In 1997, Oregon passed a “Death with Dignity Act,” which authorized physician-assisted suicide as a legal medical option for Oregon residents. However, since most terminally ill patients in the United States don’t have the option of physician-assisted suicide, some health professionals have suggested voluntary refusal of food and fluids as an alternative means of hastening death. Few studies have examined the voluntary refusal of food and fluids, and the issue remains controversial among health professionals.

A study in the July 24, 2003 issue of The New England Journal of Medicine surveyed a group of Oregon hospice nurses and reported that one-third of them had at least one patient who had refused to eat or drink in order to hasten death. Furthermore, the nurses rated 92% of these patients’ deaths as “good,” meaning they were peaceful, with little apparent suffering and pain.

About the Study

In 2001, the researchers mailed questionnaires to 429 nurses in home hospice programs for patients in Oregon. The nurses were asked to provide information on the most recent patient they cared for in the past four years who had voluntarily chosen to refuse food and fluids with the intention of hastening death. The nurses also provided information about their most recent patient who had participated in physician-assisted suicide.

The nurses rated possible reasons for why the patients stopped eating and drinking, and rated the patients’ overall pain, suffering, and peacefulness in the two weeks before death. Also, the nurses scored the patients’ “quality of dying” on a 10-point scale, as either “bad” (a score of 0 to 4) or “good” (a score of 5 to 9).

Based on this information, the researchers compared the suffering, pain, peacefulness, and overall quality of death in patients who voluntarily refused food and fluids to patients who used physician-assisted suicide.

The Findings

Of the 307 nurses who returned the questionnaire, one-third reported having a patient who voluntarily stopped eating and drinking in order to hasten death. According to the nurses, 85% the patients died within 15 days after stopping food and fluids.

The nurses reported that the most important reasons for voluntarily refusing food and fluids were a readiness to die, the belief that continuing to live was pointless, a poor quality of life, a desire to die at home, and a desire to control the circumstances of death. The nurses rated only 8% of these patients’ deaths as “bad.” The rest were rated as “good,” with high levels of peacefulness and low levels of suffering and pain. When compared with patients who underwent physician-assisted suicide, those who stopped eating and drinking were rated as having less pain and suffering and being more at peace in the last two weeks of life.

Although these findings are interesting, they are limited because they are based on the memories of nurses who observed deaths up to four years prior to the survey. Also, because Oregon’s laws on patient-assisted suicide may heighten awareness of end-of-life care among patients and health care professionals, these findings may not apply to hospice patients outside Oregon.

How Does This Affect You?

Despite the assumption that most people would not willingly choose to starve to death, the nurses in this study report that a significant number of hospice patients voluntarily refuse food and fluids to hasten their deaths, and that the deaths of these patients are relatively peaceful and with low levels of pain and suffering.

This study brings up an important question: Is voluntary refusal of food and fluids a viable alternative to physician-assisted suicide for hastening death in terminally ill patients? Future studies are needed to find out if this practice is widespread in hospice patients outside of Oregon. In the meantime, no matter where you live, if a loved one is faced with a terminal illness, it is certainly reasonable to raise the issue of a peaceful death through voluntary withdrawal of food and water. It may be one of the most humane options available to patients with terminal illnesses .