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• How do you define voluntarily stopping eating and drinking?
  Shunichi Nakagawa, Craig D. Blinderman
  Published on: 22 May 2019
• A comment to Shinjo T et al.: collusion in VSED
  Friedrich Stiefel, Kenji Nakamura, Takeshi Terui and Kunihiko Ishitani
  Published on: 22 May 2019

• Published on: 22 May 2019

  How do you define voluntarily stopping eating and drinking?

  • Shunichi Nakagawa, Palliative Care Physician Columbia University Medical Center
  • Other Contributors:
    • Craig D. Blinderman, Palliative Care Physician

  Dear Editor
  In this issue, Shinjo et al reported that, among Japanese home hospice physicians and palliative care specialists, 32% replied that they had experience in caring for patients who had voluntarily stopped eating and drinking (VSED). 1 Their mean years of clinical experience overall, and in the field of palliative medicine, were 26 years and 13 years, respectively. According to the authors, Japanese patients were also trying to implement VSED to hasten their deaths themselves.

  We congratulate the authors on publishing this very important epidemiologic data in Japan. As the authors point out, the study is limited by both recall and social desirability biases, which could explain some inaccuracy in their survey results. Moreover, we wonder whether the way in which VSED was defined in this study also contributed to the relatively high prevalence of physicians who had experience with this practice.

  In their questionnaire, VSED was defined as “terminal ill patients electing to stop taking water and nutrition despite the fact that they do not suffer from a difficulty in oral intake such as gastrointestinal obstruction or cachexia”. VSED is an under-recognized practice and there are few data available. Especially in Japan, as they reported, only half of the palliative care physicians were aware of VSED. While their definition was not inaccurate, it is possible that this definition failed to convey the gravity of VSED and, as a result, physicians...

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  Dear Editor
  In this issue, Shinjo et al reported that, among Japanese home hospice physicians and palliative care specialists, 32% replied that they had experience in caring for patients who had voluntarily stopped eating and drinking (VSED). 1 Their mean years of clinical experience overall, and in the field of palliative medicine, were 26 years and 13 years, respectively. According to the authors, Japanese patients were also trying to implement VSED to hasten their deaths themselves.

  We congratulate the authors on publishing this very important epidemiologic data in Japan. As the authors point out, the study is limited by both recall and social desirability biases, which could explain some inaccuracy in their survey results. Moreover, we wonder whether the way in which VSED was defined in this study also contributed to the relatively high prevalence of physicians who had experience with this practice.

  In their questionnaire, VSED was defined as “terminal ill patients electing to stop taking water and nutrition despite the fact that they do not suffer from a difficulty in oral intake such as gastrointestinal obstruction or cachexia”. VSED is an under-recognized practice and there are few data available. Especially in Japan, as they reported, only half of the palliative care physicians were aware of VSED. While their definition was not inaccurate, it is possible that this definition failed to convey the gravity of VSED and, as a result, physicians who were not familiar with VSED did not fully grasp the concept. Although there are no strict criteria or definitions of VSED, based on the literature2, it should fulfill the following conditions as shown below:

  Conditions for VSED
  1 Patients are terminally ill, but not imminently dying.
  2 Patients have clear decision-making capacity.
  3 Patients have unbearable physical, psychological, existential, or spiritual suffering.
  4 Patients have had a thorough discussion with their family and physicians about all the possible options to alleviate their suffering.
  5 Patients have undergone recommended palliative measures, but their suffering is refractory, or was not controlled to a level acceptable to the patient.
  6 Patients are willing to accept that VSED will likely hasten their death.
  7 Patients voluntarily stop eating and drinking; it is not due to nausea, anorexia-cachexia syndrome, bowel obstruction, or other etiology that impairs food and fluid intake.

  Like other potentially death-hastening options, such as withdrawing life-sustaining therapy (WLST), or palliative sedation, VSED should not be initiated without significant deliberation. VSED should be considered only after all the other options to alleviate patient suffering are exhausted. Considering that the patient is not on any life sustaining treatment and is not imminently dying, the process 4) and 5) should take at least weeks to months, as shown in case anecdotes in the literature. 2-4

  In this study, we are concerned that these conditions were not met for a couple of reasons.
  First, there are very few palliative care specialists in Japan. The Japanese population over 65 years old is 3.461 million and surveyed palliative care specialists in Japan were 914. This means that numbers of palliative care physicians per 100,000 people aged over 65 years is 2.64 in Japan, as opposed to 15.7 in the United States. 5. Based on the relative paucity of hospice and palliative medicine specialists for elderly patients in Japan, we would expect that there is an under recognition and integration of palliative care concepts and, as such, procedures like VSED would not be commonly practiced. Of course, there may be an underlying cultural predilection to this way of ending one’s life, as it may be bound up in preserving patient dignity, autonomy, and honor.

