VSED: Voluntarily Stopping Eating and Drinking at End of Life

Medical and legal notice: This information is educational, not medical or legal advice. VSED is a serious end-of-life decision involving clinical, ethical, family, and legal questions. It should not be undertaken on the basis of general information alone. A qualified clinician and, where relevant, a lawyer familiar with the person’s jurisdiction can help assess the situation and explain available care and protections.

Voluntarily stopping eating and drinking, commonly called VSED, is a deliberate decision made by a person with decision-making capacity to stop oral food and fluids with the intention of hastening death. It is distinct from the reduced appetite or ability to eat that can occur as illness advances. The distinction matters: one is an intentional choice; the other may be part of the body’s changing needs and abilities.

People encounter questions about VSED amid serious illness, disability, distressing symptoms, or concern about future loss of capacity. There are no simple answers that fit every person or setting. A careful discussion considers capacity, suffering, options for symptom relief, the patient’s values, family circumstances, and what local law and care institutions permit. The goal here is to explain the issues without encouraging or prescribing a course of action.

What VSED means, and what it does not mean

The American Nurses Association (ANA), in its 2017 position statement, describes VSED as a deliberate decision to stop eating and drinking, made with the primary intention of hastening death. The decision must come from the patient, who must have decision-making capacity. A surrogate or family member cannot make the VSED decision on someone else’s behalf.[1]

VSED should not be confused with a person who eats less because illness has reduced appetite, swallowing ability, energy, or interest in food. The ANA notes that reduced intake can be a physiological part of end-stage disease, and that people nearing death may have less desire for food and fluids. When someone wants to eat or drink, their wishes should be accommodated if possible. Comfort and symptom relief remain important when intake declines naturally.[1]

It is also different from stopping medically provided nutrition or hydration, such as tube feeding or IV fluids. Those decisions have their own clinical and legal considerations. The fact that a person has declined a medical intervention does not, by itself, establish that they have chosen VSED.

It is also different from medical aid in dying (MAiD). As one jurisdiction-specific example, Oregon’s Death with Dignity Act describes eligible terminally ill patients voluntarily self-administering medication prescribed by a physician for that purpose.[6] This Oregon description is not a statement of the law elsewhere. VSED, as described above, is a patient’s deliberate decision to stop oral food and fluids; the distinction does not settle every legal or clinical question about VSED. For a separate overview of MAiD, see medical aid in dying and Death with Dignity.

Why someone may raise the question

People may raise VSED while living with serious illness or disability, or when they fear a future loss of function or decision-making capacity. Some may describe symptoms or suffering that feel intolerable. Others may be worried that choices available to them are limited. These concerns deserve careful attention, not assumptions about why a person is asking.

A VSED question can also be a way of asking for help with pain, breathlessness, anxiety, depression, loneliness, spiritual distress, caregiving pressures, or uncertainty about what lies ahead. Asking about VSED does not by itself show that a person has made a settled decision. It is reasonable for clinicians to ask what is driving the concern and what forms of relief or support the person wants to explore.

A palliative-care assessment can help clarify symptoms and discuss comfort-focused options, whether or not a person is considering VSED. The National Institute on Aging describes palliative care as something that can be provided alongside treatment intended to cure an illness, and hospice as a specific type of palliative care with its own eligibility criteria.[4] Ask local providers what services and eligibility rules apply. The distinction is explained in this guide to hospice and palliative care. A conversation about symptom relief should not be treated as an attempt to persuade someone in either direction.

For example, imagine that a person with a progressive illness tells a clinician, “I can’t keep living this way.” That statement needs a careful response. The clinician might ask what is hardest, whether there is immediate danger, what treatments and supports have been tried, and whether the person feels pressured. The purpose is to understand the person’s situation and assess needs, not to assume that VSED is either the intended request or the only option.

Capacity, informed choice, and voluntariness

Capacity is central to a VSED decision. A general clinical framework for medical decision-making considers whether a person can understand relevant information, appreciate how it applies to their situation, reason about options, and communicate a choice. Capacity is specific to the decision and circumstances. A physician assesses it, with consultation from another clinician when needed; state definitions may differ.[3] For VSED, a qualified clinician should assess the particular decision in context and explain the applicable process.

The ANA says the patient’s decision must be informed and that depression or other factors that impede decision-making must not encumber the choice.[1] That does not mean that every person who has depression lacks capacity. It means that a qualified clinician should explore whether distress, a potentially treatable condition, cognitive changes, medication effects, coercion, or other circumstances are affecting the decision. Assessment may involve more than one professional when the situation is complex.

Voluntariness also requires attention. A person should be able to speak privately with a clinician if pressure from relatives, caregivers, finances, or institutions may be influencing them. Family members may have strong feelings, but neither their agreement nor their disagreement substitutes for the patient’s own capable decision. Similarly, a family member’s consent does not authorize initiating VSED on another person’s behalf. Separate nutrition or hydration decisions for someone lacking capacity should follow the patient’s known preferences, clinical guidance, and applicable local law.

