How should a Catholic hospice respond to patients who choose to voluntarily stop eating and drinking in order to hasten death?

The Linacre Quarterly is the official publication of the Catholic Medical Association (distinct from the larger Catholic Health Association).



In a recent issue, Maureen Cavanagh published "How should a Catholic hospice respond to patients who choose to voluntarily stop eating and drinking in order to hasten death?"  Cavanagh is Manager of Ethics Services for St. Peter's Health Partners in Albany, New York.



This is her abstract:  "The practice if voluntarily stopping eating and drinking (VSED) in order to hasten death poses a unique problem for the Catholic hospice. Hospice staff may be confronted with patients already on their service who decide to pursue this option for ending their lives. Patients not on hospice service who are contemplating VSED are often advised to contact hospice for symptom palliation associated with the process if VSED."



"Intentionally hastening death not only violates the sanctity if human lift and the Ethical and Religious Directives the Catholic hospice is bound to uphold. but it also runs counter to the general philosophy that hospice neither hastens nor postpones death. At the same time, hospice programs have a strong philosophy of non-abandonment of patients. This article will analyze the ethical issues from the perspective of the Catholic tradition and suggest strategies for the Catholic hospice to respond to this group if patients."



Stanley Terman shared his response to Cavanagh's article:  "The author's position is clear: Life always has value and the intent to die is always wrong. Voluntarily stopping eating and drinking to hasten dying thus violates Catholic principles. It also violates the stated philosophy of hospice—to neither hasten nor postpone death."



"She recommends even secular health care professionals on staff at hospices refuse to provide palliative care if the cause of suffering is solely due to VSED (which it rarely is). Ideally, hospice staff would inform prospective patients about their position ahead of time, but for patients who decide after admission they prefer to die by Voluntarily Stopping Eating and Drinking, hospice staff should not abandon them but instead 'present a life giving alternative… and reassure patients that pain and other uncomfortable symptoms are manageable.' She admits, 'No patient can be forced to take food or fluids,' and 'No patient should be urged to eat if eating causes distress,' but if hospice staff remain involved, they can 'offer food and fluid if requested and tolerated by the patient.'"



"Major disagreement: The publication of one article by Ivanovic et al. does not eliminate the possibility that some hospice patients will be motivated to request Voluntarily Stopping Eating and Drinking for any reason they consider compelling, including intractable pain and suffering."



"I can appreciate that human beings have a responsibility to honor the gift of life and therefore may not end life to end suffering. However when this mandate is combined with an undeservedly extremely negative view of the ultimate method to relieve pain and suffering—Palliative Sedation to Unconsciousness[1]—patients might find themselves in an environment where they are forced to endure unbearable end-of-life suffering."



[1] She quotes Rady et al., who wrote it "may represent a cruel and inhumane method of terminating life." Rady,  M,   and J.  Verheijde. 2012.  Distress from voluntary refusal of food and fluids to hasten death: What  is the role of continuous deep sedation. Journal if Medical Ethics 38: 510-2. Palliative Sedation is similar to general anesthesia so palliative care clinicians do not need "empirical evidence for its efficacy...in managing distress." The American Medical Association’s Opinion 2.201 states that “physicians may consider Palliative Sedation to Unconsciousness for those terminally ill patients whose clinical symptoms have been unresponsive to aggressive symptoms-specific treatments.” My clinical experience with patients and my personal experience with my own fasting led me to conclude that patient's discomfort solely due to VSED is mild, can be treated easily, and will therefore rarely, if ever, require palliative sedation solely for VSED.