Dr Saheb Sahu
VSED stands for “Voluntarily Stopping Eating and Drinking”. It refers to a conscious decision by an individual to cease food and fluid intake with the intention of hastening death. While it is not a new concept, VSED has gained attention in recent years as a discussion about end-of-life autonomy and assisted dying has become more prominent.
Indian Context
“Prayopavesa” is a term from Hinduism and refers to the practice of a voluntary fast unto death. The term is derived from Sanskrit, where “prayas” means “effort’ or “striving” and “upavesa” means “sitting down” or “dwelling”. Combined together “prayovesa” can be understood as the act of sitting down in the effort of voluntarily giving up life through fasting. The practice is deeply rooted in Hindu religious and philosophical traditions.
“Samadhi marana” (Sanskrit) is another concept in Hinduism, that involves achieving death through deep meditation or Samadhi. The term combines “Samadhi”, which refers to a state of intense concentration and spiritual absorption, and “marana’ which means “death”.
‘Sallekhana” (Prakit) consists of two words: “sala” meaning “instrument” and“lekhana” meaning to “thin out” or“destroy”. It is a supplementary vow in the ethical code of conduct of Jainism. It is the religious practice of voluntarily fasting to death by gradually reducing the intake of food and liquid.Sallekhana is also known as ‘samadhi-marana”or “sanyasana-marana”.
British legal codes made all forms of suicide illegal in India, including the horrible practice of “sati”. In March, 2018, Indian Supreme Court made passive euthanasia (intentionally letting a patient die by withholding artificial life support such as respirator or tube feeding) legal under strict guidelines. The patient must consent through a living will (a legal document expressing the wishes), must be terminally ill or in a vegetative state. The same Supreme Court Judgement also directed the legislators for scrapping of code 309, which penalizes those who survive suicide-attempts.
What would a good death look like?
The definition of a good death will vary from person to person. Some people will say that there is no such thing as “good death”- all deaths are unnecessary, unwanted and unwelcome. But ultimately there is no escape from death. The question is how to minimize the pain and suffering associated with the process of dying. There are some agreements that most dying persons will like to die at home and not in a hospital intensive care unit, with minimal pain and suffering, surrounded by family and friends, have an opportunity to say goodbye and not to have their lives prolonged pointlessly.
Palliative vs Hospice care
The best bet to ensure that your death is yours is access to hospice care. Palliative care involves comfort measures to relieve symptoms and improve quality of life, but you can continue the treatment for your disease. Palliative care can be utilized at any stage of a serious illness, whereas hospice care is just comfort measures at the end of life. There is a shift of focus from curing the disease to improving the quality of one’s last days.
Hospice is often framed as “giving up”, but, ironically, when researchers have compared hospice vs non-hospice patients’ survival, the patients in hospice live on average about a month longer than similar patients who do not choose hospice.
Physician- Aid in Dying
There are limits to palliative and hospice care. In spite of the best efforts by the healthcare team, some patients experience unbearable pain and suffering and request their doctors to end their lives. Physician assisted dying or medical aid in dying or physician assisted suicide (different interchangeable terms), allows the terminally ill to end his or her life through the voluntary self administration of a lethal dose of medication expressly prescribed by a physician for that purpose. But Physician aid in dying is legal only in few countries around the world. It is legal in Australia, Austria, Belgium, Canada, The Netherlands, New Zealand, Portugal, Spain, Switzerland and certain states in the United States.
The Benefits of VSED
VSED is a conscious decision by an individual to voluntarily and deliberately choose to stop eating and drinking with the primary intention of hastening death. The benefits of VSED are: dying at home, it’s legal everywhere, one does not need any one’s permission and one can change one’s mind anytime. Just knowing there is a “way out” can provide relief from feeling of desperation. It can also prevent people from contemplating a more violent way out.
What Is VSED Like?
There have been several independent studies to evaluate VSED. The average time of death after stopping eating and drinking any liquid is about seven days, though 8 percent lived for more than two weeks. The duration will vary based on a person’s ill ness, his or her nutritional status prior to VSED. A person may live little longer by not eating any solid food but if he/she does not drink any kind of liquid, death will come sooner because of dehydration.
Hunger pangs and thirst may occur the first day or two, but these sensations are usually tolerable. These discomforts can be alleviated by mild sedation, lip balm and cool water rinse. Weakness will be natural. Some people may experience disorientation at the end stage.
Some researchers now believe that the state of terminal dehydration may even have some analgesic (pain killing) effect, presumed to be due to the release of endorphins (body’s own pain killing hormone), which acts as natural pain blocker.
There are some other side benefits to the dehydration process. There is less worry about incontinence, catheters or bed pans (because of less urine from dehydration) and less nausea and vomiting. There is also less coughing and choking because of less secretion in the mouth and throat. The death process is relatively painless but slow. The dying person has some time to say goodbye to his or her loved one’s in her or his own home.
Conclusion
Voluntarily stopping to eat and drink to kill oneself can pose various challenges. Some of the concerns include potential discomfort for the person and the emotional impact on the family. Most of the discomforts are of short duration and can be easily treated. The bottom line is VSED appears to provide most terminally ill patients with a peaceful and gentle death. It is not a new concept. It goes back to 6th century BCE or earlier to India. Because of modern debate on “right to die”, “physician-assisted suicide”, and “euthanasia”, it has come to the forefront, as a prefer way to die.
The understanding and acceptance of VSED continue to evolve, with ongoing discussion in medical, ethical and legal circles.
The role of advance care planning is crucial in navigating end of life decisions. Clear and documented communications about one’s preferences are critical. They should include: a properly executed “Will and Testament” to divide one’s assets, designating someone “With Durable Power of Attorney (DOPA) to make legal and financial decision, executing a “Living Will” or “Advance Health Care Directive” about the course of treatment( Respirator, Tube feeding, Cardio pulmonary Resuscitation(CPR) and do not resuscitate(DNR), VSED, and organs donation etc.). Most important of all, one should and must discuss one’s end of life wishes with his or her family members and physicians. The earlier the better, especially if one is of advanced age or suffering from a serious illness.
Sources
- Dr Saheb Sahu. Assisted Dying. www.Odishawatch.in, Dec 28, 2021
- Michael Greger, M.D., FACLM.How Not To Age. Flatiron Books, New York: 2023