First Study on Patients Who Fast to End Lives
By DONALD G. McNEIL Jr.
I n her 23 years of nursing, Maria LaTrace had only one such case: a dying woman who decided to hasten her death by going without food or water. "She was terminal with cancer, she would vomit, she wasn't able to tolerate a lot of food," said Ms. LaTrace, managing nurse at Jacob Perlow Hospice of Beth Israel Medical Center in New York. "She said, 'I'm not going to eat or drink, and please remove the IV now.' Her family said no, but she was very strong-willed, very spirited. If you looked at her blood work and vital signs, you wouldn't think that the next day she'd be dead. But to my surprise, the next day she was." In the rancorous debate over euthanasia, assisted suicide and other ways for terminally ill patients to end their lives, doctors note that one option is always legal: a sane, alert person can simply refuse to eat or drink. It is an option rarely taken, but now the first survey of nurses whose patients took it has contradicted the popular assumption that such a death is painful and gruesome. Almost all the 102 Oregon nurses surveyed said their patients who refused water and food had died "good deaths," with little pain or suffering, generally within two weeks. The study, which appeared last week in The New England Journal of Medicine by coincidence, the same week that The British Medical Journal devoted an entire issue to studies on death and dying raises difficult questions for those on both sides of the debate. Its authors hesitated to publish it for fear of encouraging suicides. They went ahead, the lead author said, because it was clear that some patients were already choosing such deaths and the medical community needed to set standards. "I had hesitations about publishing it because there are too many vulnerable patients out there, many of them with depression," said the lead author, Dr. Linda Ganzini, a professor of psychiatry at Oregon Health and Science University. "But it worries me more that patients and families may make this decision and not involve us," she added, referring to doctors and nurses. "If our only response is disapproval or outrage, then people will do this and not let us know." In the study, 102 of the 429 hospice care nurses who were mailed questionnaires replied that they had cared for at least one patient who chose to hasten death by declining food or fluids. (Hospice care typically takes place at home; under its "hospice provision" for patients who have less than six months to live and have given up curative care, Medicare pays most costs.) The nurses were asked to describe the patients and rank their deaths on a scale from 0 to 9, with 9 being "a very good death." The patients averaged about 74 years old a decade older than the typical Oregon patient requesting euthanasia and said they were ready to die and felt their quality of life was poor. For 85 percent of the patients, death came within 15 days. Overall, nurses gave the deaths a median score of 8. Eight nurses rated their patients' deaths as "bad" (a score of 0 to 4). Twelve said they thought their patients had a mental disorder, including some who were clinically depressed. Rita L. Marker, executive director of the International Task Force on Euthanasia and Assisted Suicide, which opposes euthanasia, called it "somewhat grotesque to be rating deaths as if they were Olympic events." She said her group did not dispute that patients might legally refuse food and water, but said that some of the study's authors supported assisted suicide and that the study was "an advocacy piece to make death by dehydration seem more attractive and benign." Dr. Diane E. Meier, director of the Hertzberg Palliative Care Institute at Mount Sinai Medical School in New York, opposes giving patients the option of starvation because she fears that many doctors are incompetent at recognizing clincal depression, as opposed to gloom, in the dying. She said the study's real revelation was that only "a tiny, tiny percentage" of Oregon's hospice-care patients she calculated it at 0.3 percent opted for starvation.