Can someone just die of nothing

Fasting to death : A self-determined end without agony

"I enjoyed the pleasant things of this world, the youth hours are how long, how long have passed, April and May and Julius are far away, I am nothing more, I no longer like to live." When it comes to speaking, life was obviously tasty. But now he or she seems "full of life". Possibly because of the pain, limitations and discomfort that illness and old age bring with it.

13 days after she decided not to eat or drink anything from now on, a very old lady died. Now, every four years, her daughter writes about this last time in her mother's life ("Fasting to death. Voluntary renouncement of food and fluids. A case description", Mabuse 2016). Reports on one last independent plan, on the emotional turmoil into which he plunged the relatives, on the strength of will it required, and on an ultimately quite peaceful death.

The author Christiane zur Nieden, humanities scholar, alternative practitioner for psychotherapy, wife of a general practitioner and palliative medicine specialist and has worked as a death and grief counselor for decades, wants people who choose this type of dying, but also their relatives, to take their 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 on this path.

The very old eat little anyway and are not very thirsty

For healthy people in the middle of life, the voluntary renouncement of food and fluids, abbreviated as FVNF by experts, may seem brutal. Associations with hunger strikers who use fasting as a means of pressure arise, but above all the tormenting idea of ​​being thirsty and not allowed to drink. However, Zur Nieden makes it clear that it would be inappropriate to think in terms of “starvation” or “dying of thirst” in view of her mother's decision. And not just because the mother voluntarily refrains from eating and drinking. In the last phase of their life, very old people often eat little anyway and are significantly less thirsty. Finally comes the actual dying phase of the last few days and hours, "in which hunger is almost never there and thirst usually only arises with inadequate oral care", explains the Swiss palliative medicine specialist Domenico Borasio in his book "Die Self-Determined" 2014). Possibly giving the dying liquid via infusion puts an unnecessary strain on their organism.

However, the decision to FVNF is made days or weeks earlier, and zur Nieden shows that the process is not free from stress. "Drink the next glass of water with pleasure, I have drunk it too often without being mindful," says the mother on one of the first days. It sounds wistful. All the more important are the small but frequent love services in oral care, supported by professional tips: "Small crushed ice, carefully placed on the dry tongue on a small spoon, promotes a smile on my mother's face."

The good thing is: the decision can be revised

Because of their increasing weakness, people who want to go this way need support and guidance. From relatives, but also from doctors and nurses. Most of the time they are clearly conscious for many days, can take care of things and say goodbye. The relatives can also repeatedly suggest that they change their minds, but have another drink or something to eat. The good thing about the voluntary waiver is that the decision can be revised, at least at the beginning. With suicide it is practically always different.

But is it even a form of suicide? Doctors and nurses may be concerned about this question because, since the end of 2015, Section 217 of the Criminal Code has made “business-like” promotion of suicide a criminal offense. Christiane zur Nieden wrote that by renouncing her mother “heralded the process of death with suicidal intent”. Dying itself was not physically different from natural dying processes.

Fasting to death is neither suicide nor discontinuation of therapy

The philosopher Dieter Birnbacher, member of the Central Ethics Commission of the German Medical Association, makes it clear that palliative medical support is not only unproblematic at the FVNF, it is even necessary. When he calls the fasting to death a “passive suicide” in the magazine “Humanes Leben, Humanes Dieben”, then he would rather point out possible collisions with the religious ban on suicide.

Jürgen Bickhardt from the Palliative Care Team Fürth gGmbH and Roland Martin Hanke, in turn, describe the FVNF in an article for the “Deutsche Ärzteblatt” as a “very own way of acting”, which should not be equated with the termination of medical treatment or with suicide. In the end there is a natural death, without any outside influence. In her opinion, this should also be ticked on the death certificate. "Acute kidney failure" should then be considered as a diagnosis.

The fasting of death does not get anyone into trouble and is not legally seen as aiding and abetting suicide, the medical lawyer Oliver Tolmein also reassured doctors in the “Zeitschrift für Palliativmedizin”: “It is by no means necessary to put a person who wants to starve himself to death against his own Will to feed. As long as the person concerned acts of their own free will. ”Christiane zur Nieden advises drawing up an advance directive and giving someone you trust a power of attorney. In addition, it should be clarified by a doctor that the person willing to die has made his decision freely and responsibly: This is the only way to legally protect the people around him if they continue to act in his sense after he has lost consciousness.

The person becomes sleepy, eventually loses consciousness

In fact, when the body is no longer supplied with fluids, the urea in the blood rises, the kidneys limit their function, the person becomes sleepy and eventually loses consciousness. In a study that appeared in the New England Journal of Medicine in 2003, over half of the interviewed nurses in hospices rated this form of death on a scale from zero (very excruciating) to nine (very peaceful) with eight to nine, practically none of the professional supervisors gave her less than five points.

Over a third of hospice carers reported having seen a person cause death from 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 “Way out at the end of life. Self-determined death through voluntary renunciation of food and drink ”(Reinhardt-Verlag, 2012), on the other hand, the Dutch psychiatrist Boudewijn Chabot and the German neurobiologist Christian Walther report that around 2,800 people do it every year in the Netherlands. The number of unreported cases is certainly high, as the boundaries to the “completely normal” rejection of food and drink by the dying are fluid.

And “fasting to death” is not a new idea. Even the Greek philosopher Democritus is said to have decided at the blessed age of 109 years not to eat or drink anything, as Birnbacher reports with reference to ancient sources. As an exception, at the request of his sister, he took another spoonful of honey, it is said. He wanted to celebrate another holiday with his family.

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