Stopping Eating Research Articles

Caregiver Influences on Eating Behaviors in Young Children: A Scientific Statement From the American Heart Association.

A substantial body of research suggests that efforts to prevent pediatric obesity may benefit from targeting not just what a child eats, but how they eat. Specifically, child obesity prevention should include a component that addresses reasons why children have differing abilities to start and stop eating in response to internal cues of hunger and satiety, a construct known as eating self‐regulation. This review summarizes current knowledge regarding how caregivers can be an important influence on children's eating self‐regulation during early childhood. First, we discuss the evidence supporting an association between caregiver feeding and child eating self‐regulation. Second, we discuss what implications the current evidence has for actions caregivers may be able to take to support children's eating self‐regulation. Finally, we consider the broader social, economic, and cultural context around the feeding environment relationship and how this intersects with the implementation of any actions. As far as we are aware, this is the first American Heart Association (AHA) scientific statement to focus on a psychobehavioral approach to reducing obesity risk in young children. It is anticipated that the timely information provided in this review can be used not only by caregivers within the immediate and extended family but also by a broad range of community‐based care providers.

FOOD FOR THOUGHT: VOLUNTARY PALLIATED STARVATION AND WITHDRAWAL OF ARTIFICIAL NUTRITION

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.

Doing and Allowing in the Context of Physician-Assisted Suicide

Supporting the (active) rational suicide of a patient with a terminal disease is opposed by a majority of German doctors, whereas assistance in such patients’ hastening their death by voluntarily stopping eating and drinking (VSED) is predominantly judged to be acceptable. Are these two positions compatible? It is argued that the normative differentiation cannot be justified by the fact that the assistance in active suicide is itself active, whereas assistance in VSED is merely passive. Even in "letting die" a patient from hastening death by refusing nutrition and hydration there is an active element in the doctor's/the palliative care team's assurance that they will provide palliative support in case of need. Nor can the difference in evaluation be justified by relevant differences in the causal situation. Enabling a patient to perform VSED and assisting a patient's active suicide under the same circumstances are, as far as causal relevance is concerned, on a par. This holds, at least, on a condition view of causality in the tradition of John Stuart Mill. Finally, the paper discusses whether there are other morally relevant dimensions by which actively and passively supporting a patient suicide under the relevant circumstances differ, again with a negative result.

The associations of palliative care experts regarding food refusal: A cross-sectional study with an open question evaluated by triangulation analysis.

Health professionals in oncologic and palliative care settings are often faced with the problem that patients stop eating and drinking. While the causes of food refusal are very different, the result is often malnutrition, which is linked to health comorbidities and a high mortality rate. However, the professionals lack the time and knowledge to clarify the cause for each patient. What associations do health professionals have when faced with food refusal? To investigate the associations that health professionals in oncological and palliative settings have about denied eating behavior. A cross-sectional study, starting with an open question focusing professionals' associations regarding food refusal. The results were inductively analyzed, whereby generic categories were developed. Subsequently, the categories were transformed into quantitative data to calculate the relationships between the categories. A total of 350 out of 2000 participants completed the survey, resulting in a response rate of 17.5%. Food refusal is primarily associated with physical and ethical aspects and with end-of-life. Half of the participants frequently find that patients refuse to eat. The attitudes show that the autonomy of the patient is the highest good and is to be respected. Even in the case of patients with limited decision-making capacity, the refusal to eat is acceptable. Clarifying the cause of food refusal requires a great deal of knowledge and is strongly influenced by the associations of health professionals. While the associations have very negative connotations, information and training is needed to make professionals aware of this and to change their associations. With this knowledge and in an interprofessional cooperation, mis-labelling of patient settings can be avoided and fears can be reduced.

Advance Directive as Ulysses Contract: The Application of Stopping of Eating and Drinking by Advance Directive.

Increased attention is being paid to "dementia directives," advance directives tailored to persons with dementia that outline what treatments an individual with dementia might wish to receive or forgo should they lose capacity. Particular focus has been placed on the request to have assisted oral feedings withheld, the so-called Stopping of Eating and Drinking by Advance Directive (SED by AD), the purpose of which is to hasten death. This article reviews the available literature regarding the practice of SED by AD and explores the clinical and ethical aspects as they present at the bedside. Our review aims to show that practical, clinically applicable ways to approach such requests must be developed in order to balance the fundamental principles at play.

