We have noted in our End of Life section on this Web site resources that better inform and prepare individuals who may be experiencing death for the first time. We also provide links to organizations that seek to help prepare an individual for the passing of a loved one. There is no doubt, that with medical advances that can prolong life so too will arise moral issues as to what extent medicine can support life although the quality of living does not keep step with medical advances. Recently, researchers at the Mayo Clinic are drawing a distinction between one’s lifespan and their healthspan, or the quality of one’s life at a given time. Recognizing that a majority of adults over 65 will develop at least two chronic diseases such as diabetes or heart disease, the issue become one of determining how the quality of life changes s the effects of chronic or other diseases make radical changes in our lifestyle. there is a growing awareness that individuals have the right to direct their medical treatments and guide their life in accordance with the quality of life that may accompany chronic disease or failing overall health. Legal documents such as advance directives and no not resuscitate orders can assist an individual in making decisions as to how long and to what extent they wish medical interventions to prolong their life.
One alternative to death without the intervention of another individual is the decision to stop taking food or liquids. Unlike assisted suicide, the cessation of taking food or liquids is an individual choice that can be specified in an advance directive. Stopping eating is not suicide as it I a choice made by an individual who is at the end of their natural life. When this decision is made, an individual becomes progressively weaker and death comes weks or months sooner than if the individual had been hydrated and nourished. Individuals making this decision do so to avoid prolonging pain, to gain control over their own death, According to a study in the New England Journal of Medicine, individuals who make this decision are generally the elderly who have a poor quality of life.
Legally, the United States Supreme Court ruled in 1990 ( Cruzan vs. Director 1990) that artificial nutrition and hydration are not different than other life-sustaining treatments. Courts in the United States have made the following rulings consistently in the recent past:
• Competent adults may refuse artificial nutrition and hydration treatments even though this action may hasten death;
• Surrogate decision makers may withdraw artificial nutrition and hydration;
• Surrogate decision makers may refuse artificial nutrition and hydration on behalf of an incompetent adult.
One might question whether the cessation of providing water and food is effectively killing a patient or allowing a person to die as an indiviual cannot live without food and water. Generally if an individual has expressed the desire for the cessation of food and water the health care team and patient’sfamily members discuss if hydration and food will benefit the patient. Physically, a person’s body begins to shut down prior to death thus food and water are processed in manner distinct from a healthy individual. Providing water may actually bloat an individual and providing food may cause intestinal problems and discomfort.
Does And Individual Suffer When Food and Water are no Longer Given to Them
Medical research indicates there is no suffering. The New England Journal of Medicine (Jacobs, 2003)reported 94% of nurses reported these patients’ deaths as peaceful. The cessation of eating and drinking is a normal part of the dying process that typically occurs days to weeks before death. Once the body becomes mildly dehydrated, the brain releases endorphins which act as natural opioids, causing the patient to feel euphoria as well as less pain and discomfort. Surprisingly, few patients express the feeling of hunger or the need for water although the mucous membranes and mouth do become very dry and are generally moistened to lessen the discomfort.
How Does Cessation of Food and Water Compare to Doctor Assisted Suicide?
When death by voluntarily stopping of eating and drinking was compared with death resulting from physician-assisted suicide (actions, which an individual helps another person who is terminally ill die upon their wanting to do so) nurses reported that patients in the former group had less suffering, less pain, and were more at peace than the latter group. Nurses reported that both groups had a high quality of death, which sounds strange but means that their deaths proceeded with lower levels of pain and struggle.
How Long After Does Death Occur?
Once a person stops eating and drinking, death usually occurs within two weeks. He may continue to take small amounts of water to swallow pills or moisten his mouth, and these small sips of fluids may prolong the dying process by a couple of days.
The decision to stop drinking and obtaining food is clearly a serious decision which must involve the individual, relatives, and care providers. In making that decision one must consider religious, moral, ethical, and medical issues. The best solution to making the decision is to have a discussion of long before one is nearing the end of life. For that reason, people state their preference in their advance directive following discussion with their family members, religious representatives, and physicians.
Cruzan v. Director, Missouri Department of Health, 110 S.Ct. 2841 (1990).
Jacobs S. Death by Voluntary Dehydration — What the Caregivers Say. N Engl J Med 349:325, July 24, 2003.