 Palliative care, comfort measures for serious advanced illness has its limitations. There are always some tough cases left with an unacceptable quality of life, despite our best efforts. When suffering cannot be sufficiently relieved, the option of VSED, as it means to shorten life, may present a welcome strategy. VSED stands for Voluntarily Stopping, Eating, and Drinking, which until recently was rarely discussed as a viable option. Why is that the case? Well, historically, it's had a bad rap for good reason. In Nazi Germany, patients in psychiatry hospitals were starved to death. Normally, feeding vegetables to patients would be a good thing, but with so few calories, patients died of starvation within a matter of months. I think the understandable knee-jerk response from many doctors who have not witnessed a VSED death may be to fear that such a death might be unduly painful, prolonged, and inhumane. But as I covered in my last video, those fears are not supported by clinical reality. It appears VSED provides most patients with a peaceful and gentle death that is generally well tolerated and occurs within two weeks of beginning the fast. Two weeks is still a long time, though. Advocates of physician-assisted suicide, where, for example, a doctor prescribes a lethal dose of sleeping pills, suggests that's a more humane option. I hear some poor patient with unbearable suffering asking their doctor for help in ending their lives, and their physician is like, too bad, starve yourself to death. But if you're in one of those 42 states where assisted suicide is illegal, what are doctors supposed to do? Thanks to the 14th Amendment, patients everywhere have the right to refuse medical care. Yeah, but food is different, say critics, because it's a necessity. But hey, look, if people can refuse to be put on a respirator to save their life, then maybe they should be able to refuse food and drinks, since there ain't nothing more necessary than breathing. Advocates of VSED point to the fact that doctors need not be involved in the decision as a good thing. But clinician support and management can be critical to provide comfort measures, for example, to manage the associated thirst, which manifests mostly as just dryness in the mouth. We're used to experiencing thirst when we continue to eat, but when both food and fluids are stopped, dehydration manifests mostly as a dry mouth. And you can trick the brain, because there are water receptors in your mouth that tell the brain that thirst is being quenched even before you swallow. So you can sponge the lips, a moist in the mouth with swabs, and there's all sorts of over-the-counter rinses and artificial saliva. But you have to be careful about sips of water or ice chips, though. Swishing and spitting may be a better option, because even just small regular sips of fluids can prolong the process indefinitely. Even without excess body fat, people carry around about 150,000 calories worth of stored energy. That's why people can starve themselves sometimes for months. Now, I was surprised by the two weeks without water. I mean, I thought you died of thirst in just a couple of days, but that's only if you keep eating. When you burn fat, you actually produce water inside your body, like a cup a day. So that's why when you stop drinking and eating, it can take a week or two and longer if you're sipping water as well. There's some medical side benefits to the dehydration process. You don't have to worry as much about incontinence or catheters or bedpans. Less nausea and vomiting is your digestive secretions dwindle. Less respiratory secretions means less coughing and choking and drowning sensations. Less swelling, which can be a problem with end-stage cancer, and that can relieve pain by taking pressure off the nerves. And mental awareness may decline, which can bring some relief to suffering patients as well, but can also present a serious ethical dilemma. At the beginning, when the patient remains cognitively and decisionally intact, they can choose to stop anytime they want. But a more difficult situation arises later should patients become delirious and forget that they ever made the decision to start asking for something to drink. On one hand, it would seem unethical to withhold fluids from a confused, thirsty patient who keeps asking for water. On the other hand, patients may be upset to find out that after they drink and delirium clears, that they find their plan didn't work. And that indeed appears to be what happens. They feel betrayed by their caretakers when they were under strict instruction to not give them food or drink. Yeah, but how are you going to deny a confused loved one's sustenance if they're begging for it? And if you think that seems hard, denying someone's heartfelt request made days before, imagine if their request was made years before. By its very name, voluntarily stopping eating and drinking, how do we apply that to the case of dementia? With no effective therapy for Alzheimer's disease and other progressive dementias on the horizon, many reach the final stage of severe dementia, characterized by complete dependence in all activities of daily living, double incontinence, inability to speak or walk or even recognize family members. And this can go on for many months or even years, which is one of the reasons why people tend to be more afraid of developing dementia than developing cancer. But by then, you may be trapped. You may wish to end your life rather than living on in that state, but when the time comes, you can't because you're in that state. So that's why sometimes people diagnosed with early dementia commit suicide when they still have the ability to do so, but that deprives them of years of life they might have otherwise enjoyed. Therefore, it would be useful to have available strategy that would definitely prevent living with a severe case of dementia for those that feel that way. Dementia need not be a trap. We can, while we are still of sound mind, write an advanced directive to withhold food and water should you ever reach that state. Unfortunately, most people don't write anything down, and in many cases even tell their spouses about their end-of-life wishes. And even if you do write it down, your wishes may not be granted, which is why groups like End of Life's Traces New York have created specific advanced directive documents to specifically address the issue of hand-feeding in those with end-stage dementia. But you know, be sure to think it through though, right? In existence that seems demeaning and unacceptable to you now may still be a value to the person you might become then. So should they respect your prior wishes or your current wishes, right? Withholding food and water from an incompetent patient who complains of thirst and hunger could be seen as itself and affront to basic dignity.