Fasting to death

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The fast to die is a form of suicide . The suicide stops eating and drinking one after the other or at the same time in order to end his own life. The fasting of death is controversial because arguments that reject the fasting of death out of ethical and moral concerns contrast with the arguments that assume a right to self-determination about ending one's own life.

People decide to take this path in different situations, for example because of a high burden of symptoms caused by illness or because the rest of life seems to be a burden for them or their relatives for other reasons. Since such wishes to die can also occur with a treatable or temporary psychological impairment, it is ethically and criminally imperative for potential supporters to check whether there is an impairment of the ability to understand. In palliative medicine , the term is “voluntary abstinence from food and fluids (FVNF)”.

In contrast to other suicide methods, this type of suicide can be broken off during the initial period without having to fear permanent consequences. If this voluntary renunciation of food and fluids is carried out consistently, death can be expected within 14 days in almost three quarters of the cases, depending on the constitution and underlying disease. In some cases it can take longer; especially if there is no fatal or serious illness. According to empirical studies, not eating and drinking is usually not a pain for the dying , but a prolonged dying process can become a burden for those affected or their relatives.

background

It is part of the dying process that the food intake and later the fluid intake is often reduced and then stopped completely. The ingestion of even small amounts of fluids, for example when taking medication, delays death. According to Boudewijn Chabot and Christian Walther, if you drink enough fluids, you can go without food for many weeks without causing death. Fasting to death is based on a conscious, voluntary decision. It can be ended again at least in the first week without permanent damage being expected, while other suicide methods usually result in immediate death or can lead to sometimes massive restrictions in survival.

Outsiders perceive dying as a gentle process by consistently avoiding food and fluid intake. A survey of nurses from hospice and palliative care facilities in Oregon in 2001 who had accompanied such a death showed that on average they had experienced the dying process as very good and peaceful. In the questionnaires for the 126 nurses, different categories (“suffering, pain, peacefulness”) were asked. Overall, they rated the last half month of the individual death process with eight points on a scale from zero to nine (“terrible” to “peaceful”).

A FAZ review of the book Way out at the end of life: Dying fasting by Chabot and Walther, on the other hand, takes a critical look at the propagated concept of the so-called fasting death: According to the book , “anorexic people and hunger strikers ” are excluded from fasting because the concept is “unbearable for young people Torment means ”, while the“ old ”are offered a death which is“ not entirely free from suffering ”.

requirements

Death fast can be defined by three conditions:

  1. A patient chooses not to consume one or the other in a state in which he is able to ingest food and fluids.
  2. His intention is to hasten the onset of death.
  3. He makes the decision to do so in a state of insight, without external pressure and in the knowledge of the scope of his decision.

In order to ensure that the person concerned can cancel his project at any time, if he still decides otherwise, there should be a drink or something to eat within his reach.

physiology

The physical symptoms of not eating and drinking run as follows: If the body is not fed, after one or two days the so-called starvation metabolism occurs , in which as little energy as possible is used. At the same time, the feeling of hunger subsides. The protein and fat reserves of the body are gradually dissolved; muscle wasting occurs. During these metabolic processes, ketone bodies such as acetone are formed . When fasting for longer periods of time, the body releases endorphins , which makes starvation more bearable and can lead to euphoric emotional states. Fasters lose an average of around 400 grams per day; initially mainly water, later protein (and thus muscle substance).

If you do not use the approx. 25 ml of water per kilogram of body weight required to maintain metabolic functions per day, dehydration occurs , which is expressed as thirst after a water loss of three percent. Speech and gait disorders can occur from around ten percent. Good oral and mucous membrane care, e.g. B. rinsing your mouth for half an hour can relieve symptoms such as thirst and dry mouth (xerostomia). In contrast, hydration via an infusion does not necessarily reduce the feeling of thirst.

Seriously ill people whose immune system is impaired by the disease or its treatment (e.g. therapy with cytostatic drugs ) also tend to develop inflammation and fungal infections such as mucositis and thrush . As a result of dehydration, the kidneys have too little fluid to maintain their elimination function. It comes to acute kidney failure with an increase of urea in the blood, which makes you sleepy time. Death usually occurs during sleep from cardiac arrest .

