While it is ultimately up to a competent person to stop eating and drinking,42 health care facilities must respond to VSED requests in an organizationally consistent and clinically consistent manner and develop clear guidelines and procedures for handling VSED requests. Educating patients about VSED can enable them to make informed decisions about whether this choice is right for them. Patients and affected facilities should consult a lawyer. VSED is morally and legally compatible with the right to refuse unwanted care. However, VSED has not been the subject of high-profile prosecutions like other so-called “right to die” issues.36 Perhaps the reason VSED has received so little attention is that few clinicians and fewer patients even know that VSED is an option. This may be because the alternative to honoring a critically ill or dying patient`s informed decision to refuse to eat and drink is to force-feed them, a prospect repugnant to courts and clinicians.37 Instead, we argue that even though VSED is classified as a type of suicide, a physician`s participation in VSED is not a form of assisted suicide. The involvement of doctors in VSED is therefore not covered by the legal provisions prohibiting VSED. Since dehydration will likely be the cause of death, it`s important not to drink anything once you start. Even sips of water can prolong the dying process.
Whether or not your state has a law on death with dignity, you have a number of ways to hasten your death. These options are legal in any state. However, none can be used alone. Rather, they require collaboration with your healthcare team and loved ones. While palliative sedation is an ethical and legal option at the end of life, it is not necessarily a right. Although you can request palliative sedation, it is up to the medical provider to determine if it is appropriate. Some doctors and hospices hesitate or do not want to approve palliative sedation. If the possibility of palliative sedation is important to you, discuss it with your hospice or other medical provider before it becomes necessary. Beyond legal issues, patients considering VSED, their families or caregivers, and clinicians may have ethical or moral concerns about the process, particularly if it is a form of suicide, if suicide is always morally wrong, and if clinicians who resist suicide are obligated to support a patient. who voted VSED (2,10,12,23).
Proponents of the permissibility of VSED point out that suicide can be rational when patients choose intentional death by known means – harm – rather than perceive greater harm, such as prolonged suffering from diseases that also result in death (24). VSED is also perceived as less likely than AID to be a forced decision: “VSED requires sustained determination of the patient`s own will despite significant conditions such as thirst and hunger. In addition, decisions regarding VSED can be reversed by the patient, at least in the early stages. Of the other decisions made as a `last resort`, VSED expresses the least concern that the choice is voluntary” (2) (p. 125). People who begin this process often express a sense of peace that they can finally “stop fighting.” Some people describe a feeling of euphoria or pleasant dizziness. There is an analgesic effect caused by dehydration that may explain this reaction. With dehydration, people often need fewer painkillers, urinate less, have less vomiting, and breathe more easily due to reduced constipation. In VSED, the patient is able to take food and drink orally, but chooses not to do so in order to hasten death.5 He deliberately refuses all food and liquids, except for small amounts of fluids necessary for oral comfort or swallowing medication. Death from dehydration usually follows within a few days to three weeks.6 A growing body of clinical literature suggests that with good palliative support, VSED leads to a relatively comfortable and peaceful death (see “Experience with VSED” below). Nevertheless, many legal, ethical and practical questions remain unanswered as to how and when a VSED request can and should be met.
The boundaries of reviewing a VSED application are not always clear, e.g. if the applicant suffers from multiple chronic conditions but is not incurable, or if the applicant is incurable but has a life expectancy of more than six months.39 A common question for nursing homes and other health care facilities is whether reviewing a VSED request could violate state and federal laws protecting patients from abuse and neglect. Some institutions mistakenly assume that this would be the case.40 Another area of uncertainty is whether an individual can make a request for VSED on behalf of a patient.41 Quill et al. (2018) note two opposing views on the role of clinicians in VSED. The first is that suicide is immoral and that any attempt to relieve it, for example by treating the symptoms of VSED, is morally and perhaps legally reprehensible. The other is that suffering, whether caused by VSED-related symptoms or other causes, should be treated with palliative care if desired (2). Jansen and Sulmasy suggest a third intermediate position, namely that it might be permissible for a physician to support a patient`s decision to refuse treatment, including diet and hydration, in the face of incurable diseases, but that the physician should not suggest it as an option so that the patient is not influenced to choose it (25). During terminal dehydration, the usual symptoms of dehydration such as headaches and leg cramps may occur.
Unlike many other methods of suicide, it cannot be performed impulsively.  However, a “point of no return” may eventually be reached when rehydration cannot be achieved by simple oral rehydration therapy if terminal dehydration must be stopped; On the contrary, it will require medical help such as intravenous therapy. Those who die from terminal dehydration usually fall into unconsciousness before death and may also suffer from delirium and alteration of serum sodium.  Stopping hydration does not produce true thirst, although a feeling of dry mouth is often referred to as “thirst.” There is ample evidence that true thirst does not occur, as well as evidence showing that the sensation of bad sensation is not relieved by intravenous administration of fluids, but by moistening the tongue and lips and proper mouth care. Patients with edema tend to take longer to die from dehydration due to excess fluid in their bodies.  Dehydration is known to cause a feeling of “mild euphoria” provided no intravenous agents are used.  A debate has erupted in the Netherlands about terminal dehydration, known as sterving [nl]. There have been allegations that unintentional dehydration occurs in nursing homes. Another doctoral dissertation found no evidence of forced “versterving” in nursing homes.  However, there was vehement opposition to the support of those who voluntarily abstained from eating and drinking.  Compared to patients who chose SAP during the same time period (which is legal in Oregon), patients who chose to refuse food and fluids were generally older, less likely to want control over the circumstances of their death, and less likely to be assessed by a psychiatrist. Dying from a lack of food alone can be longer and more unpleasant than dying from dehydration. A person can live for a very long time without eating, but dehydration (lack of fluid) speeds up the process. Dehydration can contribute to comfort rather than increased suffering by generally describing VSED in three phases: an early stage where the patient is alert and may be thirsty, but can engage with others; a medium stage, characterized by progressive weakness, because kidney function fails; and an advanced stage in which the patient is largely unresponsive until death (2,6,10) (see Table 1). Symptoms associated with VSED include thirst and difficulty urinating, especially in the first few days. Patients rarely express unbearable hunger when the body begins metabolizing fat through ketosis (10). If dehydration persists, patients become weakened and may suffer from delirium.
Patients become more sleepy over time and may fall into a coma a few days before their death. Depending on the patient`s underlying health condition and the extent to which they limit fluid intake, patients typically die within two weeks of starting VSED (6,9). Death is described as peaceful (1,9) and is thought to be caused by cardiac arrest because the transport of sodium and potassium in heart cells is disrupted (6). Voluntary cessation of eating and drinking (VSED) is an “act of a competent and capable person who voluntarily and intentionally chooses to stop eating and drinking with the primary intention of hastening death because unacceptable suffering persists” (1).