  Secondly, although VSED is more challenging than WLST both legally and ethically2, WLST is still not legalized, and is not well accepted in Japanese society. It is true that the primary goal of both VSED and WLST is to limit patient suffering and further life in an unacceptable state, but there is a difference between the two: WLST is often performed in patients whose dying is prolonged by life support, VSED is rather utilized to hasten death actively in patients who are not imminently dying. In the United States, VSED is not illegal, but its legality has not been fully tested, and remains ethically controversial. 2 WLST, on the other hand, is both legally and ethically acceptable.. In Japan, WLST has been controversial. In 2009, the Supreme Court of Japan found a physician who withdrew mechanical ventilation from a comatose patient guilty of murder. 6 Although more recent guidelines from professional medical societies support WLST in a terminally ill patient7, there is still no legal protection for physicians who perform WLST, and consequently, WLST remains still very rare in Japan.

  Based on the above, it seems unlikely that the physicians surveyed met the criteria of VSED per the above table.

  We agree that palliative care and hospice physicians should support patients who are willing to pursue VSED, including providing continuous deep sedation if necessary. But before such an option is considered, palliative care and hospice clinicians should have exhausted all available options to alleviate the suffering of terminally ill patients and their families.

  1. Shinjo T, Morita T, Kiuchi D, et al. Japanese physicians' experiences of terminally ill patients voluntarily stopping eating and drinking: a national survey. BMJ supportive & palliative care 2017 doi: 10.1136/bmjspcare-2017-001426 [published Online First: 2017/11/10]
  2. Quill TE, Ganzini L, Truog RD, et al. Voluntarily Stopping Eating and Drinking Among Patients With Serious Advanced Illness-Clinical, Ethical, and Legal Aspects. JAMA internal medicine 2017 doi: 10.1001/jamainternmed.2017.6307 [published Online First: 2017/11/09]
  3. Eddy DM. A conversation with my mother. JAMA : the journal of the American Medical Association 1994;272(3):179-81. doi: 10.1001/jama.1994.03520030013005
  4. Quill TE, Lee BC, Nunn S. Palliative treatments of last resort: choosing the least harmful alternative. Annals of internal medicine 2000;132(6):488-93.
  5. Medicine AAoHaP. Workforce Study | AAHPM 2017 [Available from: http://aahpm.org/career/workforce-study - HPMphysicians accessed December 30th 2017.
  6. @japantimes. Top court dismisses euthanasia appeal | The Japan Times: @japantimes; 2009 [updated 2009-12-10T09:01:24+09:00. Available from: https://www.japantimes.co.jp/news/2009/12/10/news/top-court-dismisses-eu... - .WkgkhyPGwi4 accessed December 30th 2017.
  7. A guideline for the end-of-life care in emergency/critical care medicine 2014 [updated November 4th, 2014. Available from: http://www.jsicm.org/pdf/1guidelines1410.pdf accessed December 31st 2017.

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  Conflict of Interest:
  None declared.

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• Published on: 22 May 2019

  A comment to Shinjo T et al.: collusion in VSED

  • Friedrich Stiefel, Chief of Psychiatric of Liaison Service University hospital Lausanne, Switzerland
  • Other Contributors:
    • Kenji Nakamura, Attending physician, palliative care
    • Takeshi Terui, Medical Director
    • Kunihiko Ishitani, President

  Letter to the Editor
  Shinjo et al. recently surveyed Japanese home hospice and palliative care physicians’ with regard to their experiences of caring for patients who voluntarily stop eating and drinking (VSED) in order to hasten death and questioned their opinion towards continuous deep sedation (CDS) as a mean to relieve patients’ refractory symptoms during VSED (1). According to the authors, attitudes of non-acceptance of CDS in VSED (36%) may have been related to the opinion that the use of sedatives during VSED was commensurate with euthanasia. Compared to Dutch family physicians - of whom an overwhelming majority endorsed CDS in VSDE -, acceptance was rather low among Japanese physicians (15%), and the authors evoke that physicians may face a « moral conflict in respecting the patient’s self-determination and allowing patient suicide ».
  While we value the authors’ contribution to this clinically relevant topic, we would like to complete their point of view with regard to the possible underlying reasons of the physicians’ attitudes. Indeed, ethical elements may play a role, but psychological dynamics may also have influenced their stance. We have previously raised attention to the existence of collusions in end-of-life care (2). Collusion, an unconscious dynamic between patients and caregivers, occurs in situations which reflect an unresolved psychological issue shared by the involved persons; it may provoke strong emotions and unreflected behaviour (3). F...

