group in your care. They are already found in at least one in every five UK care homes, according to V for Life’s 2019 survey.

Some years ago an older woman, who had been a dedicated animal rights campaigner, entered care after developing dementia. While in care, she was given food containing meat – a practice considered acceptable by staff because she ‘wouldn’t know any different’ . Yet in spite of this she still identified as a vegan. We would hope that something like this wouldn’t happen today, but staff can still be daunted by the challenges of catering for vegetarians and vegans. Recently, care providers have highlighted instances where a vegetarian/vegan with dementia has demanded meat, or tried to take it from someone’s plate. In such circumstances, those who care for them are faced with a difficult ethical dilemma.

Why might this be happening?

A step back: Is your vegetarian or vegan service user definitely asking for meat?

It seems unlikely that a service user with dementia or cognitive loss will have reconsidered their philosophical beliefs while in care. In addition to communication difficulties, people with dementia can experience specific issues around recognising food types, as well as sensory changes (including taste).

It may be that someone desires the food that they see others eating, not realising that it is meat, or something that would otherwise go against their dietary beliefs or make them ill.

A wealth of alternatives to meat and dairy are now available, and these alternatives are commonly eaten by vegans and vegetarians in their own homes. In the comfort of familiar surroundings where food preferences are known, the shorthand of sausaqe rather than vegan sausage’, or pierather than vegetarian pie’ is in common use. A person with vegetarian or vegan philosophical beliefs is highly unlikely to be imagining meat when they eat these products meat is usually now seen as a non-food. But they may simply enjoy the convenience of products that are shaped to easily fit inside a sandwich. So in a mixed environment, when meat sausages are on the table, it is easy to see how mistakes in choice could be made.

How might this be avoided?

V for Life recently launched a Memory Care Pledge that will be taken by care homes up and down the UK.

This is to help ensure that vegetarians or vegans who have capacity issues, or cognitive losses, will be offered a choice of meals, drinks and snacks that uphold their ethical beliefs.

You can sign-up and request up-to-date best practice guidance and training here or by calling the charity on 0161 257 0887.

How might this be managed?

People with dementia and their carers have the right to be able to enjoy human rights and fundamental freedoms in every part of their daily lives, and wherever they are. This includes full respect for their dignity, beliefs, and individual circumstances.

Personal profiles such as the This is medocument (Alzheimers Society) help staff to know and understand a persons wishes. Please also see the suggestions on page 16.

There is a challenge, however, if a person‘s current wishes come into conflict with their previously held convictions e.g. they are now requestingmeat.

For an older person whose convictions will have been at the core of their identity for many years, a move away from their vegetarian/vegan beliefs may further undermine a sense of identity already threatened by cognitive impairment.

Many people would be reluctant to compromise religious beliefs or allergies.

You would expect care providers to think twice before offering a bacon roll to a Rabbi with dementia, or regular toast to someone living with coeliac disease, even if a refusal causes distress. A long-standing vegetarian or vegan‘s beliefs should be similarly respected.

There is legal protection for this, too. Preventing or limiting the life choices of vegans or anyone on a special diet through indirect discrimination could be seen as acting unlawfully.

Furthermore, a vegetarian or vegan who has not consumed meat or fish or, in the case of a vegan, dairy products for perhaps 50 years or more, may well find such foods hard to digest.

CASE STUDY: LEARNING FROM ADVANCED CARE DECISIONS

A key ethical problem is what happens if someone with dementia makes a decision that contradicts their previous wishes?

Consider the case of a 75-year-old woman with Alzheimer‘s, Mrs F. When Mrs F started to lose capacity, she changed her mind about issues that had once been extremely important to her.

Her husband wanted to respect her previous wishes, and so reminded Mrs F about what she had wanted when she had full capacity. Her carers wanted to respect her current wishes, and did not remind Mrs F about her previous wishes.

Is reminding someone with dementia about decisions they made when they had full capacity coercive, or helpful?

Should care workers respect the decisions an individual made before they lost capacity; or should they uphold the decisions a person makes since living with dementia? This is a big debate with no clear answer, and it is a debate that will continue to grow as dementia figures rise in the UK.

For vegetarians and vegans, this is a pressing issue. Many people want to avoid eating meat or animal products at all costs for the remainder of their lives but right now, there is no guarantee that these wishes will be respected in the case of dementia.

For those who are adamant that they want their previous, full-capacity decisions to be respected, there may be some useful lessons:

1 It is important to have the conversation about ones future wishes. This conversation should be had with witnesses, with all implicated parties, and if possible, everyone should agree to support the decision. If a vegan or vegetarian has had these important conversations ahead of time, then people will remember this conviction and should take it into account.

2 Advanced care planning no matter how many contingencies we plan for, we cannot foresee them all. Words, whether written or oral, are subject to varying interpretations. Still, written, audio, or video documentation of Mrs Fs wishes might have proved helpful.

They might have proved helpful in fortifying Mr Fs resolve, in convincing her caretakers of what her wishes were, and perhaps they might even have proved helpful in reminding Mrs F of what her wishes were and the reasons for them.

3 Language used should be carefully crafted, e.g. “In the future, if my decision-making capacity is questionable and I appear to want meat, please consider providing me with mock meat products in their place”. Although we cannot ignore a person’s current wishes, and an advanced plan cannot be completely fixed, such a statement could provide family and caretakers with guidance about how to proceed. It could also be that crucial piece of clear information that makes a carer feel assured in their decision to question or deny a resident’s present demands for meat, and instead try to advocate for them to eat a vegetarian or vegan meal.

Our suggested good practice is to consider providing foods that look similar but that allow vegetarians/vegans to eat in accordance with their beliefs without feeling excluded.

Vegetarian or vegan meat alternatives (mock meats’) are an obvious example.

Order a free advance-care planning guide from Vegetarian for Life by calling 0161 257 0887.