Terminally Ill Choose Fasting Over M.D.-Assisted Suicide

Oregon is the only state in which physician-assisted suicide for terminally ill patients is legal. Thus, one might expect many terminally ill patients to be taking advantage of it. This, however, does not seem to be the case, Oregon Public Health Services physicians have found.

During the five years since physician-assisted suicide has been legal in their state, they reported in the March 6, 2003 New England Journal of Medicine, there has been an increase in the number of terminally ill patients who have elected this option. But the total number of people who have chosen it to date—129—is small relative to the overall number of deaths in Oregon—that is, 9 per 10,000 deaths.

What’s more, of those terminally ill Oregon patients who do decide to precipitate their deaths, twice as many die via cessation of eating and drinking than via physician-assisted suicide, according to a study reported at the annual meeting of the Academy of Psychosomatic Medicine in San Diego in November.

“I was stunned by this finding,” Linda Ganzini, M.D., a professor of psychiatry and medicine at Oregon Health and Science University and the primary author of the study, told Psychiatric News.

One reason she was surprised, she explained, is that the issue of physician-assisted suicide has gotten a lot more attention in the press than has death via refusal of food and fluids; therefore, she didn’t think that many Oregonians would be familiar with this method of dying. Yet another reason she was surprised, she said, is that she would not have expected terminally ill patients to speed death via fasting and dehydration when they could do it with physician help instead.

Nothing in Medical Literature

Ganzini and her colleagues set out in 2001 to learn something about death hurried via fasting and dehydration, since virtually nothing has been reported on the subject in the medical literature. They also wanted to learn how terminally ill Oregon patients regarded fasting and dehydration when they have access to physician-assisted suicide as well. The researchers mailed a questionnaire to nurses who cared for patients in all 50 Medicare-certified, home-hospice programs in Oregon, as well as two hospices in neighboring states that provide services for patients from Oregon. The questionnaire asked the nurses whether they had cared for any patients since 1997—when Oregon legalized physician-assisted suicide—who had elected to speed up death via physician-assisted suicide or via voluntary cessation of eating and drinking.

Of the 300 nurses who responded, 102 reported that during the previous four years they had had at least one terminally ill patient who had accelerated death via cessation of eating and drinking, whereas only 55 reported that they had had at least one terminally ill patient who had hurried death via physician-assisted suicide. In other words, when terminally ill patients wanted to die prematurely, it looked as if ceasing to eat and drink was twice as popular as was physician help.

Ganzini and her coworkers also asked the nurses to provide information about the most recent patient they had had who had elected to speed death with either method, in hopes of learning more about the types of individuals who select each methods. Those who hastened death through fasting and dehydration, they found, were significantly older and had significantly more neurological disease than did those who chose death through physician help. In contrast, those who accelerated death with physician assistance had significantly more cancer than did those who hastened death via fasting and dehydration.

Less Suffering Reported

The researchers also asked the nurse respondents to rate, on a scale from 1 to 10, the quality of deaths of patients with whom they had had contact who had rushed death either via fasting and dehydration or physician help.

The nurses rated the fasting and dehydration deaths as causing, on average, somewhat less suffering and pain than the physician-assisted suicides, and also as being somewhat more peaceful than death with physician help. In contrast, they rated the overall quality of death via both methods as being, on average, quite good. (Most patients who elected death with fasting and dehydration died within two weeks.)

The nurses’ responses likewise revealed some of the major reasons why terminally ill patients elected to die via fasting and dehydration—they were ready to die, believed that continuing to live was pointless, experienced a poor quality of life, or wanted to control the manner in which they died. Unbearable physical suffering did not appear to be a major factor.

The responses also showed that only 9 percent of the patients who refused food and liquids had contact with a psychiatrist, psychologist, or mental health nurse practitioner before they died by this method. In contrast, 45 percent of those who died via physician-assisted suicide had seen a psychiatrist or mental health professional before dying. Thus, it is unknown how many of the patients who speeded up death via fasting and dehydration did so because they were clinically depressed.

These findings have implications for psychiatrists. If a psychiatrist is called to assess a terminally ill patient who wants to die by ceasing eating and drinking, Ganzini told Psychiatric News, then he or she “should assess for depression and reversible causes of suffering and explore issues of finding meaning, developing goals, and feeling in control.” These results also raise crucial ethical issues. For instance, none of the 102 nurses who had cared for a patient speeding death via fasting and dehydration said that they would actively oppose such a choice. But three of them did say that they believe death in this manner is unethical.

An abstract of the study, “Nurses’ Experience With Hospice Patients Who Refuse Food and Fluids to hasten Death,” and an accompanying editorial are posted online, respectively, at http://content.nejm.org/cgi/content/abstract/349/4/359 and http://content.nejm.org/cgi/content/extract/349/4/325. ▪

N Engl J Med 2003 349 359

N Engl J Med 2003 349 325