Obesity Affects the Microbiota–Gut–Brain Axis and the Regulation Thereof by Endocannabinoids and Related Mediators

The hypothalamus regulates energy homeostasis by integrating environmental and internal signals to produce behavioral responses to start or stop eating. Many satiation signals are mediated by microbiota-derived metabolites coming from the gastrointestinal tract and acting also in the brain through a complex bidirectional communication system, the microbiota–gut–brain axis. In recent years, the intestinal microbiota has emerged as a critical regulator of hypothalamic appetite-related neuronal networks. Obesogenic high-fat diets (HFDs) enhance endocannabinoid levels, both in the brain and peripheral tissues. HFDs change the gut microbiota composition by altering the Firmicutes:Bacteroidetes ratio and causing endotoxemia mainly by rising the levels of lipopolysaccharide (LPS), the most potent immunogenic component of Gram-negative bacteria. Endotoxemia induces the collapse of the gut and brain barriers, interleukin 1β (IL1β)- and tumor necrosis factor α (TNFα)-mediated neuroinflammatory responses and gliosis, which alter the appetite-regulatory circuits of the brain mediobasal hypothalamic area delimited by the median eminence. This review summarizes the emerging state-of-the-art evidence on the function of the “expanded endocannabinoid (eCB) system” or endocannabinoidome at the crossroads between intestinal microbiota, gut-brain communication and host metabolism; and highlights the critical role of this intersection in the onset of obesity.

Physician Assisted Death: Last Resort Option or Out of Bounds? (FR459)

•Compare and contrast various “options of last resort,” including: voluntary stopping eating and drinking, palliative sedation, physician assisted death, and euthanasia.•Compare and contrast Unitarian and Catholic views on physician assisted death.•Describe a position on physician assisted death that takes into account differing views of morality, patient autonomy, and physician responsibility. Recent years have seen increasing acceptance of physician assisted death (PAD) in the United States with there now being eight states and the District of Columbia that have some form of legal PAD. This growing acceptance, however, continues to be met with resistance from a number of groups based in part on differing views on religion, morality, authority, and concerns regarding disability rights. What are the sources of conflict around PAD? Much of the disagreement is grounded in true differences of opinion, but at least some of the conflict arises from misunderstandings and lack of agreement regarding definitions of terms. In this concurrent session definitions of end of life “options of last resort” will be reviewed and discussed. Then arguments will be presented for and against PAD and other last resort options from the Unitarian Universalist and Catholic perspectives. Possible responses to patient requests for PAD will also be considered from each viewpoint, and consideration will be given as to how these responses might vary when practicing in a jurisdiction where PAD is legal vs. illegal. Audience participation will be encouraged throughout the session in an effort to help clarify both commonalities and issues around which these two viewpoints are truly in conflict. Attendees will leave this concurrent session with practical knowledge and tools to formulate and refine their own views on PAD.

Experiences of Family Caregivers Providing Support to Individuals Who Voluntarily Stop Eating and Drinking (VSED) to Hasten Death (TH340D)

•Describe the types of caregiving needed by individuals electing VSED.•Describe the experiences of "family" caregivers supporting an individual who elects VSED. Voluntarily stopping eating and drinking (VSED) is a method for individuals with serious illness to control the timing and means of their death. The process requires clinical and social support, but no research has investigated the experience of caregivers supporting someone through VSED. To explore the experiences of individuals who have supported a patient through VSED. This qualitative study involved semi-structured interviews with 24 former VSED caregivers in the United States between November 2018 and June 2019. Interviews represented 20 VSED attempts (19 deaths) between 2009-2018. Interviews were transcribed and analyzed using thematic analysis. Caregivers included spouses, adult children, and neighbors. Patients' diagnoses included cancer, COPD, ALS, and early dementia. All patients were enrolled in hospice or hired professional health aides. Caregivers supported patients' decision to choose a “less bad” death. Types of care included help with medical and legal preparations, physical assistance such as help toileting or turning in bed, symptom management for thirst and anxiety, medication management, and support and encouragement to refrain from ingesting fluids. Caregivers frequently had time to prepare for VSED and had agency in choosing their role (e.g. full caregiving vs focus on being present as spouse). The duration of VSED (median = 10 days, range 2-28) offered opportunities for closure, but caregivers remained vigilant for events that could derail the patient's efforts (e.g. falls requiring emergency care). Caregivers perceived deaths as comfortable and consistent with patients' wishes and felt relieved and grateful to have helped. VSED requires intensive, hands-on caregiving, but the certainty of death offers opportunity for closure.