Informed discussion includes alternatives, likely uncertainties, the possibility that the person may change their mind, and what care can be offered. The clinician should invite questions and check what the patient understands. If the person is unsure, they can ask for time, a second clinical opinion, or further support. A discussion is not a commitment, and asking for information does not obligate a person to proceed.

How the experience can vary

There is no dependable timetable that can be applied to every person considering VSED. General information cannot predict an individual’s course or experience. The treating clinician can discuss what is known in the person’s situation, what remains uncertain, and what care or support may be appropriate.

Symptoms also vary. The ANA emphasizes that meticulous oral care, comfort, dignity, human touch, and palliative support are important when nutrition or hydration is forgone.[1] Dry mouth may be a concern, but clinicians should assess the individual rather than presume that one symptom pattern applies to everyone. If the person appears uncomfortable, family members can contact the care team for guidance rather than trying to manage new symptoms alone.

Changes in alertness or behavior require clinical attention. Delirium can involve fluctuating awareness, inattention, confusion, or agitation. A 2024 review notes that end-of-life delirium can be distressing for patients and caregivers, and that evidence for medication approaches has important limitations. Treatment choices depend on the person and the clinical situation; no medicine is suitable for every case.[2]

When confusion or agitation appears, the care team can assess whether the change may be related to the illness, medication, discomfort, or another potentially addressable cause. Family members can share what they observe and ask what signs merit an urgent call. Do not start, stop, or change medication without instructions from the treating clinician.

What hospice and palliative care may contribute

Hospice or palliative-care professionals may help with symptom assessment, comfort-focused care, communication, and support for family members. Whether a particular hospice will provide care in a VSED situation can depend on its policies, clinical judgment, and local requirements. It is important to ask directly rather than assume that all programs take the same approach.

Ask a prospective hospice how it handles a patient’s stated decision, what services it can provide, how it responds if the patient changes their mind, and whom family members should call when symptoms change. A program should explain its role without pressuring the patient. If its policy does not fit the patient’s needs, ask the treating clinician or care coordinator about other appropriate services.

Hospice enrollment has its own clinical and administrative process. A person or family can review the practical questions in the hospice enrollment guide, then confirm current eligibility and coverage details with the relevant professionals. Enrollment should not be represented as a guarantee that a particular service, location, or intervention will be available.

Family caregivers may need help with daily care, communication, and the emotional demands of serious illness. The family hospice caregiving guide offers broader caregiving context. Support can include clear contact information, planned respite where available, and a shared understanding of who to call with questions. The care plan should address the patient’s comfort and preferences, not only the family’s expectations.

Preparing for a clinical conversation

A conversation with the patient’s physician or palliative-care clinician can begin with the question, “What is making life feel unmanageable right now?” The patient can explain symptoms, fears, beliefs, and what they understand about VSED. A clinician can then assess immediate needs, capacity, possible treatable contributors, and what options are available in that person’s circumstances.

It can help to bring a written list of questions. For example:

• What physical, emotional, or spiritual concerns are contributing to this request?
• What symptom relief or other support has not yet been tried or reviewed?
• How will you assess my decision-making capacity and check that I am not being pressured?
• What care could your team provide, and what are its limits or policies?
• What changes in comfort, alertness, or behavior should prompt a call?
• What should happen if I change my mind or ask for food or drink?
• Which legal or facility-specific questions need advice from a qualified local professional?

Patients may want to include a trusted person, but should retain the opportunity to speak privately with the clinician. A support person can help remember information, take notes, or communicate the patient’s preferences. They should not answer in place of the patient when the patient can speak for themselves.

Planning documents may help record broader wishes about medical care and who may speak for the patient if capacity is lost. The National Institute on Aging describes a living will as stating treatment preferences for when a person cannot make their own decisions, and a durable power of attorney for health care as naming a proxy to make health-care decisions if the person cannot communicate their wishes.[5] These documents serve different functions; ask a clinician and local legal professional how the specific documents are defined and apply where care will be provided. See the explanation of living wills and advance directives.

Legal and ethical questions that need local guidance

VSED raises difficult legal questions, and general educational material cannot establish what a particular clinician, facility, or jurisdiction must do. The ANA notes that there is some, but not universal, consensus that VSED can be an ethical and legal decision.[1] Ask the treating team and a qualified local attorney what rules apply to the particular decision and care setting. Do not rely on a blanket statement about legality in every state or country.

It is useful to separate several questions: whether a capable adult can refuse food or fluids; what duties a clinician has when a patient makes that choice; how a hospital, hospice, or long-term-care facility handles the situation; and what happens if the patient later loses capacity. The answers may not be identical. A qualified local lawyer can advise on jurisdiction-specific law, while the care team can explain clinical practice and institutional policy.

Ethical discussion often involves respect for autonomy and the duties to relieve suffering, prevent harm, and provide appropriate care. People can disagree sincerely about how those duties apply. A clinician may support comfort care while declining to recommend or manage a particular course. Ask for an explanation of the care team’s position and whether another qualified palliative-care consultation is available.

Religious and cultural views are diverse, including within the same tradition. A person may wish to speak with a trusted spiritual leader, but no single interpretation should be assumed to represent every congregation, denomination, or household. The patient’s own beliefs and the wishes they express are relevant to a respectful discussion.