More symptoms

As is often the case with disease-related death, further symptoms occur with progressive emaciation and dehydration ( desiccosis , dehydration ). This includes increasing weakness, which ultimately leads to bed rest , with the associated risks of bed sores and contractures . When standing up, there is an increased feeling of dizziness ( orthostasis ), as the blood circulation withdraws to the important organs and the peripheral blood flow decreases. Feet, arms and hands get cold and can become discolored, especially the legs appear "marbled". The amount of urine is reduced ( oliguria ), control over excretion may be lost ( incontinence ); in rare cases painful urinary retention occurs , which can be remedied by inserting a urinary catheter .

Fatigue and listlessness increase to apathy , phases of sleep become more frequent and lengthened ( somnolence ), the less frequent waking phases can be characterized by confusion and restlessness. Muscle cramps can also occur , especially in connection with febrile infections .

These symptoms can usually be alleviated with palliative medical and nursing therapy and support. Other symptoms are based on any underlying illnesses and may have to be treated accordingly further palliative .

Ethical evaluations and social acceptance

The voluntary renunciation of food and fluids is independent of the help of others and is considered a form of suicide. The background to this is that the person who renounces accepts the approaching end of life or pursues a dedicated suicide attempt. Depending on this, the event falls under the limitation of life-support measures or under the aspect of assisted suicide . The working group "Ethics at the end of life" in the Academy for Ethics in Medicine eV (AEM) advocates the application of the same decision criteria that were developed for suicide assistance, regardless of the assignment in individual cases. The fast to death can be classified as passive suicide because it does not involve any active act. It is an autonomous shaping of the dying process, which consists in refraining from ingesting food and fluids.

The social relationship to issues of euthanasia is divided; Likewise, there is no consensus on how free free will really is and how the demand for autonomy should be assessed in this context.

Legal classification and positions

The omission or refusal of life support is the latest since the adoption of the advance directive paragraphs ( § 1901a BGB) in Germany lawful. This also includes giving up food and liquids as long as this is done by a person who is capable of giving consent and who expresses his or her will in a credible and sustainable manner. The sustainable will is already documented here by the continued refusal to eat and drink. However, it must be clarified beforehand whether treatable causes (diseases such as anorexia or depression ) have led to the refusal to eat. If such reasons can be ruled out if the person concerned has a self-determined ability to see things, his will must be respected.

It is helpful to have a corresponding living will and a documented modification of the guarantee obligation. The latter in order to be able to dismiss the accusation of failure to provide assistance, which is occasionally raised when the fasting person ultimately loses consciousness.

Until 2015, a doctor who looked after a patient with palliative care while fasting for dying acted in accordance with German law and his professional ethics, because he does not contribute to death, but accompanies death. The principles for end-of-life medical care, amended by the German Medical Association in 2011, state:

“Dying may be made possible by omitting, limiting or terminating a medical treatment that has already started, if this is in accordance with the patient's will. This also applies to artificial food and fluid intake. '"

Since December 10, 2015, when the law on the criminal liability of commercial promotion of suicide came into force, the previously unpunished promotion of suicide by a third party has been made punishable in accordance with Section 217 of the Criminal Code, insofar as this is done on a commercial basis. The science of criminal law predominantly comes to the conclusion that business-like help with fasting death by hospices, nursing homes and doctors is punishable and illegal. A consistent implementation of this interpretation would, according to the legal theorist Eric Hilgendorf, "make hospice and palliative work in the previous sense impossible". The German Society for Palliative Medicine (DGP), however, sees no danger for palliative care in § 217; if certain treatment measures were terminated, this would "also be a form of 'assisted suicide" ", but primarily represent a" termination of medical treatment no longer borne by the patient's will "; "To medically accompany the so-called fasting to death [...] and, if necessary, to provide the necessary basic care to relieve feelings of thirst and hunger", is also not a criminal offense. The attending physicians refrained from “[...] expressly refused medical treatment (feeding by tube or by infusion solutions). There is no aid to suicide, but rather stressful symptoms in particular are alleviated. ”
In order to deal with the wishes expressed by patients to die, the DGP recommends, among other things, granting the patient the voluntary renunciation of food and fluid intake as a“ possible alternative ”.

Section 217 of the Criminal Code was declared unconstitutional and therefore null and void by the Federal Constitutional Court in a judgment of February 26, 2020 .

Church classifications and positions

The Roman Catholic Church describes suicide as a grave misconduct against both self-love and charity. In addition, it is in contradiction to the love of God, since man is obliged to receive his life gratefully and to preserve it. Man is only the administrator, not the owner of the life entrusted to him, he is not allowed to dispose of it. Voluntary assistance in suicide violates moral law.

