0:00

I hear from lots of people every

0:02

day who are concerned about how their

0:04

diet is affecting their health. They

0:07

need answers based on facts, in

0:09

other words, from the peer-reviewed medical

0:12

literature, and that is

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what I'm here for. Welcome to

0:16

the Nutrition Facts Podcast. I'm

0:19

your host, Dr. Michael Greger. Today

0:22

we explore the possibilities of how we

0:24

might have control over

0:26

our own death, retaining

0:28

dignity, privacy, pain relief, and

0:31

we start with a close look

0:33

at hospice. We have all

0:35

sorts of detailed stats about dying, but

0:38

little about the experience of death.

0:41

For the minority who die

0:43

under the care of palliative care teams,

0:46

one's death could probably be described as

0:48

good, but there's a suspicion that for

0:50

the majority who die in hospitals

0:52

or nursing homes, the experience is bad.

0:55

And that's where most people die.

0:57

In spite of widespread preference to

1:00

die at home, in

1:02

almost all populations, most deaths

1:04

occur in institutions. And

1:06

this doesn't just have consequences for the

1:08

patient, but for the

1:10

bereaved caregivers as well. Patients

1:14

with cancer who died in an intensive care

1:16

unit or hospital experienced more physical

1:18

and emotional distress and worse quality of

1:20

life at the end of life, and

1:24

their caregivers suffer five times the

1:26

odds of suffering post-traumatic stress disorder

1:28

and nearly nine times the odds

1:31

of severe prolonged disabling grief. When

1:34

researchers have looked into the care of

1:36

dying patients in hospitals, it hasn't been

1:38

pretty. Basic interventions

1:40

to maintain patient's comfort were

1:42

often not provided. Contact

1:45

with dying patients was minimal, and

1:47

the distancing and isolation worsened as

1:50

death approached. For example, a 52-year-old

1:52

woman with metastatic cancer spread to

1:54

her liver. She had

1:56

gross abdominal distention, was jaundiced and

1:58

very breathless. But alert,

2:01

her eyes were swollen and

2:03

she shed yellow tears.

2:06

The patient received no

2:08

care from the

2:10

nurses delegated to give care. Yet

2:13

in the nursing record, it was recorded that

2:15

attention had been given to her personal hygiene

2:17

and pressure areas to prevent bed

2:20

sores or hygiene in eyes, but

2:22

it was all a lie. The only

2:24

attention she got was to receive a

2:27

commode from a nursing assistant. Back

2:30

time totaled six minutes over the

2:32

four and a half hours, the

2:34

researchers kept track. In

2:36

contrast, what would a good

2:38

death look like? Retaining control,

2:41

dignity, privacy, pain relief.

2:43

You choose where, you choose how.

2:46

Emotional support, respecting your wishes, saying

2:48

goodbye, and being able to leave

2:50

when it's time to go and not

2:53

have life prolonged pointlessly. One's

2:55

best bet for all that is access to

2:58

hospice care. Palliative

3:01

care is comfort measures to relieve symptoms

3:03

and improve quality of life, utilized at

3:05

any stage of serious illness, whereas hospice

3:08

is just comfort measures when

3:10

focus shifts from curing the

3:13

disease to improving the

3:15

quality of one's last days. Hospice

3:18

is often framed as giving up, but

3:21

ironically, when you compare hospice

3:23

versus non-hospice patient survival, the

3:26

patients in hospice actually live longer.

3:30

Patients who choose hospice care live on

3:32

average about a month longer than similar

3:34

patients who do not choose hospice. Randomize

3:37

those with advanced lung cancer to early palliative

3:39

care, and they don't live

3:41

a month longer. They live two and a

3:44

half months longer. I mean, that's like the

3:46

survival benefit you might get from a standard

3:48

chemotherapy regimen. And in

3:50

fact, that's one of the ways hospice

3:52

could extend survival, by avoiding the risk

3:55

of overtreatment with chemo and its related

3:57

toxicity. There are, however,

4:00

limits to palliative care. Even

4:02

under hospice, where one would assume

4:05

excellent palliative care, there are those

4:07

who appear to unavoidably spend their

4:10

last months in uncontrollable

4:12

pain. And this

4:14

unbearable suffering, despite our best efforts,

4:17

leads to requests for ending a

4:20

patient's life prematurely. Although

4:22

physicians system suicide is gaining acceptance,

4:25

it's only legal in eight states plus

4:27

DC. In

4:29

contrast, V-S-E-D is

4:32

legal throughout the U.S. Voluntarily

4:36

stopping eating and drinking, V-S-E-D, can

4:38

be defined as a conscious decision

4:40

to voluntarily and deliberately choose to

4:42

stop eating and drinking with a

4:44

primary intention of hastening death because

4:47

of the persistence of unacceptable suffering.

