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.