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Batzler YN, Schallenburger M, Maletzki P, Tenge T, Schlieper D, Schwartz J, Neukirchen M. Caring for patients during voluntarily stopping of eating and drinking (VSED): experiences of a palliative care team in Germany. BMC Palliat Care 2023; 22:185. [PMID: 37986161 PMCID: PMC10662259 DOI: 10.1186/s12904-023-01308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Health-care professionals are confronted with patients who wish to end their lives through voluntarily stopping eating and drinking (VSED). During VSED, symptoms such as agitation, thirst or psychological distress may arise, thus making close medical accompaniment necessary. Dealing with these symptoms can put a high burden on palliative care teams. Furthermore, divergent perceptions of the ethical classification of VSED may lead to moral distress. The aim of this study was to assess the influence of experience gained over time on the burden of palliative care professionals while accompanying patients during VSED and to assess the perceptions of coping strategies. METHODS This is a prospective single-centre study conducted at the Interdisciplinary Centre for Palliative Care at University Hospital Duesseldorf, Germany. At two points in time (T1, T2) one year apart, team members of all professions who were actively involved in the accompaniment were eligible to complete a pretested questionnaire. RESULTS Team members perceived the symptom complex of psychological distress, anxiety, and agitation to be the most burdensome symptoms for the patients (T1: 28/49, 57.1%; T2: 33/59, 55.9%). Thirst was the second most observed symptom (T1: 17/49, 34.7%, T2: 19/59, 32.2%). These were also the most burdensome symptoms for individual team members. Most team members found there were no general moral concerns. There was a decrease in the perceived importance of support strategies such as ethical counselling (85.7% versus 63.6%). CONCLUSIONS Accompanying patients during VSED is a challenge for health-care professionals. When comparing T2 to T1, less emphasis lies on the importance of ethical counselling or psychiatric assessment to build a foundation for the accompaniment. Moral and ethical concerns seem to play a minor role. More in-depth studies covering a bigger sample size as well as qualitative studies are needed.
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Affiliation(s)
- Yann-Nicolas Batzler
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| | - Pia Maletzki
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Theresa Tenge
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Schlieper
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jacqueline Schwartz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Interdiscipilinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Centre for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
| | - Martin Neukirchen
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Anaesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Interdiscipilinary Centre for Palliative Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Centre for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Düsseldorf, Germany
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Stängle S, Fringer A. "Discussion or silent accompaniment: a grounded theory study about voluntary stopping of eating and drinking in Switzerland". Palliat Care 2022; 21:85. [PMID: 35610598 PMCID: PMC9128132 DOI: 10.1186/s12904-022-00941-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background Voluntary stopping of eating and drinking as an option to end life prematurely is gaining international attention, and health care professionals are increasingly confronted with the wish to die through voluntary stopping of eating and drinking by individuals. While to date, there are no guidelines in Switzerland to orient professional support, it is of interest how professionals and other people involved react to the situation. The aim of this qualitative study was to explore how health care professionals in Switzerland accompany individuals during voluntary stopping of eating and drinking and to analyze this decision-making process. Methods Charmaz's grounded theory constructivist methodology uses guidelines for systematic, theory-driven data analysis underpinned by a pragmatic philosophical perspective. Data were collected in autumn 2016 as part of a regional palliative care conference on voluntary stopping of eating and drinking. All participants of the expert meeting (N = 50, including nurses, counsellors, ethicists, medical doctors, politicians, volunteers, and relatives) were invited to the focus group interviews, of which N = 47 participated. We conducted five focus group interviews, each lasting one hour. Results The results showed that the accompaniment of those willing to die during voluntary stopping of eating and drinking was either discussed and cleared with one another or was unspoken and silently accompanied. Conclusions The demands of participants for more knowledge must be heeded, and there is also a need for systematic instructions on how to proceed in the case of voluntary stopping of eating and drinking support and what needs to be considered.
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Affiliation(s)
- Sabrina Stängle
- Institute of Nursing, ZHAW School of Health Professions, Katharina-Sulzer-Platz 9, 8401, Winterthur, Switzerland. .,Department of Nursing Science, Witten/Herdecke University Faculty of Health, Stockumer Strasse 12, 58453, Witten, Germany.
| | - André Fringer
- Institute of Nursing, ZHAW School of Health Professions, Katharina-Sulzer-Platz 9, 8401, Winterthur, Switzerland.,Department of Nursing Science, Witten/Herdecke University Faculty of Health, Stockumer Strasse 12, 58453, Witten, Germany
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Abstract
Abstract. Besides physician-assisted suicide, there is another end-of-life practice under discussion: voluntary stopping of eating and drinking (VSED). In this study, we assess the occurrence of VSED in outpatient care and evaluate nurses’ attitudes about it. We recruited 395 nurses (24% response rate) in our online survey. The occurrence of VSED in Switzerland lies at 0.5%. Most nurses (84.6%) were aware of VSED, and 39.5% had experienced it with patients. VSED was mostly (70.3%) regarded as a natural death, and nearly all (95.1%) were willing to care for these patients; however, about one-quarter (26.5%) expressed moral concerns. Our results show that VSED occurs in rare cases, and that nurses are willing to accompany patients during this VSED, but express moral concerns.
