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“Terminal fasting presents many moral conflicts”

Sabrina Stängle is conducting research at the School of Health Professions on the decision of people to voluntarily refuse food and fluids at the end of their lives. She has recently been able to show that almost one in two family doctors has accompanied somebody during this process. Stängle wants to create a factual basis for terminal fasting in her research, since the discourse surrounding this topic is throwing up a great deal of controversy.

In cases where life is linked to much suffering, some people take the decision to end their lives by refusing to take in any further food and fluids.

Sabrina Stängle, you have asked Swiss family doctors about their experiences with patients who choose to fast until they die, and about the doctors’ views on this matter. What gave you the impetus to research this subject?

Thanks to highly specialised medicine, people in Switzerland are able to survive many diseases from which they would die in other countries where the medical care is not up to the same standard. Alongside all the good that this progress brings, it also has its dark side. Survival can go hand in hand with a great deal of suffering. For example, pain, dizziness or nausea can proliferate to such an extent that those affected want to die. And then there are the patients for whom all treatment options have been exhausted, despite the highly developed medicines available, so that nothing more can be done to help them. However, their sickness will still entail further months of suffering. Here too, it may be that those affected want to put an end to their suffering.

How many family doctors come into contact with this topic?

Our study has shown that almost one in two of the family doctors surveyed has already had experience of patients wishing to fast themselves to death. Some 0.7% of all deaths in 2017 were attributed to terminal fasting, equating to 458 people. It can be assumed, however, that the real figure is much higher. Not everyone announces their decision to stop eating and drinking.

The majority of family doctors have a positive attitude towards the issue. Why? And where did the doctors in the survey express concerns?

Most doctors classify terminal fasting as natural death. This may be because it does not lead to an abrupt death, but rather is characterised through a natural process. It is also viewed as positive that those wishing to die can stop this process if they feel that their will to live outweighs their suffering. I can also imagine that the family doctors frequently back the decision taken by such individuals since they are able to understand and relate to their situation due to their long-standing relationships with the patients and their knowledge of their life and suffering. And although one in every five family doctors expressed moral concerns about accompanying people who are fasting themselves to death, almost 98% feel that people have a right in such instances to medical and nursing care.

What challenges arise in cases where patients wish to fast themselves to death?

Terminal fasting can be a long process; it takes 14 days on average. However, just how long it takes depends greatly on a person’s physical condition. In the case of very weakened individuals, death can occur more quickly, while the process for those who are simply of an advanced age can last longer. Generally speaking, both our metabolism and the speed at which we regenerate slow down as we age, and our thirst and hunger decrease. This can prolong the dying process. On the one hand, this can be stressful for both those affected and their relatives. On the other, the slow process allows family and friends to take their leave of their loved ones, as well as to resolve conflicts and be together in the last days.

A further challenge is delirium. After just a few days without food and fluids, many affected individuals fall into this state and are no longer fully conscious. This can mean that they ask for food and drink, thus presenting their carers with a moral dilemma. It is extremely difficult, as well as ethically questionable, to refuse to provide somebody in this situation with something existential like liquids. If the person wishing to die comes out of their state of delirium, however, they may feel that they have been deceived when they find out that they were given liquids against their will. It is therefore important to prepare everybody involved in advance for such possible incidents and to define the procedure to be followed.

And of course, very importantly, relatives often find it difficult to understand their loved one’s wish to die. Especially if the person wanting to end their life is not experiencing severe physical suffering, but rather is experiencing loneliness or is afraid of becoming increasingly dependent on others. A further complication can arise when family members deal differently with their loved one’s wish to die. For example, while the partner may understand and support this desire, the children may not be able to do so.

How could doctors and healthcare professionals, as well as relatives and the individuals who wish to die themselves, be supported in dealing with this sensitive issue?

The subject presents many moral conflicts. One important step would be to include the subject of terminal fasting in the basic training of doctors and nurses, for example. At present, this issue is not addressed during their training, though it is at least treated in continuing education courses in palliative care and medicine. Since terminal fasting mainly takes place at home or in old people’s and nursing homes, Spitex organisations and the homes themselves need to consider this subject more, as well as family doctors. This will give their employees the confidence to act. Finally, a standardised and professional approach is needed. As there are no guidelines on terminal fasting in Switzerland yet, healthcare professionals have to find their own way to deal with it. With our research, we want to change that; we want to provide a factual basis for dealing with terminal fasting, and also to standardise and professionalise the approach to it.

About the researcher

Sabrina Stängle
Research Associate at the Institute of Nursing