Voluntary Stopping Eating and Drinking

by Mark Hughes, MD, MA

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    00:01 Another concept that we should consider in palliative care, especially for patients toward the end-of-life, there may be some patients when they still have capacity, when they are, you know, still, you know, able to make their own decisions, decide that they want to discontinue eating and drinking.

    00:21 So they feel that they are suffering from their condition, maybe it's a terminal illness.

    00:26 And one means of them deciding to end their life would be discontinuing any eating or drinking.

    00:34 So they're not going to get any nutrition and hydration.

    00:37 So the patient is, generally considered physically able to take nourishment, but now is making an active decision to discontinue any kind of oral intake.

    00:47 And, you know, depending on how long the person, you know, decides to discontinue these fluids or you know, any kind of nutrition, death is expected to happen within one to three weeks.

    01:00 So, it'll be that they'll develop dehydration that leads to renal failure and so on, and they will die or as they become, more and more delirious or unconscious, there's going to be other some intervening complication and pneumonia or infection that causes their death.

    01:22 Now, it is the case that many patients, if they have an advanced illness or terminally ill, just sort of naturally their body loses their appetite.

    01:32 They will have decreased oral intake of food and fluids.

    01:36 So that's part of the process of being terminally ill.

    01:39 But here, there's also a conscious decision just to not take in any food or fluids.

    01:47 And this is controversial, so there are places where assistance in dying is available.

    01:54 So that might be, you know, prescription medication, there might be euthanasia available.

    02:01 But this is a means of the patient sort of taking trial and voluntarily making this decision that they wish to stop eating and drinking and have that lead to their death.

    02:12 So the expectation is that this is an informed patient, they have capacity.

    02:17 This is part of the same calculation that a patient can do refusal of any any treatment.

    02:23 And voluntary stopping eating and drinking is just one other kind of refusal for them.

    02:28 It's an extension of that basic right to refuse treatment if they if they do not wish to receive it.

    02:34 There are some, you know, interesting questions that should be asked.

    02:38 And again, your worldview may influence how you think about these questions, I'm just going to pose them and have you think about them, how you would answer them, or how you would counsel a patient to think about these things.

    02:52 So in another lecture, I talked about the difference between ordinary and extraordinary treatment.

    02:57 Ordinary treatment would be something that you expect there's a benefit, and typically a person would be obliged to, you know, pursue a treatment that would keep them alive.

    03:06 Whereas an extra ordinary treatment or extraordinary treatment is one where the burdens outweigh the benefits, and therefore the person is not obliged to pursue that treatment.

    03:18 So for voluntary stopping eating and drinking, VSED, as I'll call it, there is this question, does a person have an obligation to try to maintain their life? You know, is there an expectation that they should try to eat even if they have decreased appetite, they should try to take in some nutrition.

    03:37 Different religious viewpoints might say, that there is that obligation.

    03:41 Other people with a different worldview would say, No, they don't have that obligation, they have a right to die if they so desire.

    03:48 Another question to consider.

    03:50 So if this is voluntary and done just by the patient, some patients might decide not to even involve the physician or health care team in these decisions, the concern there as well, if physicians are not involved, are there possibilities that there could be treatable depression that would be missed.

    04:10 So if the person is making this decision out of a mental illness out of depression, if you are treated the depression, might they have changed their mind for this desire for hasten death, and instead chosen to continue eating? Another question for you to think about.

    04:26 So what is actually causing the death of the person? As I said, it's typically going to be in cases where there's a terminal illness, and the person has intractable suffering.

    04:37 When they stop eating and drinking, are we going to say that the cause of death is the underlying disease? Or is it more as a result of the patient's will and resolve to bring about their death by not taking in the nutrition hydration? Another question, so will the patient experience thirst and hunger? So will that contribute in any way to their suffering? So while they're conscious, there might be a dry mouth, they might feel thirsty, they might feel hungry, is that a contributor to their suffering rather than a way to relieve their suffering when they made this this conscious decision? As they become, you know, less than less aware of what's going on, if they, you know, become so dehydrated that they go into uremic unconsciousness, then maybe they're not experienced any kind of thirst or hunger, but while they are still conscious and voluntarily deciding not to eat and drink, are they in any way contributing to their suffering? Another question, so what should those that are around them, whether they're involved with clinicians or its family members, how do we know that it is actually a voluntary decision and and they're maintaining their voluntariness to follow through in this? So is it a matter of continuing to offer them the opportunity to eat and drink? Or if we keep doing that and saying, "Do you want to eat? Do you want to drink?" Is that actually undermining the patient's resolve? Or is it a way to sort of confirm their voluntariness in the decision? It might be better to just ask amore general question of is this you know, something you want to continue doing? Rather than you know, putting food in front of their face or a drink in front of their face and say, Do you want this? That might be too damaging to them? Alright, another question to think about for VSED.