On the occasion of the debate on the legislative initiative to ban business-like aiding and abetting suicide, the Council of the Evangelical Church in Germany stated in November 2012 that from a Christian perspective, suicide should be fundamentally rejected because life is understood as a gift through which the person should not dispose of himself. However, "the general rejection does not rule out that people in an extreme emergency and exceptional situation can come to a different decision" that an outsider cannot assess and that has to be respected. However, any form of organized assisted suicide should be rejected.

literature

  • Boudewijn Chabot, Christian Walther: A way out at the end of life: Self-determined death through voluntary renunciation of food and drink. 5th updated edition. Reinhardt, Munich 2017, ISBN 978-3-497-02706-4 .
  • Christiane zur Nieden: Fasting to death: Voluntary abstinence from food and fluids. A case description. Mabuse, Frankfurt am Main 2016, ISBN 978-3-86321-287-2 .
  • J. Bickhardt, RM Hanke: Voluntary renouncement of food and liquids: a very unique way of doing things. In: Deutsches Ärzteblatt . 111 (14), 2014, pp. A-590 / B-504 / C-484.
  • W. Putz, B. Steldinger: Patients' rights at the end of life. Health care proxy, living will, self-determined death. Beck im dtv, Munich 2014, ISBN 978-3-406-65397-1 .
  • Boudewijn Chabot: Taking Control of your Death by Stopping Eating and Drinking. 2014, ISBN 978-90-816194-3-1 .
  • Ralf J. Jox: Let die - about decisions at the end of life. rororo, 2013, ISBN 978-3-499-63032-3 .
  • Peter Godzik : 36 years after “Gramp”: The handicapped people have played out. In: ders .: Hospice committed. Experience and impulses from three decades. Steinmann Verlag, Rosengarten b. Hamburg 2011, ISBN 978-3-927043-44-2 , pp. 153-167.
  • Judith K. Schwarz: Death by voluntary dehydration: Suicide or the right to refuse a life-prolonging measure? In: Widener Law Review. 2011, Vol. 17, pp. 251-361.
  • M. Kloke: Anorexia, Cachexia, Nutrition and Hydration. In: M. Kloke, K. Reckinger, O. Kloke (eds.): Basic knowledge of palliative medicine. Book accompanying the basic course in palliative medicine , Deutscher Ärzte-Verlag , Cologne 2009, ISBN 978-3-7691-1222-1 .
  • Judith K. Schwarz: Exploring the Option of Voluntarily Stopping Eating and Drinking within the Context of a Suffering Patient's Request for a Hastened Death. In: Journal of Palliative Medicine. Vol. 10, No. 6, December 2007, pp. 1288-1297.
  • Stanley A. Terman: The Best Way to Say Goodbye: A Legal Peaceful Choice At the End of Life. 2007, ISBN 978-1-933418-03-2 .
  • ER Goy, LL Miller, TA Harvath, A. Jackson, MA Delorit: Nurses' Experiences with Hospice Patients who refuse Food and Fluids to hasten Death. In: The New England Journal of Medicine . Volume 349, 2003, pp. 359-365.
  • J. Jacobs: Death by Voluntary Dehydration: What Caregivers say. In: The New England Journal of Medicine . 2003, pp. 325-326.
  • TE Quill, B. Lo, DW Brock: Palliative options of last resort: A comparison of voluntary stopping eating and drinking, terminal sedation, physician-assisted suicide, and voluntary active euthanasia. In: Journal of the American Medical Association . 278, 1997, pp. 2099-2104.
  • C. Justice: The “Natural” Death While Not Eating: A Type of Palliative Care in Banaras, India. In: Journal of Palliative Care. 11 (1), 1995, pp. 38-42.
  • BL Bernat, B. Gert, RP Mogielnicki: Patient refusal of hydration and nutrition. An alternative to physician-assisted suicide or active euthanasia. In: Archives of Internal Medicine. 153, 1993, pp. 2723-2728.

