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Distress from voluntary refusal of food and fluids to hasten death: what is the role of continuous deep sedation?
  1. Mohamed Y Rady1,2,
  2. Joseph L Verheijde2,3
  1. 1Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
  2. 2Center for Biology and Society, College of Liberal Arts and Sciences, Arizona State University, Tempe, Arizona, USA
  3. 3Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, Arizona, USA
  1. Correspondence to Professor Mohamed Y Rady, Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ 85054, USA; rady.mohamed{at}

In assisted dying, the end-of-life trajectory is shortened to relieve unbearable suffering. Unbearable suffering is defined broadly enough to include cognitive (early dementia), psychosocial or existential distress. It can include old-age afflictions that are neither life-threatening nor fatal in the “vulnerable elderly”. The voluntary refusal of food and fluids (VRFF) combined with continuous deep sedation (CDS) for assisted dying is legal. Scientific understanding of awareness of internal and external nociceptive stimuli under CDS is rudimentary. CDS may blunt the wakefulness component of human consciousness without eradicating internal affective awareness of thirst and hunger. Patients may suffer because of the slow dying process following dehydration and starvation. The difficulty to adequately control distress, without bringing the dying process to a rapid conclusion by lethal pharmacological interventions, can cause feelings of guilt among hospice and medical staff. Furthermore, the double-effect principle is not applicable in these situations because the primary objective of VRFF is to hasten death. Legal and societal debate should focus on sharpening the boundaries between assisted dying and palliative care. This separation is necessary to: 1) uphold trust in the patient-phyician relationship, and 2) preserve integrity and ethics of the medical profession.

  • Physician-assisted dying
  • palliation
  • euthanasia
  • end-of-life care
  • suffering
  • sedatives
  • opioids
  • dehydration
  • starvation
  • definition/determination of death
  • care of the dying patient
  • attitudes toward death
  • autonomy
  • ethics committees/consultation
  • informed consent
  • philosophical ethics

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  • Correction notice This article has been corrected since it was published Online First. An earlier version was uploaded in error.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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