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Affiliation(s)
- Sabrina Stängle
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Institute of Nursing, ZHAW School of Health Professions, Winterthur, Switzerland
| | - Wilfried Schnepp
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Daniel Büche
- Palliative Centre St. Gallen, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - André Fringer
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Institute of Nursing, ZHAW School of Health Professions, Winterthur, Switzerland
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Abstract
Abstract. Most cases of voluntarily stopping eating and drinking (VSED) occur in the context of severe underlying diseases with concomitant dwindling needs for food and fluids. In these cases, VSED resembles the rejection of a medical treatment. While this is the leading difference to suicide, however, there are also situations within VSED in which aspects of suicide prevention must be considered. After defining the relevant terms and presenting a literature review, we outline options of dealing with different death wishes and provide recommendations oriented toward the possibilities of suicide prevention in the context of abstaining from food and fluids.
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Affiliation(s)
- Barbara Schneider
- Department of Addictive Behaviors, Psychiatry and Psychotherapy, LVR-Klinik Köln, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt/Main, Germany
| | - Ronja S Müller
- Institute of Ophthalmology, University College London, UK
| | - Uwe Sperling
- Geriatric Center, University Medical Center Mannheim, Germany
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Stängle S, Schnepp W, Büche D, Häuptle C, Fringer A. Family physicians' perspective on voluntary stopping of eating and drinking: a cross-sectional study. J Int Med Res 2020; 48:300060520936069. [PMID: 32787706 PMCID: PMC7427036 DOI: 10.1177/0300060520936069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 05/26/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE We aimed to determine how often patients who choose voluntary stopping of eating and drinking (VSED) are accompanied by Swiss family physicians, how physicians classify this process, and physicians' attitudes and professional stance toward VSED. METHODS We conducted a cross-sectional study between August 2017 and July 2018 among 751 practicing family physicians in Switzerland (response rate 74%; 70.7% men; average age 58 (±9) years). We used a standardized evidence-based questionnaire for the survey. RESULTS VSED is well-known among family physicians (81.9%), and more than one-third (42.8%) had accompanied at least one patient during VSED. In 2017, 1.1% of all deaths that occurred in Swiss nursing homes or in a private home were owing to VSED. This phenomenon was classified as a natural dying process (59.3%), passive euthanasia (32.0%), or suicide (5.3%). CONCLUSIONS Although about one in three Swiss family physicians have accompanied a person during VSED, family physicians lack sufficient in-depth knowledge to address patients and their relatives in an appropriate manner during the process. Further training and development of practice recommendations are needed to achieve more standardized accompaniment of VSED.International Registered Report Identifier: DERR1-10.2196/10358.
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Affiliation(s)
- Sabrina Stängle
- Faculty of Health, Department of Nursing Science, Witten/Herdecke University, Witten, Germany
- School of Health Professions, Institute of Nursing, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Wilfried Schnepp
- Faculty of Health, Department of Nursing Science, Witten/Herdecke University, Witten, Germany
| | - Daniel Büche
- Cantonal Hospital St. Gallen, Palliative Centre St. Gallen, St. Gallen, Switzerland
| | - Christian Häuptle
- Cantonal Hospital St. Gallen, Centre for General Practitioner Medicine, St. Gallen, Switzerland
| | - André Fringer
- Faculty of Health, Department of Nursing Science, Witten/Herdecke University, Witten, Germany
- School of Health Professions, Institute of Nursing, Zurich University of Applied Sciences, Winterthur, Switzerland
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Stängle S, Schnepp W, Büche D, Fringer A. Long-term care nurses' attitudes and the incidence of voluntary stopping of eating and drinking: A cross-sectional study. J Adv Nurs 2019; 76:526-534. [PMID: 31659779 DOI: 10.1111/jan.14249] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/25/2019] [Accepted: 10/14/2019] [Indexed: 11/29/2022]
Abstract
AIMS To assess the incidence of voluntary stopping of eating and drinking (VSED) in long-term care and to gain insights into the attitudes of long-term care nurses about the VSED. DESIGN A cross-sectional study. METHODS Heads of Swiss nursing homes (535; 34%) answered the Online-Survey between June - October 2017, which was evaluated using descriptive data analysis. RESULTS The incidence of patients who died in Swiss nursing homes by voluntarily stopping eating and drinking is 1.7% and 67.5% of participants consider this phenomenon highly relevant in their daily work. Most participants (64.2%) rate VSED as a natural death accompanied by health professionals and patients are also granted the right to care (91.9%). This phenomenon is expected by the participants less at a young age and more in old age. CONCLUSION Participants' overall views on the VSED are very positive, whereas it is assumed that VSED is a phenomenon of old age. Professionals still lack sufficient knowledge about this phenomenon, which could be clarified through training. IMPACT Voluntary stopping of eating and drinking is much discussed interprofessional, but there is a lack of knowledge on how this is perceived in the context of long-term care and about the incidence of the phenomenon. Voluntary stopping of eating and drinking is rare but noticeable end-of-life practises that is considered by professionals to be mainly dignified and peaceful, although moral concerns make it difficult to accompany. These findings call on long-term care institutions to discuss VSED as an end-of-life practice. Positioning on the issue provides clarity for staff and patients and promotes to develop standardized care. International Registered Report Identifier (IRRID): DERR1-10.2196/10358.
