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ZHAW study collects data on death by starvation in Swiss old people’s homes for the first time

Voluntarily forgoing eating and drinking, also known as the voluntary stopping of eating and drinking (VSED), or starving to death, can be an option for critically ill people to prematurely and autonomously end their lives. In Switzerland too, social awareness of death by starvation is gradually growing. The research team at the ZHAW Institute of Nursing has now collected empirical data for the first time on the prevalence of this phenomenon in Swiss old people’s homes.

VSED (the voluntary stopping of eating and drinking) is a controversially debated means of committing suicide that has hardly been researched in Switzerland. Now, for the first time, there is data on how widespread this phenomenon of death by starvation is in Swiss old people’s homes. As shown in a survey within the framework of the ZHAW research project entitled “Voluntary Stopping of Eating and Drinking in Switzerland from Different Points of View”, 1.7% of all deaths in the homes can be attributed to death by starvation. Around one-third of all 1,500 old people’s homes in Switzerland took part in the survey. In absolute terms, 1.7% corresponds to approximately 460 people each year who prematurely end their lives with VSED in Swiss homes. However, the actual number of cases could be considerably higher, according to project manager André Fringer, who is also co-head of the nursing science research team and of the the MSc in Nursing at the ZHAW School of Health Professions. He also states that the management and nursing staff questioned assume that only about a quarter of the death by starvation cases are actually stated to be such by the affected persons. In the other cases, residents of these homes simply quietly reduce their food and drink intake and then finally give it up altogether.

Risk of false interpretations

However, Fringer urgently warns against interpreting any refusal of food or fluids by those at the end of their lives as an attempt to die by starvation. The reason for this is that the voluntary nature of death by starvation is linked to the power of judgement of the dying person and should not be confused with any other form of refusal to eat. “The risk is that the loss of appetite, which often occurs in the last phase of life, may be interpreted as a death wish,” Fringer states. He fears that, in particular with regard to those people who suffer from dementia, “a judgement will quickly be made that the person no longer wants to eat”. As a result, it could very well be that a person suffering from dementia could refuse food and drink from a nurse, but accept it from a dementia expert without a problem. Fringer says that, in the case of dementia, the refusal to eat should therefore be examined very critically and clearly regulated. He goes on to say that, in general, death by starvation raises a series of ethically difficult questions and health professionals who have to deal with this topic at work must be sensitised to it. “They should already be confronted with this topic during their training and develop an approach to it,” he states.

Death by starvation largely viewed positively

The survey of old people’s homes shows that a serious debate about this topic is needed, both socially and politically. Sabrina Stängle, co-author of the study and a doctoral student, says that two-thirds of the homes that took part in the survey describe this topic as extremely relevant to their daily work. Moreover, in every second care institution, there has already been at least one case of death by starvation. A large number of the survey participants judged VSED positively and as a dignified and natural way of ending one’s life. However, according to the study, there is often a lack of knowledge and of a clear approach to handling death by starvation professionally in the institutions. The authors state that these care facilities should thus discuss VSED openly and develop clear positions.

The Swiss Academy of Medical Sciences (SAMW) is financing this ZHAW research project and provides guidance in this regard. The SAMW has recently included VSED in its «Handling Dying and Death» guidelines (available in German only), which have great impact in the healthcare sector. The Swiss Professional Association for Nurses (SBK), for example, recommends that its members pay attention to and apply the SAMW guidelines.

Data and approaches for GPs and Spitex to follow

In the early summer of 2020, André Fringer and Sabrina Stängle will publish data from additional sub-studies regarding the prevalence of death by starvation outside Swiss old people’s homes. Here, they will draw upon information from GPs and Spitex organisations. This study will look at the approach of GPs and Spitex to death by starvation also, and how they deal with this.

Announcement

Professor André Fringer held a talk on death by starvation at the SAMW «Research in Palliative Care 2014–2018» symposium on 21 November, 2019 in Berne, entitled “Voluntary Stopping of Eating and Drinking (VSED) in Switzerland”.

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