    06:34 So as I said, as a patient becomes more dehydrated, they're going to lose their mental clarity.

    06:40 So how can we be sure at that point that the act is still voluntary, as we get toward the end of the process, someone's going to need to continue not offering them the nutrition and hydration, as they become more and more unconscious.

    06:56 So how do we know that it is still a voluntary act? Difficult situation, something to consider, you know, especially if you're a clinician and a patient is offered, this is something that they want to consider, needs to have an informed consent process to really talk about all of these issues.

    07:15 So when this has been proposed in the ethics literature, you know, there are certain safeguards should be put in place to make sure that we're protecting vulnerable patients who might be considering this as an option.

    07:27 So top of the list is that there should be excellent palliative care.

    07:31 So similar to when we were thinking about, you know, the doctrine of double effect, we should make sure that we are delivering, you know, good palliative care to ease any of the symptoms or distress or suffering that they might be experiencing, so that that's not, you know, pushing them to make this decision.

    07:51 Patients should be fully informed of their condition, they should understand what the risks and benefits of voluntary stopping eating and drinking are.

    07:58 They should be told what the alternatives are, that there are other ways to help them with their suffering.

    08:07 Really, this should be voluntary, so we need to confirm that the patient has come to this voluntarily, it's a decision that they've made by themselves.

    08:14 It's not the result of undue influence.

    08:18 And, you know, we don't want either a family member or a clinician to propose this to them as an option, it really should be something that the patient voluntarily comes to themselves.

    08:28 And that decision should be enduring.

    08:30 So maybe there's some period of time to make sure that they are consistent that this is something they want to do.

    08:37 Just to make sure that the vulnerability has been addressed adequately.

    08:42 Generally, you would want to have an independent second opinion, both to confirm what the diagnosis of the patient is, you know, if it is a terminal illness, what their prognosis is, to confirm that the patient has decision making capacity, to review what the palliative measures that have been used, and make sure are there any other things that we could do to help relieve the symptoms.

    09:06 Make sure that you know this desire for hasten death is not due to treatable depression or if there is mental illness, try to treat that first.

    09:15 And see if the patient might change their mind about voluntary stopping eating and drinking.

    09:20 And really give you know, the second opinion, having the patient meet with that other clinician is an opportunity for them to reconsider their decision, make sure really they are consistent in it.

    09:33 And because you know, the doctor patient relationship is intimate.

    09:36 It's, you know, a one on one relationship, we really as a safeguard, really need to know that there's a means of accountability when this is being considered.

    09:48 So there should be adequate documentation of the discussion with the patient and their enduring desire to pursue this.

    09:58 There should be some review by other clinicians to make sure that this is, you know, consistent with all these safeguards.

    10:05 And, you know, again, some patients may decide to go down this path and choose this option of voluntary stopping and eating and drinking.

    About the Lecture

    The lecture Voluntary Stopping Eating and Drinking by Mark Hughes, MD, MA is from the course Ethical Considerations in Palliative Care.

    Included Quiz Questions

    1. Death
    2. Decreased side effects of treatment
    3. Decreased pain
    4. Decreased bowel movements
    5. Increased appetite
    1. 1 - 3 weeks
    2. 1 - 3 days
    3. 1 - 3 months
    4. 1 - 3 hours
    5. 1 - 3 hospital admissions
    1. Informed patients with capacity can refuse nutrition.
    2. Informed patients without capacity can refuse nutrition.
    3. An informed patient without capacity can allow families to refuse patient nutrition.
    4. An uninformed patient with capacity can allow families to refuse patient nutrition.
    5. Informed patients with capacity can accept nutrition.
    1. Excellent palliative care
    2. Full information about risks and benefits
    3. Voluntary enduring decision
    4. Documentation and review
    5. Dependent second opinion
    1. Surgical oncology services
    2. Palliative care services
    3. Full information on alternatives
    4. Voluntary decision
    5. Independent second opinion

    Author of lecture Voluntary Stopping Eating and Drinking

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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