Alan is 84 and suffers from late stage dementia. His advance directive, drawn up some 20 years ago, states that once he has lost capacity, he does not want to have any surgical procedures at all, even if required to save his life. Alan has recently taken to wandering outside his nursing home. Sometimes staff do not realise that he has slipped out until they see him in the garden unsupervised. On one of his unscheduled trips out Alan stepped on a rake which had been left out by the groundsmen. However none of the staff observed this incident, and Alan did not tell anyone he had hurt his foot. Consequently the injury went undetected to a point where Alan's leg is beyond saving and now requires to be amputated to save his life.

The nursing home staff and Alan’s GP are aware of his advance decision, but Alan himself is now visibly upset about being in such pain, begging them to do something to make the pain stop and make him well again. Alan’s granddaughter is firmly of the view that his dementia is so far advanced that these statements have no legal or moral force and should be ignored in favour of the clear statement Alan made while he had capacity, that he did not want treatment in these circumstances. What should happen to Alan, and how would you ethically justify the option you chose?