(125) The ethical ‘double effect’ of palliatively using appetite-suppressing psychiatric medications during voluntary refusal of eating and drinking

Abstract:

Background:  

Voluntarily stopping eating and drinking (VSED) refers to the deliberate choice of a capacitated person to, because of intense suffering related to a medical condition, stop eating and drinking to hasten death. Although VSED is practically and legally distinct from physician-assisted suicide, it often raises ethical questions for clinical team members including consult-liaison psychiatrists. Minimal literature has examined the ethical implications of prescribing appetite-decreasing medications during VSED. We describe a case where such examination was sparked by the presence of bupropion in the regimen of a patient planning VSED. 



Case:  

A geriatric man with a history of follicular lymphoma in remission was admitted to the hospital after 9 months of progressive symptoms including paresthesia, lower extremity weakness, gait imbalance, and dysfunction of the bowel and bladder. Escitalopram and bupropion were initiated during this course for depressed mood. Extensive neurologic workup (EMG, NCS, biopsy of muscle and sural nerve) suggested an ALS-like syndrome or immune-mediated polyneuropathy. Plasma exchange did not improve symptoms, and symptoms were expected to be progressively disabling. The patient decided to stop eating and drinking to hasten death. Psychiatry was consulted for capacity to stop eating and drinking, which his wife supported. Psychiatric evaluation revealed demoralization without evidence of delirium or a decompensated mood episode as well as sufficient capacity to pursue VSED. Bupropion in the patient’s regimen sparked discussion regarding the implications of appetite suppressants in VSED. Appetite suppression with medication was proposed as a palliative intervention to reduce discomfort from hunger, although there was distress regarding facilitation of a dying process. After 3 days, the patient no longer wished to pursue VSED. He was discharged to a nursing home and died in hospice care 3 months later. 




Discussion:  
Physicians continue symptomatic care throughout a VSED course, but use of medication (e.g. stimulants, topiramate, bupropion) to decrease hunger discomfort during VSED is underexplored. Symptomatic interventions during VSED include oral swabs and sprays to minimize thirst, anxiolytics, antipsychotics for agitation, and palliative sedation (Lowers, 2021; Wechkin, 2023). As in this case, patients undergoing VSED often resume eating and drinking, citing reasons such as family encouragement, hunger or discomfort, and improvement in mood (Ganzini, 2003). Use of opioids and benzodiazepines is common in palliative sedation, which is labeled as a double effect in both increasing comfort and risk of death concomitantly. Medication-induced appetite suppression during VSED creates a similar double effect, albeit less imminent and probable death risk.


Conclusion:    
In the context of VESD, psychiatric medications that decrease appetite may create a ‘double effect’ of concomitantly improving comfort and while increasing likelihood of death. Further ethical analysis is warranted regarding ethical contrast with the double effect in palliative sedation.

References: 

• Lowers J, Hughes S, Preston NJ: Overview of voluntarily stopping eating and drinking to hasten death. Ann Palliat Med 2021;10(3):3611-3616. 


• Ganzini L, et al.: Nurses' experiences with hospice patients who refuse food and fluids to hasten death. NEJM 2003;349:359-365. 


• Wechkin H, et al.: Clinical guidelines for voluntarily stopping eating and drinking (VSED). J Pain Symptom Manage 2023;66(5):e625-e631.

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: There is limited guidance on the process of VESD, and role of psychiatric medication is a grey area. As in many areas of medicine, grey areas often exacerbate inequities in care. This work sheds light on the potential role of medications that could be integrated into a clear care guideline and made standard for all patients.