Consciously refusing food and drink
Definition supplied by KNMG (Royal Dutch Medical Association) + V&VN (Dutch nurses and carers association): Consciously refusing food and drink in order to speed up the end of life.
This description implies the decision taken by someone personally to not eat or drink any more with the intention of speeding up the end of their life. This includes refusing the food and drink that is offered. This also implies refusing the artificial administration of food and fluids.
Causes of abstention from fluids
1. Natural terminal dehydration
Terminal dehydration can be described as the natural process of dehydration in the final stages of life. The dying patient will eat and drink less and less, because the body no longer needs it. The body subsequently dehydrates, the patient becomes drowsy and finally falls asleep. This is the usual manner of dying which occurs quite frequently.
If terminal dehydration is described like this, it usually does not elicit any questions. Or maybe the question as to whether someone should be artificially fed, for instance by means of a feeding tube or infusion.
2. Conscious abstention from fluids
Abstention from fluids can be described as a way of dying, when the taking or administering of fluids is consciously refused. Some doctors and organisations point to this possibility, when for instance the patient has a GP who does not want to assist in euthanasia. In this case the patient can decide to stop eating and drinking, as a result of which he or she will soon dehydrate and die.
This can also be done with patients as a matter of policy: the caring staff offers no or insufficient food and drink. If so, then this must be recorded, otherwise there can be no formal policy.
Clearly, this manner of terminal dehydration will encounter conscientious objections, as opposed to natural terminal dehydration.
Defining a position from a Reformed perspective
1. Natural terminal dehydration
When a seriously ill or very old patient indicates that they can no longer tolerate food, this will generally have to be accepted. The patient is ‘spent’. In these cases, it is better to be careful with a fluid infusion or with a feeding tube. The artificial administration of fluids and food may contribute to the patient suffering from more shortness of breath, pain and fear. So the disadvantages become greater than the advantages.
2. Conscious abstention from fluids
The conscious choice to die, because the GP does not want to assist with euthanasia, is explicitly rejected by Bible-believing Christians. The patient can then decide about his own life, which is in conflict with the confession that our suffering is in God's hands: He has given us life and He calls us out of it at His own time.
At the same time, it should be realised that ageing can be a great burden. The constant limitations, the dependency on others, the difficulties and loneliness can make ageing a great burden. This demands warm and intensive care, so that the patient feels supported, in spite of all limitations and difficulties. Clearly, this makes a tremendous claim on (Christian) charity. Giving a cup of cold water (Matth. 10:42) is symbolic for the attention and support of the neighbour. Sometimes it is not easy if the other one makes gestures to turn away. But it is not about whether we have a feeling of sympathy for the other, it is about obeying our Instructor and reverence for the life He has given. It is a given fact that tact and determination are sometimes required. And that we come short in this respect too.
But: would God, who gave His only Son, not give these things to us too, if we were to ask Him? (See Romans 8:32).
When the departmental policy stipulates that one must assist with consciously abstaining from fluids and so to intentionally speed up the end of life, you will have to make known that you have conscientious objections and so cannot assist in this policy.
Dehydration
It is important to realise that the process of dehydration with natural terminal dehydration does not involve suffering. On the contrary. In general, a patient who gradually dehydrates does not have many complaints. On the other hand, the administration of artificial food and fluids can cause problems, such as shortage of breath (‘fluid behind the lungs’, as a consequence of the infusion). So in these situations it is better not to administer artificial fluids and food, but to stimulate ordinary food and drink.
The artificial administration of fluids and food in the dying stage, turns a natural process (of dying) into an illness that needs treatment. This disregards the character of dying, and suggests that ‘healing’ (postponement/cancellation) of the dying process must be offered.
The situation is totally different if a seriously ill person gets pneumonia. The temporary administration of fluid, in combination with giving antibiotics, can then make sense. In those cases, the insertion of an infusion is sometimes essential. The same applies when the patient has a stroke or contracts another illness. The temporary administration of fluids can help someone through a difficult phase (of illness).
If in the last stage of life, someone indicates that they are thirsty, this can be best quenched by giving small sips to drink or by keeping the lips moist with a flannel or gauze. This will make the thirsty feeling disappear.
Confusion of terminology
Sometimes hospital staff cause confusion here by quickly using the word ‘dehydrated’. If an older person is admitted to hospital, blood tests sometimes show that the renal function has deteriorated. The renal function can be improved by administrating someone more fluids, for instance via an infusion. If the patient or the family subsequently hears that ‘your mother was dehydrated’, the nursing home or care home ( where mother lived) is sometimes viewed with bitterness, because they offered her too little to drink.
That accusation could of course be justified, but sometimes the patient is the cause of the problem. He or she no longer wants to drink because the body does not need it. The infusion, that was given to the patient in hospital, is then only a temporary solution. It is not really a real solution, but it merely masks the problem, because as soon as the infusion is removed, the renal function will gradually deteriorate again. In those cases it continues to be important to offer enough food and drink, but finally it will have to be accepted that someone eats or drinks too little. Then the patient will die, not because he or she drank too little, but he or she drinks too little because the body is ‘spent’.