VSED: Voluntarily Stopping Eating and Drinking

UNDERSTANDING VSED:

VSED is an End-of-Life option that is legal in all 50 United States. Simply defined, it means to voluntarily refuse all food and liquids, including those taken through a feeding tube, with the understanding that this will cause you to die. It is a legally recognized and a protected constitutional right for a mentally competent person to refuse medical treatment, including food and hydration, to hasten their death.

That being said, it is not an easy process or one that should be attempted without assistance. VSED will require commitment, will power and resolve. You can live for quite a long time without eating but dehydration (lack of fluids) will speed up the dying process. Generally speaking, dying from VSED will take an average of ten days. While most people will take a week or two for this process, in some cases it can be only a few days and others as long as several weeks. While the process takes determination, it is usually not painful and can lead to a peaceful death when accompanied by adequate caregiver support and palliative care.

• Preparation for VSED usually starts with an initial clearing of the gut, similiar to the preparation for a colonoscopy. This will help with prevention of constipation and abdominal pain later. After the cleanse, no food or water is ingested.

This process should not be attempted without support. If possible, get your family members, caregivers, death doula, healthcare professionals all on board before starting the process. Educate yourself on what happens during the process and what steps you want to take to make sure you continue the process to the end. Lastly, be sure you have your legal and financial paperwork in order and your medical equipment, medications, hospice team and support team ready before you begin your fasting.

WHAT DOES THE VSED PROCESS FEEL LIKE?

There are no known unique symptoms associated with a death by VSED. Pain, hunger (in the first days), thirst, dry mouth, shortness of breath, and agitation are commonly reported but these symptoms should be manageable with medical and caregiver support.

In the beginning most people feel the same as they did before starting VSED. Hunger pangs and thirst are common the first days, but this discomfort can usually be alleviated with mild sedatives or distraction and relaxation techniques.

Agitation, delirium and extreme dryness and thirst may occur. Your Hospice nurse or physician can prescribe medications and caregivers can provide dryness comfort. Drinking liquids will prolong the process and make it more uncomfortable. Since dehydration will most likely be the cause of death, it is important not to drink anything once you start. Even sips of water may slow the dying process. You may need to be reminded that you are going through this process and why you chose to do it.

After a few days, your energy levels will decrease, and you will become less mentally alert and sleepier. Most people begin to go in and out of consciousness by the third day and later become unresponsive.

People who go through the VSED process often express a sense of peace that they can finally "stop fighting." Some people describe a sense of euphoria or pleasant lightheadedness. This could be explained by the analgesic effect caused by dehydration.

The symptom management with VSED is the same as with other dying patients:

• Feelings of thirst are lessened with careful mouth care, I.E., brushed teeth, lip balm, oral foam swab sticks, occasional spritzing with a fine mist of water and cool cloths to the face.

• Dry mouth and throat are helped with using a cool air humidifier in the room

• Dry skin can be soothed with lotion and cool, wet cloths

• Shortness of breath and anxiety are lessened with prescribed medications:

During the first few days of the process, you can interact almost normally with friends and family, and may take pleasure in hearing stories, listening to music, being read to and watching TV or movies. This is a precious, sacred time for doing the work of dying; saying goodbye, forgiving and being forgiven, and expressing love. Help prepare your caregiving team with a list of ways your would like to be comforted and distracted.

WHAT STEPS DO I NEED TO TAKE:

• First and foremost, get your financial and legal affairs in order. Complete a POLST, and Advanced Health Care directive and speak to your health care agent about being your advocate.

• You will need to have medical assistance. Contact a Hospice for intake and understand that you may not be hospice-eligible for several days into the process. Make sure you have a physician in place to prescribe medications needed to alleviate pain and discomfort during the process. Discuss with your physician and caregivers the options for medications i.e. pain and anxiety medications, palliative sedation , etc.

• If you will not be at home and are planning to execute this process in a facility, it is important that you and your caregiving team meet with the facility director to discuss the process and come to an agreement before starting. Facility staff need to understand the process and make sure the patients wishes will be honored.

• Food smells and cooking sounds can be difficult for someone who is not eating or drinking. Try to plan so this can be avoided. Also, do not leave food our to tempt the client, especially while they are still mobile.

• Consider the use of alternative methods of pain relief and distractions such as healing touch, reiki, acupressure, aromatherapy, CBD and cannabis.

• Prepare instructions for confusion and possible delirium. By day four or five you may still be conscious but your memory and endurance can be compromised. It is not uncommon for the dying individual to become confused and request fluids. This is s difficult situation for caregivers who are now caught between the person's earlier, competently expressed wishes and a now compromised, thirsty desire. Prepare for this situation in order to be sure your wishes are honored and to protect your caregivers from accusations of neglect or maltreatments.

• Make sure caregivers, or at least one point person is available to remind you why you are not eating or dinking should you become confused. Work with the client to prepare this language ahead of time. Keep the message consistent, something like: "You chose to stop eating and drinking so you will avoid being put on a feeding tube, moved to an assisted living facility , etc. I can give you something to drink but it will prolong your plan, would it help if I just moistened your mouth with a sprite of cool water and wiped your face with a cool cloth?

• Document your choice. We strongly suggestion making video(s) but at the very least, you should write down your wish to do this while you are still very lucid. Let the caregivers know where the video(s) are stored and how to play them for the client. You can do this in writing or create video(s) with explicit instructions, such as first you want to be reminded of why you chose VSED, increase care for oral dryness and to medically treat any agitation before acquiescing to you.

• It is suggested that the client create two videos, one shorter one (around one minute) that shows the clients speaking to his/herself. Something like: "Hi, this is yourself, I'm reminding you that I chose to stop eating and drinking and die a natural death because I have a terminal disease, and if I continue on I will.........(fill in with personal reasons such as end up in a facility, forget your loved ones, spend the remainder of your life in bed with constant care etc)

• A second, longer video (3-5 minutes) is recommended to serve several functions:

a) it can serve as a legal recorded document of the clients decision;

b) as a potential reminder to the client (and caregivers) during the VSED process; and

c) as reassurance to a grieving family that this type of death was, exactly what their loved one wanted or intended. This video should record the client describing their reasons for doing VSED, such as family history or familiarity with their current diagnosis or skilled nursing facilities, significant declining markers during the disease such as no longer being able to read, garden, travel, visit family, care for themselves, or any other personal reasons for choosing to hasten their death.

• Preparation for VSED usually starts with an initial clearing of the gut, similar to the preparation for a colonoscopy. This will help with prevention of constipation and abdominal pain later. After the cleanse, no food or water is ingested.

https://www.jpsmjournal.com/article/S0885-3924(23)00565-1/fulltext

https://vsedresources.com/wp-content/uploads/2020/11/Guide-to-Managing-VSED_Nov-2020.pdf

https://eolcoregon.org/end-of-life-choices/voluntarily-stopping-eating-and-drinking-vsed/

https://deathwithdignity.org/resources/options-to-hasten-death/