Research ArticleOriginal Research

Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking

Eva E. Bolt, Martijn Hagens, Dick Willems and Bregje D. Onwuteaka-Philipsen
The Annals of Family Medicine September 2015, 13 (5) 421-428; DOI: https://doi.org/10.1370/afm.1814

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Cumulative survival curve for duration until death after start of VSED.

    VSED = voluntary stopping of eating and drinking.

    Note: Median time to death was 7 days. Data for 86 patients; 10 responding physicians did not remember, and 3 missing (13.1%).

Tables

  • Table 1

    Background Characteristics of Physician Respondents: Family Physicians With and Without VSED Experience

    CharacteristicTotal (N = 708)Experience With VSED (n = 313)No Experience With VSED (n = 383)
    Age, y
     Mean (SD)a50 (8)52 (8)49 (9)
     Range31–7232–7031–72
    Sex, male, %616260
    Is religious, %b373639
    Working experience as family physician, y
     Mean (SD)a19 (9)20 (9)18 (9)
     Range1–422–391–42
    Additional expertise, %
     Received training in palliative carec737572
     Palliative care consultant223
    Experiences with VSED, %
     Experience with VSED46100NA
     Experience with VSED in the last year919NA
    Palliative sedation in VSED, %
     Has administered palliative sedation in case of VSED2347NA
     Conceivable to administer palliative sedation in case of VSEDa,d,e819073
    PAS, %
     Has performed PAS798277
     Conceivable to perform PASd939392
    VSED and PAS, %
     Has ever suggested VSED to a patient with a wish for PASa344921

    • NA = not applicable; PAS = physician-assisted suicide; VSED = voluntary stopping of eating and drinking.

    • Note: Missing values ranged from 1.0% to 3.8%, unless otherwise specified.

    • ↵a Significant difference between respondents with experience with VSED and respondents without this experience, calculated by Fisher’s exact test (2-tailed) for dichotomous variables and by independent t test for continuous variables. P <.001 in all cases.

    • ↵b As described by respondent. Religion was Christianity in 93% of cases.

    • ↵c Not including regular curricular training.

    • ↵d Physicians who had done so were categorized under conceivable.

    • ↵e Missing values for 13.1%.

  • Table 2

    Characteristics of 99 Patients Who Hastened Death by VSED

    Characteristic% (95% CI)
    Age at the time of death
     ≤65 y6 (3–13)
     66–80 y23 (16–33)
     >80 y70 (60–78)
    Partner
     Yes25 (18–35)
     No, widow(er)64 (54–72)
     No, other11 (6–19)
    Residence
     Home (independently or with family)52 (42–62)
     Residential home42 (33–52)
     Hospice5 (2–12)
     Other1 (0–6)
    Diagnosisa
     A somatic disease, not cancerb39 (30–49)
     Cancer27 (19–37)
     (Early-stage) dementia12 (7–20)
     Psychiatric disease7 (3–14)
     No severe physical or psychiatric disease24 (17–34)
    ECOG performance statusc
     04 (1–10)
     18 (4–15)
     211 (6–19)
     347 (38–57)
     429 (21–39)
    Life expectancy
     <1 wk2 (0–8)
     1–4 wk32 (23–41)
     1–12 mo41 (32–51)
     >1 y26 (18–35)
    Patient was mentally competent
     Yes90 (83–95)
     Partly7 (3–15)
     Nod2 (0–8)

    • ECOG = Eastern Cooperative Oncology Group; VSED = voluntary stopping of eating and drinking.

    • Note: Missing values ranged from 0.0% to 5.1%.

    • ↵a Respondents could give one or more answers.

    • ↵b 10% Neurologic disease, 10% musculoskeletal or rheumatic disease, 9% cardiovascular disease, 7% respiratory disease, 6% sensory loss or general decline, 4% pain syndrome, 3% diabetes, 4% other.

    • ↵c ECOG performance status: (0) fully active; (1) restricted in physically strenuous activity but ambulatory and able to carry out light work; (2) ambulatory, capable of all self-care but unable to carry out work activities; up and about more than 50% of waking hours; (3) capable of only limited self-care, confined to bed/chair for more than 50% of waking hours; (4) completely disabled, no self-care possible, totally confined to bed or chair.27

    • ↵d Two patients were not mentally competent: 1 had depression and 1 had depression and early-stage dementia.