4:50

I've talked about fasting to extend one's

4:53

life. What about

4:55

fasting to shorten? We

4:58

hear a lot about physician-assisted suicide,

5:00

but V-S-E-D has not gained nearly

5:02

as much attention. This is presented

5:04

as perplexing, since supposedly it's a

5:06

relatively peaceful and comfortable way to

5:08

die. But is it really?

5:10

How long does it take? How would

5:12

you do it? I'll talk about

5:14

the pros and cons and practical implications

5:17

next. Perhaps

5:20

in an ideal world, every patient with

5:22

a life-limiting illness would receive optimal hospice

5:24

and palliative care such that no one

5:26

would ever wish to hasten their own

5:29

death. Unfortunately, the

5:31

reality is that despite our best efforts,

5:34

some with terminal illness continue to

5:36

suffer, leading increasing number of patients

5:38

across the country to

5:41

explore V-S-E-D to

5:43

escape intolerable suffering,

5:46

voluntarily stopping eating and drinking.

5:50

Some of the pros include dying at home,

5:52

which is what most people's preference is. You

5:55

don't have to spend your fleeting hours

5:58

dealing with doctors and lawyers. There's

6:00

no waiting period in Oregon. For example,

6:02

their death with dignity act requires a

6:04

15-day waiting period before you can get

6:07

physician assistance. Whereas choosing to stop eating

6:09

and drinking would seem to afford more

6:11

control. I mean, even just knowing it's

6:14

an option can be a comfort. Those

6:17

who learn about VSCD may feel

6:19

empowered by the knowledge that they

6:21

can choose this option without seeking

6:23

anyone's permission. And because it's legal,

6:25

it can be openly discussed. Just

6:28

knowing that there's a way out

6:30

can provide relief from feelings of

6:32

desperation and entrapment, and

6:34

a feeling of control may itself be

6:36

therapeutic. It can also prevent people from

6:39

contemplating a more violent way out, and

6:41

patients don't have to feel pressured to

6:43

end their life prematurely while they still

6:45

can. Physician assisted

6:47

death with dignity laws require patients

6:49

to take the lethal drug cocktail

6:52

themselves. If you have

6:54

ALS and are worried about losing your

6:56

muscular function, you might feel the need

6:58

to end your life before you're ready

7:00

while you still have the capacity. In

7:03

fact, Dr. Kevorkian's first was a woman

7:05

diagnosed with Alzheimer's who wanted to end

7:07

it before it got too late, potentially

7:10

depriving her and her family of years she

7:12

might have still been able to enjoy. While

7:16

physician assisted suicide entails a

7:18

single instantaneous and irrevocable act,

7:21

death from VSCD occurs

7:24

over several days, allowing time

7:26

for patients to change their mind and

7:29

for healing goodbyes. But

7:31

what is it actually like? There's

7:33

lots of anecdotes floating around

7:35

describing death on VSCD as

7:37

peaceful, painless, and dignified. Fortunately,

7:40

the evidence is more than just

7:42

anecdotal. There have been several independent

7:45

studies, so let's look at the

7:47

data. Average time of death,

7:50

after stopping eating and drinking, was about

7:52

seven days, though 8% lasted more than

7:54

two weeks. And

7:58

how was it? Ask a hundred h- hospice

8:00

nurses, and on a scale of

8:02

zero, very bad death, to nine,

8:04

a very good death, the average

8:06

score, the quality of these

8:09

deaths, as rated by the nurses, was

8:11

eight. The researchers concluded that

8:13

people usually die a good death within

8:15

two weeks after stopping food and fluids,

8:18

according to the nurses, rating

8:20

those last days of life as peaceful,

8:22

with low levels of pain and suffering.

