Self-determination, care and necessity as justification
If there is necessity as justification (Section 34 StGB; Sections 630d,e BGB) in which a medical intervention must be carried out for the benefit of the 'body' or 'life' of a person suffering from dementia, and if at the same time there is no opportunity to inspect any living will or to question any custodians or representatives, this may also be carried out without consent. In addition to coercive treatment, this includes measures such as confinement or placement in a closed psychiatric facility (Section 1906 BGB; Sections 312 et seq. FamFG). The (subsequent) approval of the custodianship court is usually required for the accommodation of patients.
Furthermore, a custodianship court may review decisions of the custodians or authorized representatives about medical measures if they may result in the death of the person under custodianship or in serious and long-lasting damage to health (Section 1904 BGB) as well as to measures involving deprivation of liberty (Section 1906 BGB) and so-called coercive medical treatment (Section 1906a BGB).
Such an additional review by a custodianship court is not necessary if an existing living will of the persons under custodianship shows that the implementation or omission of the measure corresponds to the will of the person. Insofar as the living will contains statements to this effect, this also includes the implementation or omission of measures which the person under custodianship, who is already incapable of giving consent, refuses to take. These constellations usually occur in the context of measures that deprive people of their liberty, such as restraint with bed belts or medical treatment which they attempt to evade. In order to ensure that these are measures for the benefit of the person and that it can be assumed that the refusal is due to illness, Sections 1906 and 1906a contain supplementary provisions which must be fulfilled in order to take such measures.
See for the relevant legal regulations:
Federal Ministry of Justice. German Civil Code (BGB). Unofficial table of contents. Online Version (German)
Federal Ministry of Justice. Act on Proceedings in Family Matters and in Matters of Non-contentious Jurisdiction (FamFG).Online Version (German)
Federal Ministry of Justice. Criminal Code (StGB).Online Version (German)
The Federal Ministry for Family Affairs, Senior Citizens, Women and Youth provides general information in its information portal "Wegweiser Demenz":
Bundesministerium für Familie, Senioren, Frauen und Jugend (2024): Wegweiser Demenz. Rechtliches. Rechte und Pflichten. Online Version (German)
More on the issue of confinement measures, coercive medical treatment and contrary natural expressions of will:
Gertz, H.-J. (2018): Rechtlicher Rahmen: Einwilligungsfähigkeit und ihre Substitute, Fahrtauglichkeit. In: Jessen, F. (ed.): Handbuch Alzheimer-Krankheit. Grundlagen – Diagnostik – Therapie – Versorgung – Prävention. Berlin, Boston: De Gruyter, 174-186, 176, especially 180f. (German)
Raack, W. / Thar, J. (2022): Leitfaden Betreuungsrecht für Betreuer, Vorsorgebevollmächtigte, Angehörige, Betroffene, Ärzte und Pflegekräfte. 8. Aufl. Köln: Bundesanzeiger. (German)
Stechl, E. / Knüvener, C. / Lämmler, G. / Steinhagen-Thiessen, E. / Brasse, G. (2012): Praxishandbuch Demenz. Erkennen – Verstehen – Behandeln. Frankfurt a.M.: Mabuse, 271f. (German)
See for an ethical consideration of the conflict between self-determination and care:
Rippe, K.-P. (2018): Alzheimer-Erkrankungen, Autonomie und zwei Paradigmen der Pflegeethik. In: Deutsche Zeitschrift für Philosophie 66(1), 75-86. doi: https://doi.org/10.1515/dzph-2018-0007 Online Version (German)
Deutscher Ethikrat (2012): Demenz und Selbstbestimmung. Stellungnahme, insbesondere 68f. Online Version (German)
Deutscher Ethikrat (2018): Hilfe durch Zwang? Professionelle Sorgebeziehungen im Spannungsfeld von Wohl und Selbstbestimmung, 172 ff. Online Version (German)
Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e.V. (DGPPN) (2014): Achtung der Selbstbestimmung und Anwendung von Zwang bei der Behandlung psychisch erkrankter Menschen. Eine ethische Stellungnahme der DGPPN. In: Der Nervenarzt 11. doi: 10.1007/s00115-014-4202-8 Online Version (German)
Knell, S. (2022): Demenz: Ethische Aspekte. In: Sturma, D. / Lanzerath, D. (ed.): Demenz. Naturwissenschaftliche, rechtliche und ethische Aspekte. Baden-Baden: Verlag Karl Alber, 143-148. Online Version