The rise of suicides using a deadly dose of barbiturates in Amsterdam and Rotterdam, the Netherlands, between 2006 and 2017

IntroductionThe three ‘advised’ suicide methods are helium asphyxiation, voluntarily stop eating and drinking and the use of a deadly dose of medication such as barbiturates. The aim of this study was to analyse the number of suicides resulting from barbiturate overdose and examine the influence of publications and internet on this suicide method in the two larger cities of the Netherlands. MethodsData of suicides by medication and drugs overdose were extracted from the electronic registration systems of the forensic physicians of the district of Amsterdam and Rotterdam over the period 1 January 2006–31 December 2017. We analysed whether or not the number of suicides using barbiturate overdose has significantly risen since 2013. This was the year ‘right-to-die-organisations’ informed individuals about this method and a book was published describing this as a humane death. In addition, a regression analysis was used to examine which factors predict a suicide resulting from barbiturate overdose. ResultsA total of 553 overdose suicides were identified and 91 suicides resulting from barbiturate overdose were included for further evaluation. During 2013–2017 there were significantly (p < 0.00) more suicides resulting from barbiturate overdose compared to 2007–2012.Individuals using barbiturate overdose to die by suicide were significantly (p < 0.00) older than those using other medication and drugs (65 years compared to 55 years respectively). 48% of these cases were male. In barbiturate suicides, information sources (books or information on the internet, p < 0.01) and the presence of family during suicide (p < 0.00) occurred significantly more often than in suicides resulting from other medication and/or drugs overdose. The odds for barbiturate suicides were 4.8 higher (CI 2.6–9.2) after 2013 compared to before 2013 after correction for age, sex, city and postmortem toxicology results. DiscussionOur data showed a rise in suicides resulting from barbiturate overdose whereas the total number of inhabitants and suicides resulting from medication overdose has remained more or less constant. Easy access of information or medication through the internet and ‘right-to-die-organisations’ may have directly impacted the rise in suicides resulting from an overdose of barbiturates. To our knowledge this is the first study analysing the rise of barbiturate suicides and the influence of media in published literature.

VSED as an Alternative to MAiD: A Pan-Canadian Legal Analysis

Voluntary Stopping Eating and Drinking (VSED) is an alternative to Medical Assistance in Dying (MAiD) for patients who want to hasten their death but do not either want, or do not have, the option of MAiD. VSED for the purposes of this paper is: 1) a patient with capacity electing to stop eating and drinking as a means of hastening their death with or without physician support; or 2) a previously capable patient refusing oral and artificial nutrition and hydration through an advance directive. This paper looks at the legal status of VSED across the country and whether a competent person can cause his or her own death through VSED and secondly, whether health care providers must respect a previously competent person’s prior capable expressed wishes regarding VSED. Competent individuals are legally permitted to refuse oral and artificial nutrition and hydration in all provinces and territories across Canada. Previously competent persons are legally permitted to refuse artificial nutrition and hydration through a valid advance directive in all provinces and territories across Canada. Previously competent individuals can refuse oral nutrition and hydration through a valid advance directive in Newfoundland and Labrador, Nova Scotia, Prince Edward Island, Quebec, Ontario, Alberta, British Columbia, Yukon and Nunavut. In New Brunswick, Manitoba, Saskatchewan and the Northwest Territories the legal status of VSED for a previously competent person refusing oral hydration and nutrition through an advance directive is less certain. Therefore, VSED is a legal alternative to MAiD for many individuals in Canada.

The Voluntary Stopping of Eating and Drinking: Dying with Dignity?

To die with dignity is a common wish but not one that is easily granted. Professor Dr André Fringer and Mrs Sabrina Stängle, both of the Zurich University of Applied Sciences, are investigating the voluntary stopping of eating and drinking (VSED) as a means to hasten death as an alternative to active euthanasia. Their work is driving forward our understanding of the medical and ethical ramifications of this practice.

Identification of potential drugs for treatment of hepatic lipidosis in cats using an in vitro feline liver organoid system.

BackgroundHepatic lipidosis is increasing in incidence in the Western world, with cats being particularly sensitive. When cats stop eating and start utilizing their fat reserves, free fatty acids (FFAs) increase in blood, causing an accumulation of triacylglycerol (TAG) in the liver.ObjectiveIdentifying potential new drugs that can be used to treat hepatic lipidosis in cats using a feline hepatic organoid system.AnimalsLiver organoids obtained from 6 cats.MethodsEight different drugs were tested, and the 2 most promising were further studied using a quantitative TAG assay, lipid droplet staining, and qPCR.ResultsBoth T863 (a diacylglycerol O‐acyltransferase 1 [DGAT1] inhibitor) and 5‐aminoimidazole‐4‐carboxamide 1‐β‐D‐ribofuranoside (AICAR; an adenosine monophosphate kinase activator) decreased TAG accumulation by 55% (P < .0001) and 46% (P = .0003), respectively. Gene expression of perilipin 2 (PLIN2) increased upon the addition of FFAs to the medium and decreased upon treatment with AICAR but not significantly after treatment with T863.Conclusions and Clinical ImportanceTwo potential drugs useful in the treatment of hepatic lipidosis in cats were identified. The drug T863 inhibits DGAT1, indicating that DGAT1 is the primary enzyme responsible for TAG synthesis from external fatty acids in cat organoids. The drug AICAR may act as a lipid‐lowering compound via decreasing PLIN2 mRNA. Liver organoids can be used as an in vitro tool for drug testing in a species‐specific system and provide the basis for further clinical testing of drugs to treat steatosis.