8:24

More so even than those who

8:27

chose physician-assisted suicide. This was in

8:29

Oregon, so patients could have chosen

8:31

that instead, but nearly twice as

8:34

many patients decided instead to take

8:36

matters into their own hand by voluntarily

8:39

stopping, eating, and drinking. Interestingly,

8:41

loved ones seemed to agree with

8:44

voluntary refusal of food and fluids

8:46

perceived as carrying less emotional baggage

8:48

for the family, more letting go

8:51

than taking more active approach. A

8:54

study in the Netherlands that interviewed confidants,

8:56

like friends and family that witnessed it,

8:58

found that most considered it

9:00

quote-unquote dignified death. Hospice

9:03

physicians seemed to agree, with

9:05

nearly 90% surveyed reporting that

9:07

their VSCD patients experienced peaceful

9:10

and comfortable deaths. The

9:13

state of terminal dehydration may even

9:16

have some analgesic effects and pain-killing

9:18

effects, presumed to be due to

9:20

the release of endorphins, which act

9:22

as natural pain blockers. So, concluded

9:25

this review, VSCD may reflect all

9:27

12 principles of

9:29

a good death, retaining control

9:31

and dignity. One

9:34

of the most famous accounts was

9:36

Dr. David Eddy's description of his

9:38

own mother's VSCD. My

9:40

mother was elated. The

9:43

next day happened to be her 85th birthday,

9:45

which we celebrated with a party, balloons and

9:47

all. She was beaming from

9:49

ear to ear. She

9:51

had done it. She had found the way. She

9:54

relished her last piece of chocolate

9:56

and then stopped eating and drinking.

9:59

The last four days, My mother

10:01

greeted her visitors with her first smile

10:03

she had shown for months. She

10:05

energetically reminisced about the great times she had

10:07

had, about all the things she was proud

10:09

of. She especially hoped I

10:12

would tell you about her traveling alone across

10:14

Africa at the age of 70 and surviving

10:16

a capsized raft on Wyoming Snake River at

10:18

82. She also found

10:20

a calming self-acceptance in describing things in

10:23

which she was not proud. She

10:25

slept between visits but woke up brightly

10:28

whenever she was touched, to share

10:30

more of her memories and to say

10:32

a few more things she wanted us to know. On

10:35

the fifth day it was more difficult to wake her. When

10:38

we would take her hands, she would

10:40

open her eyes and smile, but she

10:42

was too drowsy and weak to talk very much. On

10:44

the sixth day we could not wake

10:46

her. Her face was relaxed and her

10:49

natural smile. She was breathing unevenly

10:51

but peacefully. We held

10:53

her hands for another two hours until

10:55

she died. Without hoarding pills, without

10:58

making me into a criminal, without putting

11:00

a bag over her head and without huddling

11:02

in a van with a carbon monoxide machine,

11:05

she had found a way to bring her life

11:07

gracefully to a close. Right

11:10

about this, David. Tell others how well this

11:12

worked for me. I'd like this to be

11:14

my gift. Whether they

11:16

are terminally ill, in intractable pain, or

11:18

like me, just knowing

11:21

that the right time has come for them,

11:23

more people might want to know that this

11:25

way exists and maybe more physicians

11:27

will help them find it. We

11:31

would love it if you could share with

11:34

us your stories about reinventing your health through

11:36

evidence-based nutrition. Go to

11:38

nutritionfacts.org/testimonials. We may be able

11:40

to share it on social

11:42

media to help inspire others.

11:45

If you see any graphs, charts, graphics,

11:47

images, or studies mentioned here, please go

11:49

to the Nutrition Facts Podcast landing page.

11:52

There you'll find all the detailed information you

11:55

need, plus links to all the sources we

11:57

cite for each of these topics. My

12:00

latest book, How Not to Age, is out now,

12:03

premiering at number two on the New York Times

12:05

Best Sellers list. Check

12:07

it out at your local public library. And of

12:09

course, all the proceeds of the sales of all

12:11

my books goes directly to charity. nutritionfacts.org

12:14

is a nonprofit, science-based public service where

12:17

you can sign up for free daily

12:19

updates on the latest in nutrition research,

12:21

with bite-sized videos and articles. Everything

12:24

on the website is free. There

12:27

are no ads, no corporate sponsorships,

12:29

no kickbacks, strictly non-commercial. I'm

12:32

not selling anything. I just put it

12:34

up as a public service, as a

12:36

labor of love, as a tribute to

12:38

my grandmother, whose own life was saved

12:40

with evidence-based nutrition.