Fasting to die : a self-determined end without agony

No longer eating and drinking can be a self-determined way of dying. But this requires a good accompaniment.

Last Labors of Love. When the body weakens, support is all the more important

"The pleasant things of this world I have enjoyed, the youthful hours are, how long, how long gone, April and May and Julius are far away, I am nothing more, I no longer like to live." The old person who has his say in these Holderlin verses has obviously tasted life. But now he or she seems "full of life". Possibly because of the pain, limitations and discomforts that come with illness and old age.

13 days after her decision not to eat or drink anything from now on, an elderly lady died. Now, four years on, her daughter writes about this last period in her mother’s life ("Death Fasting. Voluntarily giving up food and liquids. A Case Description," Mabuse 2016). Reported a final independent plan, the emotional turmoil it threw loved ones into, the willpower it required, and an ultimately quite peaceful death.

The author Christiane zur Nieden, spirit scientist, welfare practical woman for psychotherapy, wife of a general practitioner and Palliativmediziner and for decades as dying and mourning companion actively, wants to take humans, who decide for this kind of dying, in addition, their member, the fear away. She does it by enriching the very personal account of the last two weeks of her mother’s life with factual information about the stages of this journey.

The very elderly eat little anyway and have little thirst

To healthy people in the middle of life, the voluntary renunciation of food and fluids, abbreviated by experts as FVNF, may seem brutal. Associations with hunger strikers who use fasting as a means of exerting pressure come up, but above all the agonizing idea of being thirsty and not allowed to drink. Zur Nieden makes it clear, however, that it would be inappropriate to think in terms of "starving" or "dying of thirst" in view of her mother’s decision. And not just because the mother voluntarily gives up food and drink. In the last phase of their lives, the very old often eat very little and are much less thirsty. Finally comes the actual dying phase of the last days and hours, "in which hunger is almost never present and thirst usually only arises from inadequate oral care," explains Swiss palliative physician Domenico Borasio in his book "Selbstbestimmt sterben" (C.H.Beck, 2014). Giving dying patients fluids by infusion is an unnecessary burden on their organism.

The decision for the FVNF is made days or even weeks earlier, and zur Nieden shows that the process is not free of stress. "Drink the next glass of water with relish, I drank it too often without mindfulness," says the mother on one of the first days. It sounds longing. All the more important are the small but frequent labors of love in oral care, backed up by professional tips: "Small crushed ice, placed carefully on a small spoon on the dry tongue, promotes a smile on my mother’s face."

The good thing is: the decision can be revised

Already because of the increasing weakness, people who want to go this way need support and guidance. From relatives, but also from doctors and caregivers. They are usually many days with clear consciousness, can regulate things and say goodbye. Moreover, the relatives can always suggest to them to change their minds, to drink a glass again after all, to have a bite to eat. The good thing about the voluntary renunciation is: The decision can be revised, at least at the beginning. In the case of suicide this is practically always different.

But is it a form of suicide at all? Physicians and caregivers may be concerned about this question because, since late 2015, Section 217 of the Penal Code has criminalized "businesslike" promotion of suicide. Christiane zur Nieden writes that her mother "initiated the dying process with suicidal intent" by giving up her life. The dying itself had not differed physically however from natural dying processes.

Death fasting is neither suicide nor a discontinuation of therapy

Philosopher Dieter Birnbacher, a member of the Central Ethics Committee of the German Medical Association, makes it clear that palliative medical assistance with FVNF is not only unproblematic, but even required. When he calls fasting to die a "passive suicide" in the journal "Human Living, Human Dying," he would rather point out possible collisions with the religious ban on suicide.

Jurgen Bickhardt from the Palliative Care Team Furth gGmbH and Roland Martin Hanke, on the other hand, describe the FVNF in an article for the "Deutsches arzteblatt" (German Medical Journal) as a "very unique way of acting" that should neither be equated with the discontinuation of medical treatment nor with suicide. At the end there is a natural death, without external influence. In their opinion this should also be marked on the death certificate. As diagnosis then for example "acute renal failure" should be considered.

Fasting for the dying does not get anyone into trouble and is not legally considered assisted suicide, medical lawyer Oliver Tolmein also reassured doctors in the "Zeitschrift fur Palliativmedizin" (Journal of Palliative Medicine): "It is by no means necessary to feed a person who wants to starve himself to death against his will. As long as the person concerned acts of his or her own free will." Christiane zur Nieden advises to write a living will and to give a person of trust a health care proxy. In addition, it should be clarified by a physician that the person wishing to die made his decision freely and responsibly: Only this legally safeguards those around him if they continue to act on his behalf after he has lost consciousness.

The person becomes sleepy, finally loses consciousness

In fact, when the body is deprived of fluids, urea in the blood rises, the kidneys restrict their function, the person becomes drowsy, and finally loses consciousness. In a study that appeared in the New England Journal of Medicine in 2003, more than half of the hospice caregivers surveyed rated this form of death as eight to nine on a scale of zero (very agonizing) to nine (very peaceful); virtually none of the professional caregivers gave it less than five points.

More than one-third of hospice caregivers reported they had witnessed a person bring about his or her death through FVNF at least once. When Borasio asked the same question at a German nursing congress, more than half of the participants raised their hands. In her book "Ausweg am Lebensende. Selbstbestimmtes Sterben durch freiwilligen Verzicht auf Essen und Trinken" (Reinhardt-Verlag, 2012), on the other hand, the Dutch psychiatrist Boudewijn Chabot and the German neurobiologist Christian Walther report that around 2800 people in the Netherlands do so every year. The number of unreported cases is certainly high, but the boundaries to the "normal" refusal of food and drink by dying people are fluid.

More on the topic

Fasting to die instead of euthanasia On the eighth day she was dead – and smiling

End without agony. Fasting is considered a gentle, almost natural way to end life. But the new law on euthanasia has unsettled doctors and homes

And "fasting to die" is not a new idea. The Greek philosopher Democritus is said to have decided at the blessed age of 109 not to eat or drink anything, as Birnbacher reports with reference to ancient sources. At the request of his sister, he has exceptionally taken a spoonful of honey, it is said. He wanted to celebrate another holiday with his family.

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