Voluntary Stopping of Eating and Drinking (VSED) at the End-of-Life in Swiss Nursing Homes and Inpatient Palliative Care Institutions: An Explanatory Sequential Mixed-Methods Study (VSED-ELiS)

Background

Voluntary stopping of eating and drinking (VSED) is increasingly recognized as a self-determined end-of-life option in Switzerland and internationally. While its ethical and clinical implications have been discussed in academia, its practical and professional implementation in institutional care remains poorly understood and or developed. Healthcare professionals (HCPs), particularly in nursing homes and inpatient palliative care settings, are increasingly confronted with diverse VSED cases. However, there is a striking lack of structured guidance, shared standards, and professional consensus on how to support patients and families in such complex decisions. The Swiss Academy of Medical Sciences (SAMS) has acknowledged VSED as an ethically permissible option, yet its recommendations address individual HCPs rather than institutions. Since 2022, certified palliative care institutions in Switzerland are required to establish VSED guidelines - but implementation remains unclear. Workforce shortages and skill mix issues in Swiss nursing homes compromise nutritional care and raise the risk of wrongly interpreting reduced intake as intentional VSED—particularly when less qualified staff under time pressure misread medically or cognitively caused eating difficulties.

Aims

The aim is to address these gaps by developing an evidence-based national best practice recommendation for handling of VSED. The focus is explicitly on nursing homes and inpatient palliative care units, where VSED is most frequently observed and where challenges around care quality, ethical dilemmas, and staff competencies are particularly acute. The project will also clarify how VSED differs from other forms of food refusal, how its covert and implicit forms can be safely identified and managed, and sensitise healthcare professionals to these important risks of misinterpreting VSED.

Method

To achieve this goal, the project adopts an explanatory sequential mixed-methods design (Creswell & Plano Clark, 2018), combined with a final Delphi consensus process. It includes three phases:

• Phase I:
  An integrative review and a nationwide online survey targeting nurses (all qualification levels, including APNs) and physicians (including family doctors in nursing homes) will assess current VSED practices, institutional guidelines, and HCPs’ knowledge, attitudes, and moral challenges.
• Phase II:
  Based on quantitative findings, semi-structured interviews will be conducted in all major Swiss regions (German, French, and Italian-speaking) to explore the deeper experiences and coping strategies of HCPs in handling VSED. The findings from both phases will be integrated (Pillar Integration Process) to identify key themes and practices that promote safety, dignity, and clarity for patients, families, and professionals.
• Phase III:
  A Delphi survey with national experts will validate the synthesized findings and lead to the final formulation of the national best practice recommendation. This recommendation will be culturally and linguistically adapted into German, French, and Italian and made publicly available.

(Expected) Results

The project goes beyond the current state of knowledge by combining ethical, medical, and nursing science perspectives in a rigorously interdisciplinary approach. It contributes novel empirical insights, especially regarding implicit VSED, sedation practices, and the perspectives of younger patients. The expected output—a validated and nationally adapted best practice recommendation—responds to urgent institutional needs and will be disseminated across Switzerland through stakeholder networks, conferences, and professional journals. It will support high-quality, ethically grounded care and reduce risks of misjudgment, conflict, and moral distress among HCPs. By closing the implementation gap and aligning institutional responsibilities with ethical and clinical best practice, this research will set a new standard for the professional management of VSED in Switzerland.