More People Are Voluntarily Stopping Eating and Drinking as an End-of-Life Choice

Why some people choose terminal fasting, the difficulty in tracking VSED, and why it’s considered a legal and ethical alternative to MAID.

Over the last decade, the “death with dignity” movement has been gaining ground. Medical Aid in Dying (MAID) laws have slowly proliferated, and discussions about end-of-life decisions are becoming more commonplace, even touted by celebrities. But one choice, Voluntarily Stopping Eating and Drinking (VSED), also known as terminal or end-of-life fasting, seems to be increasing in prevalence more quietly.

Because VSED is legal throughout the United States and does not require medical provider involvement, it has become the de facto method for hastening death, particularly for those who don’t legally qualify for MAID. Advocates argue VSED allows individuals to exercise autonomy and have a more active role in their final moments, while critics express concerns about potential discomfort and the need for proper medical supervision. But VSED has been a traditional means of dying in the home for generations and is often thought of as a “natural” way of dying.

For those who are suffering, hastening death is rarely their first choice. Instead, it is often the only legal option available to maintain a sense of autonomy and choose how they wish to face the dying process.

What is VSED? 

VSED is when a mentally capable individual decides to control their own dying by making a conscious decision to refuse foods and fluids of any kind, including artificial nutrition and hydration, in order to advance the time of their death. 

Dying with the aid of VSED takes approximately 10 days, on average, but the process can be shorter or longer depending on the initial health status of the person doing VSED. (If there is a disease process involved, the time to death may require fewer days, but for those who aren’t considered terminally ill it can be two weeks or longer.) If neither food nor water is ingested at all, the body’s organ systems begin to shut down within the first week, and the person enters a coma a few days before death. 

The Difficulties in Tracking VSED

How often people actually elect to use VSED to hasten death is difficult to officially determine. One 2024 paper cited by the Palliative Care Network of Wisconsin pointed out that only a few studies have tried to measure its prevalence, and this data overlooks the possibility that patients might participate in VSED without a medical clinician ever knowing (therefore evading official record).

The Annals of Palliative Medicine (APM), an open access journal for palliative medicine research, published an overview of VSED in 2021, citing the statistics from the few known studies regarding VSED prevalence: A 2020 study conducted among 751 practicing family physicians in Switzerland which found that one in three had assisted a person during VSED; a 2017 study in Japan that found 32% of physicians surveyed had experience of caring for patients during VSED in a clinical setting; and a survey of 978 Dutch family physicians that reported 46% had cared for a person who elected VSED. One earlier Dutch study on Voluntary Refusal of Food and Fluid (VRFF), their equivalent of VSED, concluded 2.1% of their annual deaths could potentially be attributed to that methodology.

One of the only quantitative studies regarding VSED in the United States was published in the New England Journal of Medicine in 2003. A questionnaire was sent to all nurses employed by hospice programs in Oregon, and of the respondents, 33% reported that they had cared for at least one patient within the last four years who deliberately hastened death by voluntary refusal of food and fluids. Since then, hospice care has exponentially expanded, and anecdotal evidence points to the fact that the prevalence of VSED has, as well. 

Although reliable data on how many people choose VSED is limited, the practice occurs often enough that it has become an increasingly common topic of discussion within the medical community. The Journal of Pain and Symptom Management (JPSM) felt it necessary to issue a special article in 2023 to outline official Clinical Guidelines for Voluntarily Stopping Eating and Drinking, writing in the introduction that “VSED has emerged as a topic of increasing interest for patients who face a diminishing quality of life.” Written by a group of physicians and academicians from across the United States, the introduction continues, saying “we have fielded many inquiries about VSED, and have come to recognize the need for pragmatic guidance for clinicians on this topic.”

Who Are Electing to Undergo VSED?

Although hard data is difficult to come by, the statistics regarding who opts for VSED follow a clear pattern. In APM’s VSED overview, the nurses surveyed reported that “readiness to die, poor quality of life or fear of poor quality of life, viewing continued existence as pointless, desire to die at home, and desire to control the circumstances of death as among the most common reasons for choosing VSED.” Breaking this down further, “Frequent reasons for the patients’ death wish were somatic (79%), existential (77%), and dependence [on others for care] (58%).” Commonly reported somatic issues – meaning “of the body” – included pain, fatigue, and/or dyspnea (shortness of breath), or fear of those symptoms.

In the aforementioned Dutch study, out of 99 cases of VSED: 70% of patients were older than 80 years, 76% had severe disease (27% with cancer), and 77% were dependent on others for everyday care. 

Noted in a footnote of the Netherlands’ Guidance for VSED Care based on the study’s results is the comment that many individuals seeking VSED in the Netherlands “may be doing so because they have made a request for euthanasia that was declined.” This seems to be true for many people in the United States, as well, even with the increasing availability of MAID options.

Most MAID laws require patients to have a terminal illness with a life expectancy of six months or less. However, people living with progressive diseases – like Alzheimer’s, Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS) – often experience profound physical suffering long before they meet that legal definition of “terminal.”

Likewise, individuals diagnosed with dementia or other conditions that impair cognitive function are generally ineligible for MAID because they must be able to demonstrate they have decision-making capacity at the time of their request. While these safeguards are intended to protect vulnerable people from coercion or abuse, they also mean that many individuals facing progressive, incurable illnesses are unable to access MAID when they believe they need it most.

As a result, VSED is considered an ethical and legal alternative to MAID. Everyone has the right to refuse care, including food and hydration, making VSED a viable option for anyone who chooses it.

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