Hunger Games

You’re so vain, you probably think this song is about you . . . Don’t you? Don’t You?

—Carly Simon

Margaret was 90 when she was admitted into hospital. Interestingly her ethics consultation request came from two sources almost simultaneously. The first call came from the son of a patient I had dealt with over a year ago, he called to ask for my help. He painted the following picture: His accountant’s mother was admitted to our hospital, she was dying and the patient and family were okay with it but the hospital staff was having none of it. I was given the cell number of the accountant and asked to call her at my earliest convenience. The second call came from an internal medicine resident asking me to see one of her patients who was demanding “an injection which would set her free and end this horrible existence.”

I was soon to discover that both calls were related to the same patient.

Requests for hastened deaths are not infrequent in acute care hospitals. I ably fielded her call for a potassium chloride injection, and even deep continuous sedation, imploring with her that we could not take such active measures in assisting with her death. What made Margaret’s case a bit unusual was that she did not have a “life threatening” condition per se, but with a willful determination she stated that she’d endured a long history of spinal stenosis—one that required three surgeries in the past. “My surgeon says he can’t operate on me anymore—plus I’ve had enough” she said at the end of her narrative.

Her pain was palpable and her histrionics made staff all the more uncomfortable. I recall an intern asking her to rate her pain on a scale of 1 to 10. Margaret quickly sputtered: “15!” as she reached over to take a sip of water. On the way out the door I heard the intern say to his staff: “15—as if! If she was in that much pain she wouldn’t be able to take a sip of water”!

I knew then that we would have problems.

Psychiatry was called in to consult and spent several hours over the course of the first few days of her admission talking with Margaret. The verdict: smart, articulate, capable, and reasoned in her interactions. Is there a personality issue here? Undoubtedly but her behavior was deemed completely egosyntonic (in line with her goals for herself). The team had also consulted the pain service and our hospital’s palliative care consultation team—her distress seemed refractory—but some thought she was “playing us”.

Again Margaret asked me what we could do? I dutifully informed her that she could clearly articulate to everyone (in the form of an advance directive) that in the event that she ever needed life sustaining therapies she would not want it. She seemed annoyed by this passive approach. I did tell her that along with refusing medications and treatments that she could voluntarily stop eating and drinking (VSED) as a means to bring about death sooner. She thought long and hard about this option—it truly never crossed her mind before. She stated this option sounded “hard” but then she proudly told me: “I quit smoking, drinking and my last two husbands! I can easily stop eating and drinking.”

The prevalent bioethical and legal perspective is that if you can’t take matters into your own hands—or have the medical means to end your life—VSED is a legally allowable option. However this is not without its detractors: In the later stages of dying—the need for food or water naturally diminishes. In fact not forcing food and drink at this stage of an illness is a well–known ingredient to good end of life care. Experiencing a good death necessitates we follow the body’s final journey carefully—as organs shut down we do not try to tax them back into duty. For clinicians, the early and deliberate undertaking of VSED is akin to the imparting of a stage ahead of the body’s readiness. Doing so...