Distress from voluntary refusal of food and fluids to hasten death: what is the role of continuous deep sedation?: Figure 1

Abstract

In assisted dying, the end-of-life trajectory is shortened to relieve unbearable suffering. Unbearable suffering is defined broadly enough to include cognitive (early dementia), psychosocial or existential distress. It can include old-age afflictions that are neither life-threatening nor fatal in the "vulnerable elderly". The voluntary refusal of food and fluids (VRFF) combined with continuous deep sedation (CDS) for assisted dying is legal. Scientific understanding of awareness of internal and external nociceptive stimuli under CDS is rudimentary. CDS may blunt the wakefulness component of human consciousness without eradicating internal affective awareness of thirst and hunger. Patients may suffer because of the slow dying process following dehydration and starvation. The difficulty to adequately control distress, without bringing the dying process to a rapid conclusion by lethal pharmacological interventions, can cause feelings of guilt among hospice and medical staff. Furthermore, the double-effect principle is not applicable in these situations because the primary objective of VRFF is to hasten death. Legal and societal debate should focus on sharpening the boundaries between assisted dying and palliative care. This separation is necessary to: 1) uphold trust in the patient-phyician relationship, and 2) preserve integrity and ethics of the medical profession.

Primary Care Patients Hastening Death by Voluntarily Stopping Eating and Drinking

“…The importance of physician involvement in VSED has been emphasized. 15,16,30 In the preparatory phase, physicians can provide information to patients and proxies and can coordinate care. During the process of VSED, physicians can provide necessary palliative care.…”

“…13,14 Nevertheless, in practice patients who opt for VSED often require medical support. 15,16 Physicians and nurses confronted with VSED may feel moral unease and can be reluctant to support the patient in a path leading to death. 15,17,18 Most experts agree, however, that patients are free to refuse food and fluid, much as they are free to refuse medical treatment.…”

“…9,19,20 Whether palliative sedation in case of refractory symptoms is acceptable is a subject of debate. 16 In 1993, Bernat et al described the need for systematic research on the process of VSED to help physicians understand patients' needs. 9 Two decades later this call has hardly been answered, even though VSED occurs quite frequently (0.4% to 2.1% of deaths in the Netherlands).…”

Japanese physicians’ experiences of terminally ill patients voluntarily stopping eating and drinking: a national survey

“…From an ethical point of view, the intent of patients undergoing VSED is to consciously hasten death, and the use of sedatives is a predictable consequence of instigating VSED that further accelerates death 10. Thus, there is an opinion that the use of sedatives during VSED is commensurate with euthanasia 10…”

How Should a Catholic Hospice Respond to Patients who Choose to Voluntarily Stop Eating and Drinking in Order to Hasten Death?

“…Not all caregivers are comfortable with this level of involvement in a patient's intentional death. Rady and Verheijde (2012), commenting on the use of sedation with VSED, put it bluntly, the use of sedatives with voluntarily refusing food and fluids is commensurate with euthanasia … owing to the absence of empirical evidence for the efficacy of continuous deep sedation in managing distress, it may be argued that voluntarily refusing food and fluids with sedation may represent a cruel and inhumane method of terminating life. (pp.…”