Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking

Eva E. Bolt; Martijn Hagens; Dick Willems; Bregje D. Onwuteaka-Philipsen

doi:10.1370/afm.1814

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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%).

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Table 1

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

Characteristic	Total (N = 708)	Experience With VSED (n = 313)	No Experience With VSED (n = 383)
Age, y
Mean (SD)^a	50 (8)	52 (8)	49 (9)
Range	31–72	32–70	31–72
Sex, male, %	61	62	60
Is religious, %^b	37	36	39
Working experience as family physician, y
Mean (SD)^a	19 (9)	20 (9)	18 (9)
Range	1–42	2–39	1–42
Additional expertise, %
Received training in palliative care^c	73	75	72
Palliative care consultant	2	2	3
Experiences with VSED, %
Experience with VSED	46	100	NA
Experience with VSED in the last year	9	19	NA
Palliative sedation in VSED, %
Has administered palliative sedation in case of VSED	23	47	NA
Conceivable to administer palliative sedation in case of VSED^a,^d,^e	81	90	73
PAS, %
Has performed PAS	79	82	77
Conceivable to perform PAS^d	93	93	92
VSED and PAS, %
Has ever suggested VSED to a patient with a wish for PAS^a	34	49	21

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%.

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Table 2

Characteristics of 99 Patients Who Hastened Death by VSED

Characteristic	% (95% CI)
Age at the time of death
≤65 y	6 (3–13)
66–80 y	23 (16–33)
>80 y	70 (60–78)
Partner
Yes	25 (18–35)
No, widow(er)	64 (54–72)
No, other	11 (6–19)
Residence
Home (independently or with family)	52 (42–62)
Residential home	42 (33–52)
Hospice	5 (2–12)
Other	1 (0–6)
Diagnosis^a
A somatic disease, not cancer^b	39 (30–49)
Cancer	27 (19–37)
(Early-stage) dementia	12 (7–20)
Psychiatric disease	7 (3–14)
No severe physical or psychiatric disease	24 (17–34)
ECOG performance status^c
0	4 (1–10)
1	8 (4–15)
2	11 (6–19)
3	47 (38–57)
4	29 (21–39)
Life expectancy
<1 wk	2 (0–8)
1–4 wk	32 (23–41)
1–12 mo	41 (32–51)
>1 y	26 (18–35)
Patient was mentally competent
Yes	90 (83–95)
Partly	7 (3–15)
No^d	2 (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.

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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
Somatic	79 (70–86)
Fatigue, general weakness	60 (50–69)
Physical deterioration	51 (41–60)
Pain	18 (11–26)
Dyspnea	9 (5–17)
Other physical symptoms	8 (4–16)
Existential	77 (68–85)
Suffering without hope for improvement	41 (32–51)
Tired of living	40 (32–51)
Missing a purpose in life	38 (29–48)
Dependence	58 (48–67)
Being dependent	32 (23–42)
Disability, immobility	30 (22–40)
(Fear of) loss of autonomy	27 (19–36)
Not wanting to be a burden on family anymore	15 (9–24)
No longer being able to reside independently	7 (3–14)
Loss of dignity, loss of self	37 (28–47)
Loss of dignity	29 (21–39)
Cognitive decline or inability to communicate	11 (6–19)
Social	21 (14–30)
Loneliness	15 (9–24)
Death of a loved one	8 (4–16)
Psychiatric suffering	14 (9–23)
Depressive symptoms	13 (8–22)
Fear, anxiety	3 (1–9)
Physician’s involvement and attitude
Physician had suggested the possibility of VSED to the patient	18 (11–27)
Physician could agree with the patient’s decision to hasten death by VSED	94 (87–97)
Patient had requested for PAS	19 (12–28)

PAS = physician-assisted suicide; VSED = voluntary stopping of eating and drinking.
Note: Missing values ranged from 2.0% to 4.0%.

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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 patient	46 (36–56)
Yes, by the patient’s proxy	4 (1–11)
No, but the patient had stated that he/she did not want to continue living	25 (17–35)
No	25 (17–35)
Physician or proxy involvement
No family physician or proxy	16 (10–24)
Family physician (for guidance, support, or care)^a
In preparing for VSED	21 (14–30)
During the process of VSED	55 (45–65)
Palliative sedation until death	28 (20–38)
No	38 (28–48)
Proxies^a
In preparing for VSED	44 (34–54)
During the process of VSED	53 (43–63)
No	28 (20–38)
Don’t know	3 (1–9)
Terminal phase
Symptoms in the last 3 days before death^b
Yes	36 (28–46)
None	42 (32–52)
None (but palliative sedation was given)	10 (6–18)
Don’t know	11 (6–20)
Symptoms reported^c,^d
Pain	14 (8–23)
Fatigue	9 (5–18)
Impaired cognitive functioning	8 (4–16)
Thirst or dry throat^e	7 (3–15)
Delirium	6 (2–13)
Dyspnea	6 (2–13)
Reduced consciousness	5 (1–12)
Agitation	5 (1–12)
Impaired communication	4 (1–10)
Other^f	6 (3–15)
Physicians’ impression that dying process went according to the patient’s wish
Yes	80 (71–87)
Partly	18 (11–27)
No	2 (0–8)
If partly or no, reason why^c
Duration too long	11 (6–20)
Patient preferred PAS	3 (1–9)
Communication problems	1 (0–6)
Inability to say goodbye	1 (0–6)
Agitation	1 (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%).

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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.