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.