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Patients Who Decline Food and Fluids to Hasten Death



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Am Fam Physician. 2004 Feb 1;69(3):671-675.

Terminally ill patients sometimes decline food and fluid intake to hasten death. The moral implications of this decision for patients and physicians are hotly debated, but the legal treatment of the situation is simple and straightforward: any competent person has the right to stop eating and drinking, even if this action has fatal consequences. Little has been published about what patients experience when they stop food and fluid intake. Ganzini and associates surveyed hospice nurses in Oregon, asking them to describe their most recent patient who declined oral intake as a means to hasten death.

The authors sent questionnaires to every Medicare-certified home hospice program that served patients in Oregon. The overall response rate from the 429 hospice nurses surveyed was 72 percent (307 nurses). Forty-one percent of the nurses reported having a recent patient who had stopped food and fluid intake to hasten death. In the nurses' estimation, the most important reasons that the patients stopped oral intake were readiness to die, poor quality of life, view that continuance of life was pointless, desire to die at home, and desire to control the circumstances of death. The reasons deemed least contributory included lack of social support, previously witnessed “bad death,” and depression or other psychiatric disorder. Of the 126 patients who stopped food and fluid intake, 13 percent later resumed oral intake. The most common reasons for restarting food and fluid intake were family desire for the patient to eat and hunger or discomfort when not eating.

The estimated life expectancy just before the patient decided to stop food and fluid intake was at least one month for about one half of the patients, and less than that for the remainder. Death occurred within 15 days in 85 percent of patients after cessation of oral intake.

Nurses were asked to score the patients' final experiences on a 10-point scale for peacefulness, pain, level of suffering, and overall quality of death. The median scores were low for suffering and pain (2 to 3 out of 10) and high for overall quality of death (8 out of 10). In 8 percent of cases, however, hospice nurses rated the death experience as “bad”(score of zero to 4 out of 10). Patients who had “bad” deaths after stopping food and fluid intake had higher than average pain and suffering scores and were somewhat younger.

The authors conclude that terminally ill patients who choose to stop eating and drinking to hasten their death usually die within two weeks of that decision, with low levels of pain and suffering and a good overall quality of death.

Ganzini L, et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. July 24, 2003;349:359–65.

editor's note: As is their legal right, patients sometimes make decisions with which their physicians may not agree. The moral debate about whether a terminally ill patient should be allowed to stop food and fluid intake as a means of hastening death could fill many tomes, but the available information about the specific experiences of patients choosing this route is scant. Even physicians who disagree with a patient's decision to stop oral intake may benefit from having some idea of what to expect in that situation. Surveys may be criticized as a “softer science” method, but they do provide general data in areas in which a randomized controlled trial obviously is impossible.—B.Z.

 


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