Voluntary stopping of eating and drinking (VSED) as an unknown challenge in a long-term care institution: an embedded single case study

Abstract

BackgroundChronically ill persons experience conditions of life that can become unbearable, resulting in the wish to end their life prematurely. Relatives confronted with this wish experience ambivalence between loyalty to the person’s desire to die and the fear of losing this person. Caring for a person during the premature dying process can be morally challenging for nurses. One way to end one’s life prematurely is Voluntary Stopping of Eating and Drinking (VSED).MethodsThis embedded single case study explored the experiences of registered nurses (embedded units of analysis: ward manager, nursing manager, nursing expert) and relatives who accompanied a 49-year-old woman suffering from multiple sclerosis during VSED in a Swiss long-term care institution (main unit of analysis). By means of a within-analysis, we performed an in-depth analysis of every embedded unit of analysis and elaborated a central phenomenon for each unit. Afterwards, we searched for common patterns in a cross-analysis of the embedded units of analysis in order to develop a central model.ResultsThe following central concept emerged from cross-analysis of the embedded units of analysis: As a way of ending one’s life prematurely, VSED represents an unfamiliar challenge to nurses and relatives in the field of tension between one’s personal attitude and the agents' concerns, fears and uncertainties. Particularly significant is the personal attitude, influenced on the one hand by oneˊs own experiences, prior knowledge, role and faith, on the other hand by the VSED-performing person's age, disease and deliberate communication of the decision. Depending on the intention of VSED as either suicide or natural dying, an accepting or dismissing attitude evolves on an institutional and personal level.ConclusionsTo deal professionally with VSED in an institution, it is necessary to develop an attitude on the institutional and personal level. Educational measures and quality controls are required to ensure that VSED systematically becomes an option to hasten death. As VSED is a complex phenomenon, it is necessary to include palliative care in practice development early on and comprehensively. There is a high need of further research on this topic. Particularly, qualitative studies and hypothesis-testing approaches are required.

End of Life, Food, and Water: Ethical Standards of Care

“…Properly defined, VSED refers to "a conscious and deliberate decision, by a capacitated patient suffering from advanced illness or an extremely debilitating medical condition, to intentionally refrain from receiving food or fluids by mouth, to hasten death" [49]. Those who have cared for persons choosing VSED have noted the following patient motivations for undertaking this method: willingness to die, feeling of senseless in continued life, experiencing poor quality of life, and desire to control the dying process [50]. Though considerable legal and ethical analysis has been undertaken over the past decade to clarify the moral and legal standing of VSED, continued controversy and uncertainty around its use center on the following concerns: Is it legal to offer standard palliative care to patients undertaking VSED without being viewed as "assisting" in their suicide?…”

Tiredness of Life in Older Persons: An Evolutionary Concept Analysis

“…Others decide to continue living as they place greater weight upon a natural course of the dying process [24]. For some, voluntary stopping of eating and drinking (VSED) is described as a method to control the timing and circumstances of their death [56]. For a minority, the feelings of hopelessness and despair may progress to suicidal ideation, suicide plans, attempts and ultimately completion of the act [8,57].…”

Perspectives of people accompanying a person during voluntary stopping eating and drinking: a convergent mixed methods study

“…Many participants had accompanied people during VSED; overall, patients are granted the right to medical and nursing care, and VSED is often considered an autonomous and "good" way to die (1,8,11,12,32). Although there are few qualitative studies (13), previous research indicated that accompanying a person during VSED is an individual decision (33), and that there is an implicit or unspoken form of VSED where the person does not talk about their intention or even hides it from others (14). The existing evidence is not sufficient to derive practical recommendations for health professionals.…”