Convincing Us that Dying by Starvation is Desirable

Food and water are essential for life; we know we will die without them.  If people cannot eat and drink safely and sufficiently because of frailty or illness, we do not leave them to die. We use a very simple and effective device known as a feeding tube.  PEG tube placement is a minor procedure involving a small incision that does not require general anesthesia; most anyone can have one placed.  They are a very effective means of providing nutrition to prevent weakness and death due to starvation, So why has the palliative care and hospice community put so much effort into convincing the rest or the medical community, caregivers, and society in general that feeding patients is optional, even extraordinary?

Dying of starvation is slow and unpleasant, taking up to two weeks to complete. So why does Compassion and Choices have a free booklet teaching people about VSED (Voluntarily Stopping Eating and Drinking)? Apparently people have gone through with this bizarre practice with the support of family and friends, as reported by The Daily Beast: The Nurse Coaching People Through Death by Starvation. Since they already promote the practice, why force doctors to get involved by advocating for doctor-prescribed suicide?

As the article's description states, "But what about terminally ill patients who live in states like New York, without a Death with Dignity law?" Compassion and Choices is all about suicide, regardless of prognosis.  The article goes on to say:

According to the medical literature, as well as Schwarz’s experience, most terminally ill patients die within 10 days of starting their fast. But they go into comas much earlier, often within the first three days. The hunger usually subsides quickly, but thirst sometimes causes serious pain. Oral care and medications can help.

Often patients decide against self-dehydration after meeting with Schwarz. It just relieves their anxiety to know they won’t be utterly helpless against their diseases. It’s a psychiatric opiate.

The article then speaks about the "ethical" perspective.

Timothy Kirk, a medical ethics professor at the City University of New York, predicts that the major hospice and palliative-care organizations will issue public-policy statements on the procedure soon... clinicians could learn more about the best methods for alleviating pain, and get better at predicting how long the process will take for each patient.

He noted that so far, no one has broadly challenged the procedure on ethical grounds, except within certain religious communities, such as the Catholic Church.

Thank goodness for the Catholic Church!

In 2014, The Weekly Standard published an article, The Ethics of Food and Drink about legal challenges to force the medical and long-term care communities to participate in these suicides.  It notes that the withholding of spoon feeding is now appearing as an option on some advance directives.

This all makes feeding tubes look even more extraordinary, and more like a medical intervention rather than a simple means of keeping a patient well-nourished.  The medical literature wants to believe this as well.  We currently have no good prospective studies to determine how effective feeding tubes are, just common sense.

As a Medscape review article points out, "Although difficult to evaluate, on the basis of the available evidence, PEG placement does not seem to improve the quality of life in patients with dementia."  This is because PEG are placed after significant weight loss or drop in serum albumen levels. This latter condition indicates the person is already poorly nourished by the time the tube is placed, and is one of the most significant indicators of death.  In other words, the studies are comparing patients who get tubes (who are by definition malnourished to qualify for a tube) to those who did not get tubes (because they were not malnourished and so did not qualify for a tube.)  It's no wonder feeding tubes do not seem to be very effective!

No one has yet to compare patients with the same serum albumen levels by giving one group PEGs and other group hand feeding. As another 2015 clinical review states, no level I evidence (from a systematic review of all relevant randomized controlled trials) exist.  Most studies provide only level III evidence (from well-designed controlled trials without randomization, quasi-experimental.)  And yet, in the echo chamber of the medical literature, feeding tubes have become largely discouraged in patients with dementia.

This is no longer about good medical evidence, but about bad perceptions. We have gone from maybe feeding tubes don't give much benefit to fighting against their use to VSED.  While feeding tubes need to be considered for individual circumstance, we need to stop denying them without evidence to do so.  Maybe we will come to our senses and realize once again that food and drink are essential care and that VSED-by-proxy is another name for murder.