Stopping eating and drinking can give you control over your death

The man was 91 years old when he broke his hip. Although he also suffered from the lung disease COPD, he was confident that he would recover soon. That he would be coming home a few weeks later.

But in the Hengelo rehabilitation center he fell again. When he leaned out of the wheelchair and fell to the ground, the man broke his sternum. The former Marine was so short of breath and in so much pain that the situation became unbearable for him.

Rapid euthanasia was not an option, because the family doctor with whom she had already discussed that procedure was on holiday. Waiting for him to return three weeks later was no longer possible.

Nursing specialist Erik Dierink clearly remembers offering the man another option. One that the patient himself had not thought of. “You could stop eating and drinking. Then you know the end will probably happen within two weeks.”

‘Alternative’ to euthanasia

Updated guidance for healthcare professionals was published on Tuesday which should provide clarity on this way of dying. People increasingly need control over their own end of life, sees the KNMG doctors’ federation. They don’t always want to wait for death, but prefer to decide for themselves when it will end. They often think about euthanasia. They often don’t know that dying without drinking or eating anything is also an option. And health workers are not always informed. In approximately 0.5% of deaths, the doctor deliberately indicates cessation of food and drink as the cause of death. In comparison: about 4.5% receive euthanasia.

Internal medicine oncologist Alexander de Graeff led the committee that wrote the guideline and calls it “an alternative” for people who have a death wish but cannot or do not want to receive euthanasia. “Patients and healthcare workers sometimes have the idea that this is a gruesome and inhumane process. With this guide we demonstrate that it is a difficult but usually practicable road.”

The text outlines the context in which one can die in this way and explains how to properly care for these patients. How to quench your thirst. How you can assist relatives and what people can expect from such a process.

The first guide was published in 2014. Due to new research and progress, it had to be revised. In the new text the age limit of sixty has been abolished. Until now, people under the age of sixty were “strongly advised” not to stop eating and drinking. It was thought that this would be unachievable, because hunger and thirst in young people can become unbearable. But since then, examples have been described of young people who nevertheless succeeded. It’s possible, so the argument falls away.

In the new guide, the chapter on incapacitated patients with dementia has been significantly expanded. It is detailed when this way of dying is an option for them.

The new guidance could represent a change: Doctors who previously could retain young patients no longer have to do so. And healthcare professionals now have clear tools for people with dementia.

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Rogier van Deijck, a specialist in geriatric medicine, once assisted a relatively young patient (in his forties) in such a process. He had physical ailments, but a diagnosis had never been made, so the request for euthanasia was rejected. But everyone has the right to stop eating and drinking. “Now that the age limit has been removed, I feel more supported in these situations.”

Other countries do not have such a document, says Alexander de Graeff. Except in the United States, where a condensed version of the Dutch guide was published last year.

Nursing major Erik Dierink If someone asks for a meatball, you can’t refuse it, right?

Stinging of thirst

The 91-year-old former Marine discussed the method with nurse specialist Erik Dierink, in which his loved ones also participated. Dierink: “He mainly wondered what would happen if he were in pain or thirsty. What if it becomes too heavy?” Dierink explained to him what practitioners can do to relieve the pain and thirst, and also that they could put him to sleep if the pain could no longer be controlled in any other way.

For most people, the feeling of hunger goes away after a few days. This does not always apply to thirst. To relieve this ailment, it is useful to moisten the mouth with a cotton ball, or the patient can suck on an ice cube wrapped in gauze. If nothing else helps, palliative sedation is sometimes an option. Then reduce the patient’s consciousness. It’s a complicated decision: those who sleep a lot no longer drink. And a doctor should not speed up the dying process.

Some patients become delirious, confused and may do strange things. They leave the room naked or pee in a corner. Sometimes patients in that confused state cry for water. De Graeff remembers someone going to drink the empty planters. Such behavior can be difficult and complicated for caregivers and loved ones.

Dierink issued a statement to the 91-year-old former Marine saying they would not give him liquids or food in such a situation.

Most people die within two weeks. If patients are young or continue to drink, it takes longer. Geriatrics specialist Rogier van Deijck, who cared for the patient in his 40s, says it took more than seven weeks for him to die. “He still took a few sips every now and then. This makes that process more difficult for patients, loved ones and healthcare workers.”

It often happens that people reconsider their decision. For example because it is too heavy. There are also people who first try the method for a few days out of curiosity.

Suicide

There is debate among health professionals whether stopping eating and drinking is suicide. There is a group that believes not, because it is a slow process in which the patient abandons something, whereas suicide would be an active act. It is certain, concludes the committee that drew up the guide, that assistance to these people is not assisted suicide, which could constitute a criminal offence.

According to the authors, stopping eating and drinking is equivalent to refusing treatment, just as one can refuse chemotherapy. It is the healthcare worker’s job to accompany these people in the best possible way.

Rogier van Deijck believes that this reasoning is sometimes difficult for outsiders to understand. Especially if it is a physically healthy psychiatric patient. According to the authors, as long as someone is competent about their death wish, they have the right to choose it. “Of course, we discuss in depth and investigate whether other treatment options exist,” explains Van Deijck, but patients can also refuse such treatments. “Ultimately I consider it my duty to take care of people who suffer.”

Alexander de Graeff remotely witnessed the death of a patient suffering from an eating disorder. Her psychiatrist assisted her. “If someone is suffering hopelessly and wishes to die,” he considers this process “a better alternative than suicide.” This guide, says De Graeff, is a way to make that path open to discussion.

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Dementia

The chapter on dementia was the subject of most discussion. Sometimes patients recorded their death wish at an early stage, when they were still capable. De Graeff: “But how do you manage the situation if someone has dementia and then sits calmly and eats and drinks?” Some members of the commission wanted to give much more weight to an already drafted declaration of intent. But the current text states that the patient’s behavior is decisive. Nursing specialist Erik Dierink: “If someone asks for a meatball, you can’t refuse them, right? I also introduced it to my colleagues. They see it exactly that way. Otherwise you won’t be able to look at yourself anymore.”

The 91-year-old man died after six days. Dierink: “He put together his funeral card. Family comforted. And I said goodbye very consciously. On the fifth day he began to feel drowsy. “The body produces endorphins, the kidneys do not produce urine, waste products accumulate in the blood.” The former marine died surrounded by his family.

You can talk about suicide via the national toll-free number 113 Suicide Prevention. Telephone 0800-0113 or www.113.nl.

In approximately 0.5% of deaths according to the Death Survey published in 2017, the doctor deliberately lists stopping food and drink as the cause of death.

AND more women than menand most patients are over eighty years old.

This occurs in 60% of cases serious physical illness and in 12-30% of cases of dementia.

In 19 to 45 percent of cases there was one euthanasia request rejected or not carried out.

From Updated guide The document “Support for people who stop eating and drinking to accelerate the end of life” was drawn up by representatives of professional and scientific associations on the initiative of the KNMG doctors’ federation. The Dutch Association of General Practitioners, the Dutch Association of Internists and the Dutch Association for Voluntary End of Life, among others, contributed their thoughts.

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2024-01-23 20:30:08
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