Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking

Dear Dr. Bolt and colleagues,

Thank you very much for highlighting this subject to the primary care community. As a young colleague in family medicine, I have not experienced a request for Voluntarily Stopping of Eating and Drinking (VSED) of patients yet, neither had I heard about it yet from senior colleagues, neither from professors teaching palliative care. I am suspecting a taboo to be in place, at least in my home country Belgium, to talk about this way of dying.

In my intuition, patients are even less informed about this way of dying. Now that you bring up the subject, my idea is that possibly some of the patients, at least those with a desire for hastened death, would ask themselves whether VSED would help them to die sooner and comfortably. But maybe they don't bring up the subject when talking with their doctors, just as a conversation on other end-of-life has often to be initiated by the doctor.

Now that I have read your contribution, I have better insights in the incidence and symptomatology of VSED. If in a conversation with a palliative care patient about the ways of (medically assisted) dying I will now be able to explain better what could happen if the patient starts refusing to eat and drink from a certain moment.

I am now considering to include this option as a valid one to be taken up in the general discussion of end-of-life issues. Usually, I try to talk with palliative care patients about their values for life, their ideas about in which cases they deem hospitalisation necessary and the overall intent of medical care (cure and/or care, ...) as a first step.

Sometime later, during one of the next home visits (I rarely see palliative care patients on consultations), and only when I feel the patients and the bystanders are ready to hear it, I bring the matter of what I call "the three ways of dying": (1) dying while supported by 'normal' symptom control, (2) euthanasia, which is a legal option also in Belgium (in your article called "physician-assisted suicide"), and (3) continuous palliative sedation in case of a refractory symptom in the terminal stage. I always present the first option as the preferred one, because I believe that death should be medicalized as least often as possible (most patients seem to agree with that). There must be good reasons, and well-noted medico-legal documentation for option 2 or 3.

During this general discussion of the ways of dying, the patient and I, often with some family members present, are speaking hypothetically about these options. Presenting hypothetical scenarios, early enough in the course of the disease, seems to be less confronting for the patient to think about what might happen.

I could expand my explanation of three to "four ways of dying" by telling patients and their family members something like this "Some people decide to hasten their death by voluntarily stopping of eating and drinking. This leads most of the time, especially when they don't drink anything, to death within a course of more or less one week. Sometimes it lasts for two weeks and seldom for a month before they die after having stopped eating and drinking. I want to stress, also for the family to know, that it can be normal for people in this stage of life to wake up and not to have the strength anymore to eat and drink - if that happens and no signs of reversible conditions would be found, then that is a sign of the normal course of life, leading to the final days of life. In most of those cases, stopping of eating and drinking happens just because the body is too tired to consume food and drinks. That is also the reason why doctors are reluctant to give artificial hydration and nutrition to patients in what we consider their final days of life. Do you have questions on this?"

It seems to me that, after having informed them once, having well answered the direct questions and given the opportunity sometimes, in other occasions, to talk about the subject again, only patients with a strong desire for this very specific way of dying will finally stop eating and drinking voluntarily.

Thanks again for your contribution. You had an impact on my way of counseling palliative care patients.

Competing interests: None declared