The Decision to Stop Eating at the End of Life

The decision to voluntarily stop eating and drinking at the end of life is a choice a person may make for more than one reason. Certainly, the decision may be made with the intent to hasten the dying process. But the underlying reasons may go deeper than this. Many, in fact, the majority, of people are not hungry at the end of their lives. In this setting, eating may be seen as an unnecessary discomfort while prolonging the discomfort of the underlying disease.

The end result of stopping eating is that people can take control over their own situation at the end of their lives. 

Stopping Eating vs. Suicide

Some people have been concerned that allowing a person to stop eating is, in essence, allowing them to commit suicide. But stopping eating is not suicide. It is a choice made by people who are already at the end of their life and are dying. The death, in these cases, does not occur from starvation or dehydration, but from the underlying condition that is leading to death.

Stopping eating is a natural event that is part of the normal dying process. A dying person will naturally lose interest in food and fluids and progressively become weaker. When the dying person decides to stop eating and drinking altogether, the process of progressive weakness leading to death occurs days to weeks sooner than would happen if the person were to continue eating and drinking.

Choosing to Stop Eating at the End of Life

People who are healthy may not understand why someone may voluntarily stop eating and drinking at the end of life. The underlying reason is often that the choice allows a person to regain or maintain some control over their situation. Factors leading to this reason may include the desire to avoid suffering, the desire to not prolong the dying process, and the wish to take control over the circumstances surrounding their death.

The Kind of Person Who Chooses to Stop Eating

There isn't really a "typical" person who chooses to stop eating at the end of their life, and this choice may be made by adults and children alike, with a wide range of medical conditions. According to one study, in which hospice nurses were surveyed in Oregon, the typical person who chooses to voluntarily stop eating and drinking is often elderly and considers himself to have a poor quality of life. That said, those who are younger or still have a fairly good quality of life might make this decision as well, in the hopes of avoiding the poorer quality of life which may occur by prolonging death.

Lack of Suffering 

The overwhelming conclusion of evidence to date suggests that choosing to stop eating does not increase suffering at the end of life. In the study mentioned earlier, it was found that 94 percent of nurses reported these people's deaths as peaceful.

Part of the Normal Dying Process

The cessation of eating and drinking is a normal part of the dying process that typically occurs days to weeks before death. Once the body becomes mildly dehydrated, the brain releases ​endorphins which act as natural opioids, leading to euphoria and often decreased pain and discomfort.

When a dying person voluntarily stops eating and drinking, the same process occurs, and the person may report feeling better than when taking in nutrition.

Very few people complain of feeling hungry or thirsty after the first couple of days. Mucous membranes may become dry as dehydration sets in, which is why some patients may want to moisten their mouth with drops of water for comfort. Studies looking at intravenous fluids have found that providing these fluids does not reduce the sensation of thirst if present. Instead, the use of oral swabs and lubricants can often reduce the sensation of a dry mouth when it occurs.

Stopping Eating vs. Physician-Assisted Suicide

As noted earlier, stopping eating or drinking is not, in general, considered a form of suicide in any way, either on the part of the person who is dying, or the healthcare professionals who concur with a person's choice. That said, there are some jurisdictions where voluntary stopping of eating and drinking may be legally prohibited under the rules governing suicide assistance, with regard to medical support in the decision-making process. This is currently an area of active discussion by researchers and ethicists worldwide.

There are differences between the two with regard to suffering as well. When death by voluntarily stopping eating and drinking was compared with death resulting from physician-assisted suicide, nurses reported that people in the former group had less suffering and less pain, and were more at peace than those in the latter group. Nurses reported that both groups had a high quality of death, which may sound strange, but means that their deaths proceeded with lower levels of pain and struggle.

Length of Survival 

Once a person stops eating and drinking, death usually occurs within two weeks. The person may continue to take small amounts of water to swallow pills or moisten the mouth, and these small sips of fluids may prolong the journey towards death by a few days.

Making a Decision About Voluntary Stopping of Eating and Drinking 

The decision to stop eating is not a question anyone ever anticipates asking. If you or a loved one are considering this option, make sure to discuss all of your concerns with your physician. She will likely want to make sure that there aren't treatable conditions, such as depression or untreated pain, that are contributing to your decision. She may also refer you to a  hospice social worker or a member of your religious organization (if applicable) to discuss this decision further.

It's also important to remember that you or your loved one can change your mind. If stopping eating or drinking leads to suffering or a sense of hunger or thirst, a person can certainly start eating or drinking again. It is not an irrevocable decision. Since a sense of hunger is so uncommon at the end of life, experiencing this may mean that it's not yet time.

Your loved ones may have opinions on whether you should stop eating, but this is your choice alone. No one can tell you whether you should voluntarily stop eating and drinking. Depending on your quality of life, the amount you are suffering, and your personal belief system, you can decide if this choice is right for you.

For Loved Ones of Someone Who Chooses to Stop Eating

It can be difficult to watch a loved one choose to stop eating and drinking at the end of life. It's important to remember that the decision belongs to them alone, no matter how you feel about the decision. For those who are healthy and aren't experiencing pain, it can be difficult to accept this choice. If you have a sense of hunger it can be hard to imagine that another does not. This is also a time when friends and family are often suffering anticipatory grief, a grief that can be as challenging as that which occurs after a loss. If you are struggling, reach out to your hospice team. Hospice care is designed to help the whole family, not just the person who is dying.

Bottom Line 

The cessation of eating and drinking is a normal part of the dying process, and is usually very peaceful, without a sense of hunger or thirst. People may choose to stop eating and drinking as a way to have some control over their death. This decision can generate mixed emotions, but the bottom line is that when death occurs after a person stops eating and drinking it does not occur because of starvation or dehydration. It occurs because of the underlying medical condition responsible for the dying process. In this setting, stopping eating may hasten death somewhat, but usually involves very little suffering. Most often, the voluntary stopping of eating and drinking results in a peaceful death which honors the person's last wishes.

Sources:

McGee, A., and F. Miller. Advice and Care for Patients Who Die by Voluntarily Stopping Eating and Drinking is Not Assisted Suicide. BMC Medicine. 2017. 15:22.

Quill, T., Ganzini, L., Truog, R., and T. Pope. Voluntarily Stopping Eating and Drinking Among Patients With Serious Advanced Illness—Clinical, Ethical, and Legal Aspects. JAMA Internal Medicine. 178(1):123-127.