Advance directives and future loss of capacity

VSED by advance directive, sometimes called VSED-AD, raises a separate and especially unsettled issue: whether a person can make a prior instruction about food and fluids that is intended to apply after they lose capacity, including in advanced dementia. The ANA position statement says a patient’s VSED decision remains binding if the patient later loses capacity, while also stating that a surrogate cannot make the VSED decision for the patient.[1]

That position does not mean that every care setting will interpret or carry out a directive in the same way. A document may need to meet local legal requirements, and clinicians or facilities may have questions about its scope, the patient’s present behavior, or their duties. A person considering this issue should discuss it in advance with a clinician and a lawyer who understands the relevant jurisdiction and care setting.

There is an important distinction between documenting a person’s own prior choice and giving a surrogate power to initiate VSED. The latter should not be treated as authorized merely because a relative is named as health-care agent. If a person with dementia is accepting food or drink, family members should not interpret a general directive as permission to withhold it without clinical and legal guidance.

For example, a person might write that they do not want certain interventions if they develop advanced dementia. That statement may help explain their values, but it may not answer every practical question about assistance with eating, present expressions of preference, or facility obligations. The family should seek specific advice rather than assume a document resolves the dispute.

Supporting family without taking over the decision

Family members may feel sadness, fear, disagreement, or uncertainty when someone raises VSED. There is no single correct emotional response. It can help to distinguish listening from endorsing: a relative can ask what the person wants understood, offer to attend a clinical meeting, and express concern without claiming ownership of the decision.

Agreeing on communication can reduce misunderstandings. With the patient’s permission, identify one contact person for clinical updates, decide which relatives should be informed, and clarify what information can be shared. The patient may want privacy or may prefer a broad family discussion. Neither choice should be presumed.

Families can ask the care team for guidance about comfort measures, what changes might occur, and what to do if the patient seems distressed or asks for help. If relatives disagree about what they have heard, ask the clinician to restate the plan in plain language. Family members should not initiate VSED on another person’s behalf or independently alter medication. Decisions about clinically appropriate nutrition and hydration are separate from initiating VSED and require the patient’s known preferences, the care team’s guidance, and applicable local law.

Being present does not require finding perfect words. Quiet company, listening, and asking permission before touching or helping can be meaningful forms of support. A person may want conversation, prayer, music, familiar routines, or privacy; preferences can change. A vigil is not obligatory. For practical ideas about being present, see guidance on sitting vigil with a dying loved one.

Family caregivers should also be allowed to name their own limits and ask for support. A clinician, social worker, chaplain, or counselor may help the family talk through conflict and distress. Support should be offered without making family agreement a condition of listening to the patient or without blaming relatives for having difficult feelings.

When to pause and seek more help

A VSED discussion should pause for further assessment if the person seems uncertain, cannot explain their understanding, appears pressured, or may be affected by a treatable source of distress. The same is true if symptoms are uncontrolled or the person is asking for relief but has not had a thorough review of options. A pause is not a judgment that the person’s concerns are unimportant; it creates space for informed, supported decision-making.

Urgent changes in alertness, new confusion, severe agitation, or signs of physical distress should be reported to the treating team promptly. The care team can assess the situation and advise what level of care is appropriate. Families can also ask in advance what the program considers urgent and how to reach someone after hours.

If someone’s words suggest immediate danger or an intention to harm themselves, treat that as an urgent safety concern. Stay with the person if it is safe to do so and contact local emergency or crisis support. A discussion about VSED should not replace an immediate assessment of safety, mental health, or medical needs.

A careful, person-centered next step

VSED is not a decision for relatives to make, a substitute for symptom assessment, or a procedure that general online guidance can direct. It is a serious and contested end-of-life issue that requires attention to the patient’s capacity, wishes, clinical circumstances, and jurisdiction. The ANA emphasizes that comfort, dignity, meticulous oral care, and palliative support matter when nutrition or hydration is forgone.[1]

A practical next step may simply be to tell a trusted clinician, “I want to understand VSED and what is behind my concern.” Ask for a private, nonjudgmental conversation; a careful assessment of suffering and capacity; and clear information about alternatives, care-team policies, and local legal questions. If the person is not ready to decide, they can continue the conversation without treating uncertainty as failure.

For families, the task is to listen, ask what support is welcome, and bring clinical concerns to the professionals involved. No one needs to resolve every ethical or legal question alone. Decisions should be revisited as the person’s situation and wishes become clearer, with respect for their voice and attention to comfort throughout.

Medical and legal notice: This information is educational, not a substitute for individualized medical or legal advice. Do not treat this information as authority to initiate VSED on another person’s behalf. Separate decisions about clinically appropriate nutrition and hydration require individualized consideration of known preferences, clinical guidance, and local law. Seek guidance from qualified clinicians and, where needed, a lawyer familiar with local law and the care setting.

This information is educational, not medical or legal advice. Decisions about end-of-life care require individualized assessment by qualified clinicians and, where appropriate, legal advice in the relevant jurisdiction.