VSED

VSED: The Unanswered Questions

Tackling the dilemmas and ethical controversies of this death-hastening option

C-L psychiatrists—increasingly challenged by chronically and terminally ill patients inquiring about their options to hasten death—are faced with a “gray area” over the ethics of VSED (voluntary stopping eating and drinking).

While debate continues over the rights of patients to determine the timing and manner of their death, awareness of VSED is being generated by a variety of online sources as an available death-hastening choice.

So much so that, in one state, Oregon, where physician-assisted death (PAD) is legal, VSED is twice as common as PAD.

Although VSED theoretically does not require physician involvement (in contrast to other death-hastening choices such as palliative sedation or PAD), clinical participation is critical for initial assessment and ongoing management.

Moreover, C-L psychiatrists may be asked to provide mental health consultation to evaluate for reversible mental disorders and decision-making capacity, and to help manage symptoms from the VSED process.

Academy members have been tackling dilemmas and ethical considerations to contribute to the debate and provide guidance on mental health evaluations when a patient chooses VSED.

“Many questions remain to be answered,” says Rebecca Weintraub Brendel, MD, JD, FAPM, associate psychiatrist at Massachusetts General Hospital and director of the Master of Bioethics Degree Program at Harvard Medical School.

VSED is “probably not illegal,” she concludes, as the right of an individual to withdraw from food and drink is “broadly recognized” in an endeavor to balance individual autonomy with state legal resolve to preserve life. But the legality of VSED has not been tested in the courts; there is no guiding US case law.

So, “probably not illegal” is the best guidance currently available–but there are complications in practice.

Take, for example, the VSED patient being transferred to a hospice. Significantly, in a survey of Oregon hospice workers only 3% of nurses thought VSED was immoral or unethical, but hospices are required to provide patients with adequate hydration and nutrition under preservation-of-life regulations. And, in some states, there are still legal prohibitions to assisted suicide.

PAD is somewhat clearer. While, federally, there is no right to PAD, a growing list of states have legislated to give that right. VSED, by comparison, remains a “gray area.” But as the trend shifts towards death-hastening options underscored by patient autonomy, VSED looks set to become another contender for state legislation.

Also in play is professional standard-setting and how influenced it should be by societal shifts in opinion. “How influenced should we be?” asks Dr. Brendel. She illustrates one of the tensions thus: “People clamor for something, but the ethics of our profession, what we see as our core mission as physicians, is discordant with that, and we need to preserve the integrity of the profession.”

C-L psychiatrists face such ethical issues every day in practice—tensions between two or more intuitions or principles, she says.

Ethics derive from multiple sources, including:

• Duties (deontology, or guiding rules)
• Promoting the greater good (utilitarianism)
• Characteristics of the “good and caring physician” (virtue ethics)
• Pluralism (“the many competing considerations/obligations/principles we have to balance”)

They are framed in sources of ethical guidance, such as professional codes, yet influenced by state versus federal policy; ongoing debate; and decisions over the timing of when “the tide should shift.”

Professional values in end-of-life care–including the physician’s roles in preserving the sanctity of life, and to relieve suffering–are important within the mix. So, too, are tensions emanating from the desire to treat mental illness and prevent suicide, yet respect patient autonomy.

Case discussion also helps to:

• Identify ethical considerations and tensions.
• Think about how to address each consideration.
• Develop a range of ethically permissible options.

Ultimately, multifaceted ethical considerations need to be weighed and balanced in a mental health evaluation template for responding to VSED requests–yet variable on a case-by-case basis.

The evaluation will need to cover:

• The process patients went through in considering their choice
• Advantages and disadvantages of this option as perceived by the patient and family
• Clinical challenges encountered in these patients
• Interventions that decrease patient suffering during the process
• The role of the hospice
• The impact on the family
• An assessment of decision-making capacity and voluntariness

And, in reaching such an evaluation criteria, clinicians will need to answer questions such as:

• What are the conditions in an institutional setting under which VSED is, or is not, suicide?
• When is VSED morally wrong?
• How is VSED ethically similar and different from stopping life-sustaining treatments?
• Are C-L psychiatrists obliged to inform patients that VSED may be an option for hastening death?
• Can physicians and others on the health care team conscientiously refuse to care for patients who pursue VSED?
• What should be the ethical approach to a patient who embarks on VSED but becomes delirious and requests fluids?

Some hospice workers and families witnessing suffering in VSED patients have resorted to giving fluids–yet “even small sips” can extend the VSED process significantly beyond end-of-life expectation after one to two weeks, says Linda Ganzini, MD, MPH, FAPM, Oregon Health & Science University, VA Portland Health Care System.

“Thirst is the biggest problem followed by delirium,” she says. “VSED requires considerable patient resolve and discipline.” So, too, for health care teams managing the process.

Dr. Ganzini adds to the debate by listing advantages and disadvantages of VSED:

Advantages

• Initially, VSED is entirely under patient control. (It is a result of “an active, voluntary decision.”)
• Opportunity exists to bring the family together and to work on life closure issues.
• VSED may be acceptable for patients/families who are opposed to PAD.
• It may be accessible for patients unable to access PAD.
• It may be more acceptable to health care workers than PAD.

Disadvantages

• VSED may cause suffering or be unsuccessful.
• It is not an option for those with acute suffering. “Acute suffering needs active palliative care, even palliative sedation,” says Dr. Ganzini.
• VSED is a pre-emptive choice (patients make a choice then lose decision-making capacity.)
• Patients may attempt VSED without medical supervision.
• Ethical concerns exist in some cases.

Dr. Ganzini goes into more detail, and discusses the trajectory of VSED, in this video clip from her presentation at APM 2017.