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Affiliation(s)
- Sabrina Stängle
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany.,Institute of Nursing, School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Wilfried Schnepp
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Daniel Büche
- Palliative Centre, St.Gallen Cantonal Hospital, St.Gallen, Switzerland
| | - André Fringer
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany.,Institute of Nursing, School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
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Stängle S, Schnepp W, Fringer A. The need to distinguish between different forms of oral nutrition refusal and different forms of voluntary stopping of eating and drinking. Palliat Care Soc Pract 2019; 13:1178224219875738. [PMID: 32215371 PMCID: PMC7065502 DOI: 10.1177/1178224219875738] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/20/2019] [Indexed: 11/16/2022] Open
Abstract
Voluntary stopping of eating and drinking (VSED) is a well-known phenomenon among palliative care professionals. This study intent to distinguish between different forms of VSED. In a qualitative interview study 18 relatives were interviewed about their experiences of caring a person during VSED. Different forms of oral nutrition refusal and different forms of VSED were found and described. The study results help members of the multidisciplinary team to manage the situation appropriately.
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Affiliation(s)
- Sabrina Stängle
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany; School of Health Professions, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Wilfried Schnepp
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - André Fringer
- Department of Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany; School of Health Professions, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
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Stängle S, Schnepp W, Mezger M, Büche D, Fringer A. Development of a Questionnaire to Determine Incidence and Attitudes to "Voluntary Stopping of Eating and Drinking". SAGE Open Nurs 2019; 5:2377960818812356. [PMID: 33415213 PMCID: PMC7774350 DOI: 10.1177/2377960818812356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 10/17/2018] [Indexed: 11/15/2022] Open
Abstract
Background “Voluntary stopping of eating and drinking” (VSED) is an option to hasten death at the
end of life. There are no data available about incidence of either the explicit VSED or
implicit (V)SED nor information about experiences and attitudes of health professionals
about VSED in Switzerland. Aims To develop, test, and translate a standardized questionnaire that measures the
incidence of VSED, and physicians’ and nurses’ experiences about explicit VSED and
implicit (V)SED. Methods The development of the questionnaire was based on a systematic search, which were
updated in 2016. The questionnaire was tested by palliative care specialists using
standard pretest and content validity index (CVI). Subsequently, a forward/backward
translation was made. Results The questionnaire includes 38 items. Feedback of 15 participants in the standard
pretest were positive in terms of intelligibility with an average time of 28 minutes.
After adjustment, 27 experts validated the items in two rounds. The questionnaire
achieves excellent item-CVI values between 0.91 and 1.00 and scale-CVI values of 0.97.
The forward/backward translations were each carried out by two independent translators
with subsequent building of a consensus through a consultant. Conclusion A mulitlingual questionnaire has been developed, which measures the incidence of
explicit VSED and implicit (V)SED. This questionnaire is the basis for a Swiss-wide
census of all physicians and nurses of outpatient and long-term care.
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Affiliation(s)
- Sabrina Stängle
- University Witten/Herdecke, North Rhine-Westphalia, Germany.,ZHAW School of Health Professions, Winterthur, Zürich, Switzerland
| | | | - Mirjam Mezger
- ZHAW School of Health Professions, Winterthur, Zürich, Switzerland
| | | | - André Fringer
- ZHAW School of Health Professions, Winterthur, Zürich, Switzerland
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