  • Table 3

    Family Physician-Reported Patients’ Motives for Decisions to Hasten Death by VSED (99 Patients) and Physician Involvement

    Characteristic% (95% CI)
    Patient’s Motive
    Somatic79 (70–86)
     Fatigue, general weakness60 (50–69)
     Physical deterioration51 (41–60)
     Pain18 (11–26)
     Dyspnea9 (5–17)
     Other physical symptoms8 (4–16)
    Existential77 (68–85)
     Suffering without hope for improvement41 (32–51)
     Tired of living40 (32–51)
     Missing a purpose in life38 (29–48)
    Dependence58 (48–67)
     Being dependent32 (23–42)
     Disability, immobility30 (22–40)
     (Fear of) loss of autonomy27 (19–36)
     Not wanting to be a burden on family anymore15 (9–24)
     No longer being able to reside independently7 (3–14)
    Loss of dignity, loss of self37 (28–47)
     Loss of dignity29 (21–39)
     Cognitive decline or inability to communicate11 (6–19)
    Social21 (14–30)
     Loneliness15 (9–24)
     Death of a loved one8 (4–16)
    Psychiatric suffering14 (9–23)
     Depressive symptoms13 (8–22)
     Fear, anxiety3 (1–9)
    Physician’s involvement and attitude
    Physician had suggested the possibility of VSED to the patient18 (11–27)
    Physician could agree with the patient’s decision to hasten death by VSED94 (87–97)
    Patient had requested for PAS19 (12–28)

    • PAS = physician-assisted suicide; VSED = voluntary stopping of eating and drinking.

    • Note: Missing values ranged from 2.0% to 4.0%.

  • Table 4

    Characteristics of Preparation and Terminal Phases of VSED (96 Patients)

    Characteristic% (95% CI)
    Preparation phase
    Physician was informed of the patient’s intention in advance
     Yes, by the patient46 (36–56)
     Yes, by the patient’s proxy4 (1–11)
     No, but the patient had stated that he/she did not want to continue living25 (17–35)
     No25 (17–35)
    Physician or proxy involvement
     No family physician or proxy16 (10–24)
    Family physician (for guidance, support, or care)a
     In preparing for VSED21 (14–30)
     During the process of VSED55 (45–65)
     Palliative sedation until death28 (20–38)
     No38 (28–48)
    Proxiesa
     In preparing for VSED44 (34–54)
     During the process of VSED53 (43–63)
     No28 (20–38)
     Don’t know3 (1–9)
    Terminal phase
    Symptoms in the last 3 days before deathb
     Yes36 (28–46)
     None42 (32–52)
     None (but palliative sedation was given)10 (6–18)
     Don’t know11 (6–20)
    Symptoms reportedc,d
     Pain14 (8–23)
     Fatigue9 (5–18)
     Impaired cognitive functioning8 (4–16)
     Thirst or dry throate7 (3–15)
     Delirium6 (2–13)
     Dyspnea6 (2–13)
     Reduced consciousness5 (1–12)
     Agitation5 (1–12)
     Impaired communication4 (1–10)
     Otherf6 (3–15)
    Physicians’ impression that dying process went according to the patient’s wish
     Yes80 (71–87)
     Partly18 (11–27)
     No2 (0–8)
    If partly or no, reason whyc
     Duration too long11 (6–20)
     Patient preferred PAS3 (1–9)
     Communication problems1 (0–6)
     Inability to say goodbye1 (0–6)
     Agitation1 (0–6)

    • PAS = physician-assisted suicide; VSED = voluntary stopping of eating and drinking.

    • Note: Total number of cases was 96, as data for 3 patients were missing (3.0%).

    • ↵a Respondents could give 1 or more answers.

    • ↵b Phrasing of the question: “Did the patient have physical, psychological or other symptoms or complaints in the last 3 days before death?”

    • ↵c Open-ended question; respondent could give multiple answers.

    • ↵d n = 85, 11 did not know, 3 missing (13.9%).

    • ↵e Thirst 3%, dry mouth or throat 3%.

    • ↵f Other: decubitus (2%), (deterioration of) heart failure (2%), gloom or sadness (2%), edema (1%), problems ingesting medication (1%).

Additional Files

  • The Article in Brief

    Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking

    Eva E. Bolt , and colleagues

    Background Voluntary stopping of eating and drinking (VSED) is sometimes considered a feasible way to hasten death for people who suffer unbearably. This report from the Netherlands examines physicians' involvement with VSED to better understand the characteristics and motives of VSED patients and describe the duration and prevalent symptoms in the last days of life.

    What This Study Found 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 study found almost one-half of respondents had cared for a patient who hastened death by VSED, and that patients' motives to do so were both physical and psychosocial. Patients who decided to use VSED were mostly aged older than 80 years, in poor health, and dependent on others for everyday care. 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; family physicians were involved in 62 percent of cases.

    Implications

    • The authors conclude that family physicians can play an important role in caring for VSED patients and their proxies by providing them with information, support and symptom management.
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