Voluntarily Stopping Eating and Drinking (VSED): What you need to know about this legal option to hasten death

In response to questions about VSED, the following summary is provided by End of Life Choices New York in order to help individuals make informed and thoughtful decisions about whether this option may be appropriate for them.

What is VSED?

VSED is a decision made by a competent adult to stop further intake of food and fluids with the goal of hastening her/his death. It is an intentional and voluntary (non-coerced) choice to hasten death by a decisionally capable person who suffers intolerably from an incurable and progressive, or terminal illness. VSED is distinguished from the usual diminished appetite often experienced by persons close to death in that it is a conscious decision to speed the dying process. It has been a traditional means of dying in the home for generations and is often thought of as a ‘natural’ way of dying. While it is rarely a suffering person’s ‘first choice’ to hasten death, it often is the only legal means available to patient-controlled dying.

What is the definition of a successful VSED death?

A successful VSED ‘outcome’ is understood as a peaceful death that occurs with a minimum of discomfort and occurs within a predictable period of days or weeks following the start of the fast. The cause of death is dehydration, not starvation. VSED appears to be legally available in all states IF the person choosing it is decisionally capable and makes a voluntary, informed and contemporaneous choice.

Necessary ingredients’ for a successful VSED death

1. A decisionally capable, suffering person who is VERY determined to hasten death by fasting. The person must understand the process, know what to expect, and have concluded that the burdens of living consistently out-weigh all benefits.

2. The person must have both social and care-giving support. Social support means having a caring presence provided by family members or close friends who will journey along with the person through-out the fast. They should understand the person’s reasons for making this decision, be able to provide support for the choice, and remain present to the person as they slowly slip away. Care-giving support will become necessary as the person weakens and is unable to safely get out of bed or ambulate. They will need to be kept clean, dry and comfortable in bed. VSED cannot be successfully accomplished by a person who is ‘alone’.

3. The person must have access to home hospice or palliative medical oversight. If the person is terminally ill, arranging for hospice support for this choice is not difficult. In the absence of a terminal illness, acquiring hospice or palliative care in the home can be more challenging but will be addressed later in this document. Access to palliative medical oversight is necessary because the person may need access to small doses of pain medications or anti-anxiety meds to facilitate a ‘sleepy’ state. In addition, as death nears, some persons become agitated or suffer from hallucinations; sedating medication must be available and provided promptly. The hospice physician will sign the death certificate.

4. The fourth ‘ingredient’ is the need for patience. It can be difficult to predict exactly the duration of the fast before death occurs. This can be a difficult time for families and patients who must endure the wait. And yet, because each death is unique, death will occur as it was meant to.

Clinical challenges to a peaceful VSED death

For persons who are terminally ill, forgoing food is usually not difficult as often their appetite has significantly diminished due to their disease. However, forgoing fluids CAN be very challenging. With good oral care that includes rinsing the mouth with cool water and then spitting it out, the mucus membranes in the mouth can be kept moist. Other simple measures like regularly brushing the teeth, using mouth swabs, spraying a fine mist on the back of the throat, and other interventions can keep most people feeling comfortable. If small sips of water are consumed, the process of dying may be somewhat lengthened – but the goal is always to achieve a peaceful dying process. In addition, small doses of opiates and/or anti-anxiety medications can facilitate a ‘sleepy’ state and lessen the focus on drinking.

The average length of the fast for those who are terminally ill is about 10 days, sometimes less and sometimes up to 14 days, depending upon the extent of the under-lying disease and their physical condition. In order to achieve that time goal, consumption of fluids must be stopped. Often the patient will lose consciousness several days before death occurs.

Additional clinical challenges to a peaceful VSED death

For those persons living with an incurable and progressive disease that is not a terminal condition, the process of fasting onto death can be more challenging. Many frail elderly persons suffer from multiple ailments whose symptoms impose tremendous burdens and limitations on their quality of life. Often their days are taken up by physician or other clinical appointments and they are unable to do things that previously brought them joy. And for some, their ability to plan and make thoughtful decisions may be slipping as well.  The issue of cognitive impairment or an early stage of dementia raises significant additional challenges.

For these and other age-related difficulties, the option of choosing to stop oral intake will require considerable information, psycho-social support and personal resolve. It is of particular importance that the person without a terminal illness concludes that the burdens imposed by their illness really do cause them such misery – on a regular and continuous basis – that the notion of hastening death by fasting is welcomed. They must be resolved and determined to hasten death. The issue of capacity to make this decision can become very important, and it is often the family, who know the patient best, who can make that judgment.  If the patient has lost decision making capacity, they will not be able to make this choice, as they will not be able to remember or have the resolve necessary to fast.

Another significant challenge for those without a terminal diagnosis is the difficulty of arranging for hospice or palliative medical oversight. Sometimes, long time family physicians will make a hospice referral when they hear from the patient and family that the patient “is done,” and wants to stop all life-prolonging measures. Other times, the patient must fast for several days before hospice will enroll them in their program. On other occasions, a family physician will order the palliative medications necessary to keep the patient comfortable and will sign the death certificate. All of this requires planning and much discussion.

The patient must have completed an advance directive, appointing a health care agent to speak for them in the event that decision making capacity is lost during the process.  It might be a good idea to add a written statement on the health care proxy form indicating that the patient has chosen to forgo oral feedings and refuses any hand feeding by others, in the event that capacity is lost.

The length of the fast absent a terminal disease will be longer, and can take up to three weeks if fluid intake is stopped. Again, the length of the fast depends upon the patient’s underlying physical condition and disease state.

Finally, in all cases of VSED, the patient and family should discuss ahead of initiating the fast, what is to be done if the patient seems to ‘change his/her mind’. In other words, a prior discussion should occur so the family knows what the patient wants them to do, if the patient ’forgets’ the plan that was laid to hasten death. The recommended response is to gently remind the patient of their reasons for planning to hasten death, but if she/he insists that food or fluid is to be provided…the family should comply – but in a small amount. Further offering of food or fluid should only be provided in response to the patient’s firm request.  If the patient frequently requests food or fluid, it may indicate a desire to resume eating and drinking, and the decision to VSED must be reconsidered.

Once you have read through this information, if you have questions, contact our Clinical Director, Judith Schwarz at 212 252-2015.

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