A cluster of three articles in the September/October Annals of Family Medicine address the sometimes controversial practice of patients deliberately hastening death by voluntarily stopping eating and drinking.
First, in a report from the Netherlands, researchers examine physicians' involvement with VSED to better understand the characteristics and motives of their VSED patients and describe the process in terms of duration and prevalent symptoms in the last days of life. The survey of 285 family physicians revealed VSED is not uncommon in Dutch primary care and seems to be a relatively comfortable way to hasten death if sufficient palliative care is available. Specifically, the researchers found almost one-half (46 percent) of respondents had cared for a patient who hastened death by VSED, and they found that patients' motives to do so were both physical and psychosocial. Patients who decided to use VSED were mostly older than 80 years (70 percent), in poor health (76 percent had severe disease), and were dependent on others for everyday care (88 percent). Data showed the median time until death was seven days, and the most common symptoms before death were pain, fatigue, cognitive decline and thirst or dry throat. Most patients electing VSED involved others for support (86 percent); family physicians were involved in 62 percent of cases. The authors conclude that family physicians can play an important role in caring for VSED patients and their proxies by providing them with information on VSED, support and symptom management.
In a pair of point-counterpoint editorials, two authors explore the ethical quandaries and practice issues in end of life care. Lynn A. Jansen, RN, PhD, at the Center for Ethics in Health Care in Portland, Oregon, asserts that if one has reservations about physician-assisted death, then one ought to have reservations about VSED as well. She writes that advocates of PAD often present VSED as an alternative treatment option for end of life suffering that avoids moral controversy. In reality, she argues, because VSED is understood as a clinical practice or treatment option presented by physicians, it raises challenging moral questions about the permissibility of physician collaboration in patient decisions to end their life as a means to ending their suffering.
Timothy E. Quill, MD, at the University of Rochester Medical Center in New York, asserts that VSED can be an important option for some suffering patients who wish and early death, but he concurs it is similar to PAD in many ways and should be subject to guidelines similar to those that cover PAD, including 1) clear understanding of the disease and prognosis, 2) careful evaluation of the patient's unacceptable suffering 3) full access to modern palliative measures, 4) ensuring the patient's full decision-making capacity, and 5) an independent second opinion by a palliative care expert. He concludes both PAD and VSED should be available as a last resort, but cautions the meaning attached to VSED can vary considerably from a welcomed, patient-controlled escape to an absurd end that adds to suffering as much or more than alleviating it because of the time it takes.
By Eva E. Bolt, MD
VA University Medical Center, Amsterdam, The Netherlands
By Lynn A. Jansen, RN, PhD
Center for Ethics in Health Care, Portland, Oregon
By Timothy E. Quill, MD
University of Rochester Medical Center, New York