Food for thought: Voluntary palliated starvation and withdrawal of artificial nutrition

Abstract

Background: Voluntary palliated starvation (VPS) involves voluntarily stopping eating and drinking with the intention to die and subsequently receive palliative care1. This is different to the withdrawal of artificial nutrition and hydration, which involves a pre‐existing condition that necessitates a life sustaining therapy2. This distinction is not always evident and may lead to allegations of physician assisted suicide (PAS)2. Currently physician assisted suicide is a crime in all states and territories in Australia except for Victoria1. The following case study examines these contemporary issues.

Case: Mr LT was a 64‐year‐old gentleman who had a 9‐month hospital admission following a motor vehicle accident which left him severely disabled with traumatic amputation of his right lower limb, blindness of his left eye and traumatic ischaemic bowel. This was then complicated by intra‐abdominal sepsis requiring further bowel resections, resulting in short gut syndrome and complete dependence on total parental nutrition (TPN). Mr LT wished to cease artificial nutrition due to on‐going physical and mental suffering and the prospect of a lifetime of complete nursing cares. The decision was complicated by allegations of potential PAS and conflicting legal opinion regarding the lawfulness of withdrawing artificial nutrition, obligating continuation of nutritional therapies, despite him being deemed to have capacity to make health related decisions. After multiple multidisciplinary assessments the artificial nutrition was lawfully discontinued, and his cares transferred to the palliative care team.

Discussion: In Australia, withdrawal of artificial nutrition is supported by case law1,3. Cases are confounded by questions about capacity, mental health and associations with PAS. Complicating this further, there are differences in state law. Conflict within the Queensland Criminal Code as to the lawfulness of withdrawing life sustaining artificial nutrition and hydration led to the issues in the instant case1,4. Respect for autonomy is a fundamental principle in bioethics and extends to an individual's right to refuse treatment1. This case represents a legal and ethical grey area and clearly the association between PAS and VPS is not binary. Regardless of the distinction between withdrawal of life sustaining nutrition and VPS the provision of palliative care in either case is not PAS1.

Conclusion: The withdrawal of artificial nutrition is lawful in a voluntary and competent individual. Uncertainty arises when VPS is implied and associated with PAS. It is an emerging issue and its legal status remains uncertain. Regardless, good medical practice and the provision of palliative care should overcome this uncertainty, as illustrated in this case study.