Long-term care nurses' attitudes and the incidence of voluntary stopping of eating and drinking: A cross-sectional study.

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. A cross-sectional study. Heads of Swiss nursing homes (535; 34%) answered the Online-Survey between June - October 2017, which was evaluated using descriptive data analysis. 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. 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. 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.

Controlling Death. Highlights from Harvard Medical School Annual Bioethics Conference

En 2019, la Conferencia Anual de Bioética de la Facultad de Medicina de Harvard se cuestionó si estamos controlando la muerte eligiendo cuándo y cómo morimos. Este artículo compara las investigaciones publicadas con el tema de la conferencia. Los participantes en la conferencia discutieron sobre la comodidad y la dignidad en el final de la vida, los aspectos legales y éticos de los cuidados paliativos, pero otras opciones de salida deben ser discutidas, como los cuidados paliativos, la suspensión voluntaria de comer y beber, la muerte asistida por un médico y la eutanasia activa voluntaria, así como el documento de voluntades anticipadas o el equipo de cuidados paliativos. Concluimos discutiendo qué otras condiciones de salud (psiquiátricas, cardiovasculares o respiratorias) podrían beneficiarse de las opciones de salida.

Stopping Eating and Drinking by Advance Directives (SED by AD) in Assisted Living and Nursing Homes

The Ethics Subcommittee of AMDA–The Society for Post-Acute and Long-Term Care Medicine (“The Society”) presents arguments for and against Stopping Eating and Drinking by Advance Directives (SED by AD). SED by AD is a type of advance directive in which a proxy is instructed to stop offering food and fluids to a person when they reach a certain stage of dementia. Although most conversations regarding SED by AD focus on patient autonomy and the right to determine one's care, we propose that the ethical principle of justice—the obligation to treat all individuals equally regardless of race, gender, and physical or cognitive ability—is the decisive principle in this controversy. We also suggest that implementing SED by AD can violate a physician's obligation to beneficence and nonmaleficence. On the other hand, we identify with the families of our patients who see the refusal to follow an advance directive as an injustice of the highest order. In the end, The Society is convinced that no choice can be made here without practicing an injustice: if one refuses to implement SED by AD, one violates the autonomy of the person who drew up the advance directive. If, on the other hand, one refuses food and fluid to a resident who still accepts food, one risks practicing an injustice against that person as they are now. Recognizing that we have the greatest responsibility to our patients as they present to us in the residential setting, The Society recommends against implementing SED by AD in residents who still accept food and fluids, implementing instead, a policy of comfort feeding for those with advanced dementia.

Voluntary Stopping of Eating and Drinking in the Terminally Ill #379

Voluntary Stopping of Eating and Drinking in the Terminally Ill #379

The need to distinguish between different forms of oral nutrition refusal and different forms of voluntary stopping of eating and drinking.

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.

An Ethical Discussion on Voluntarily Stopping Eating and Drinking by Proxy Decision Maker or by Advance Directive.

The number of people living with Alzheimer disease and other dementias continues to grow because of the aging of the US population. Increasingly, the issue of patient- and/or surrogate-directed withholding of oral, hand-fed food and fluids in cases of late-stage dementia is confronting caregivers. Major media outlets have covered several cases wherein patients with explicit directives or clear surrogate decision making were not allowed to face the end of their lives according to their wishes. Ethical and legal scholars, as well as many end-of-life advocacy groups, are working to develop a framework and provide guidance in these cases. A local hospice organization was faced with these ethical deliberations when an activated proxy decision maker advocated for caregivers to stop hand feeding an incapacitated patient with end-stage dementia. In this article, this case is summarized, and this important ethical issue is presented in the setting of a literature review and nursing implications.

An Ethical Discussion on Voluntarily Stopping Eating and Drinking by Proxy Decision Maker or by Advance Directive

Journal of Hospice & Palliative Nursing 21(3):p E15-E16, June 2019. | DOI: 10.1097/NJH.0000000000000564

Stopping Eating and Drinking by Advance Directives: Choose Your Injustice

Stopping Eating and Drinking by Advance Directives: Choose Your Injustice