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  Letter to the Editor
  Shinjo et al. recently surveyed Japanese home hospice and palliative care physicians’ with regard to their experiences of caring for patients who voluntarily stop eating and drinking (VSED) in order to hasten death and questioned their opinion towards continuous deep sedation (CDS) as a mean to relieve patients’ refractory symptoms during VSED (1). According to the authors, attitudes of non-acceptance of CDS in VSED (36%) may have been related to the opinion that the use of sedatives during VSED was commensurate with euthanasia. Compared to Dutch family physicians - of whom an overwhelming majority endorsed CDS in VSDE -, acceptance was rather low among Japanese physicians (15%), and the authors evoke that physicians may face a « moral conflict in respecting the patient’s self-determination and allowing patient suicide ».
  While we value the authors’ contribution to this clinically relevant topic, we would like to complete their point of view with regard to the possible underlying reasons of the physicians’ attitudes. Indeed, ethical elements may play a role, but psychological dynamics may also have influenced their stance. We have previously raised attention to the existence of collusions in end-of-life care (2). Collusion, an unconscious dynamic between patients and caregivers, occurs in situations which reflect an unresolved psychological issue shared by the involved persons; it may provoke strong emotions and unreflected behaviour (3). For example, a difficulty to deal with separation may motivate a patient to request euthanasia: anxiety provoked by impending separation (death), which he fears most, thus motivates him to hasten the process of separation (« get it over with »). If this patient meets a physician with the same difficulty, the clinician might be stressed by the request to an extent, that he either harshly rejects it (negative collusion, he creates distance in order to « get over with this anxiety provoking request ») or endorses it and even contributes to the patient’s death (positive collusion, he joins the patient in « get it over with »); in both cases, collusion hampers the clinician capacity to empathically explore the patient’s motivations for his request.
  Recently, we have proposed the Collusion Classification Grid (CCG) as a tool to further investigate collusion (4), which is considered to be prevalent in end-of-life care (5). The use of the CCG allows to identify the following elements, which may explain the attitudes towards VSED and CDS of some of the physicians. Thematic triggers of possible patient-clinician collusions in situations of VSED and CDS: separation anxiety, need of control, difficulty to face loss; positive collusion manifested as endorsement of VSED and CDS, and negative collusion as its rejection; associated emotions of collusions: anxiety, anger or sadness; potentially participating persons : patients, family members and clinicians; context-related factors influencing the occurrence of collusion: dominant discourses on rights to control one’s death (e.g., in the Netherlands) (6), or on the contrary a self, which is conceived less individually and more relationally (e.g., in Japan) (7).
  In conclusion, we try to make the point that not only ethical considerations guide clinicians in the formation of attitudes towards issues such as VSED and CDS; there are also powerful psychological motivations at work. An ethical perspective, on the other hand, is always based on an evaluation of the singular situation, a careful deliberation and a ponderation of elements in favour and against a request (8). Collusion may thus hamper ethical delberation and lead to misjudgements.

  1) Shinjo, T, Morita T, Kiuchi D, et al. : Japanese physicians’ experiences of terminally ill patients voluntarily stopping eating and drinking : a national survey. BMJ Supp and Pall Care 2017 ; 0 : 1-3.
  2) Stiefel F, Nakamura K, Terui T, and Ishitani K : Collusions Between Patients and Clinicians in End-of-Life Care : Why Clarity Matters. J Pain Symptom Manage 2017 ; 53: 776-782.
  3) The A-M, Hak T, Këter G, van der Wal G : Collusion in doctor-patient communication about imminent death : an ethnographic study. BMJ 2000 ; 321 : 1376-1381.
  4) Stiefel F, Nakamura K, Terui T, Ishitani K : The Collusion Classification Grid : a tool for clinical supervision and research J Pain Symptom Manage 2018 (in press).
  5) Low AJ, Kiow SL, Main N, et al. : Reducing collusion between family members and clincians of patients referred to the palliative care team. The Permanente J 2009 ; 13 : 11-15.
  6) Zimmermann C : Denial of impending death : a discourse analysis of the palliative care literature. Soc Sci Med 2004 ; 59 : 1769-1780.
  7) Kitayama S, Markus HR, Matsumoto H and Norasakkunkit V: Individual and collective process in the construction of the self: Self-enhancement in the Unites States and self-criticism in Japan. Journal of Personality and Social Psychology 1997; 72: 1245-1267
  8) Gracia D : Ethical case deliberation and decision making. Med Health Care Phil 2003 ; 6(3) : 227-233.

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  Conflict of Interest:
  None declared.

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