Web links

Wiktionary: Fasting to death  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ a b KNMG Royal Dutch Medical Association and V&VN Dutch Nurses' Association Guide: Caring for people who consciously choose not to eat and drink so as to hasten the end of life. Empirical data. 2015, Table 3.4, p. 17 (English)
  2. ↑ a b c Dieter Birnbacher: Fasting to death - an ethical assessment . Humanistic press service, October 2014.
  3. ↑ a b c d J. Bickhardt, RM Hanke: Voluntary renunciation of food and fluids: a very unique way of acting. In: Deutsches Ärzteblatt. 111 (14), 2014, pp. A-590 / B-504 / C-484; Retrieved December 9, 2014.
  4. ^ C. Rayment, J. Ward: Care of the dying patient in hospital. In: Br J Hosp Med, London. 8, 2011, pp. 451-455.
  5. ↑ Stanley A. Terman (Medical and Executive Director at Caring Advocates) in an interview, p. 8, accessed on December 9, 2014.
  6. ↑ a b Boudewijn Chabot, Christian Walther: Way out at the end of life. 2012, p. 49.
  7. ↑ Ralf J. Jox: Let die - About decisions at the end of life. rororo, Reinbek 2013, p. 197.
  8. ↑ Linda Ganzini, Elizabeth Goy et al: Nurses' Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death. In: The New England Journal of Medicine . July 24, 2003.
  9. ↑ healing dying. faz.net , July 20, 2012.
  10. ↑ KNMG Royal Dutch Medical Association and V&VN Dutch Nurses' Association Guide: Caring for people who consciously choose not to eat and drink so as to hasten the end of life. Characteristics and definitions. 2015, pp. 10 and 11.
  11. ↑ F. Oehmichen and others: Guideline of the German Society for Nutritional Medicine (DGEM) - Ethical and legal aspects of artificial nutrition. In: Aktuel Ernahrungsmed. 38, 2013, pp. 112–117, Section 4.3, accessed December 9, 2014.
  12. ↑ M. Kern, F. Nauck: Last phase of life. In: German Society for Palliative Medicine (Ed.): Handout Palliative Care and Hospice Work. Status 11/2006
  13. ↑ German Society for Neurology (ed.): Guidelines for diagnostics and therapy in neurology - Crampi / muscle spasm. September 2016, p. 4.
  14. ↑ G. Neitzke, M. Coors, W. Diemer, P. Holtappels, JF Spittler, D. Wördehoff: Recommendations for dealing with the desire for suicide assistance. Springer-Verlag, Berlin / Heidelberg 2013. doi: 10.1007 / s00481-013-0256-6
  15. ↑ S. Schäfer: Fasting as the last solution. In: time online. No. 16, 2014, p. 1. (www.zeit.de , accessed on December 9, 2014)
  16. ↑ KNMG Royal Dutch Medical Association and V&VN Dutch Nurses' Association Guide: Caring for people who consciously choose not to eat and drink so as to hasten the end of life. Legal and ethical aspects. 2015, pp. 19–22.
  17. ^ F. Nauck, Ch. Ostgathe, L. Radbruch: Medically assisted suicide: help with dying - no help with dying. In: Deutsches Ärzteblatt . 111 (3), 2014, pp. A-67 / B-61 / C-57]. (aerzteblatt.de accessed on December 3, 2014.
  18. ↑ BGBl. 2015 I p. 2177
  19. ^ Frank Saliger : StGB § 217 Commercial promotion of suicide. In: U. Kindhäuser, U. Neumann, H.-U. Paeffgen (Ed.): Criminal Code. (= Nomos comment ). 5th edition. Nomos, Baden-Baden 2017, marginal no. 31.
  20. ↑ Torsten Verrel : Assisted suicide - legally prohibited, allowed in individual cases? Critical comments on § 217 StGB. In: Health and Care . 2016, pp. 45, 48.
  21. ↑ Eric Hilgendorf: Statement on the public hearing of the Committee on Legal Affairs and Consumer Protection of the German Bundestag on September 23, 2015. p. 14. (bundestag.de accessed on August 8, 2017)
  22. ↑ German Society for Palliative Medicine (DGP) emphasizes: § 217 is no danger for palliative care! dgpalliativmedizin.de, February 17, 2017 ( Memento from August 8, 2017 in the Internet Archive ); accessed on August 8, 2017.
  23. ^ Medically assisted suicide - reflections of the German Society for Palliative Medicine. January 2014, pp. 11-12. (dgpalliativmedizin.de)
  24. ↑ 2 Senate of the Federal Constitutional Court: Federal Constitutional Court - Decisions - Prohibition of commercial promotion of suicide unconstitutional. February 26, 2020, accessed February 27, 2020 .
  25. ^ Catechism of the Catholic Church KKK, 2280–2283
  26. ↑ When People Want to Die - A Guide to the Problem of Medical Assisted Suicide. (www.ekd.de)
  27. ↑ Any form of organized assisted suicide is to be rejected! (www.ekd.de)