Uemura Takeshi, Krohmal Benjamin J, Higuchi Masaya
Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
John J. Lynch, MD Center for Ethics, MedStar Washington Hospital Center, Washington, DC, USA; Georgetown University School of Medicine, Washington, DC, USA.
J Am Med Dir Assoc. 2023 Oct;24(10):1442-1446. doi: 10.1016/j.jamda.2023.06.022. Epub 2023 Jul 27.
In recent years, health care providers and the general public in the United States have gained a greater awareness of Voluntary Stopping of Eating and Drinking (VSED) as a last resort option to escape from unbearable suffering, thanks to a growing number of publications, books, and documentaries. However, the challenges and issues that can arise in completing a death certificate after VSED are not well described in literature. In this article, we first present an example case of VSED in which the death certificate was issued listing suicide as the manner of death by the medical examiner. Then, we describe the challenges and issues related to death certificates in VSED cases. Because there is no consensus on whether VSED is natural death or suicide, the death certificate may need to be referred to a medical examiner in many jurisdictions, potentially resulting in suicide being designated as the manner of death. Such designations can cause reticence in providers and institutions that might otherwise support patients who choose VSED but are concerned about the legal or reputational implications of enabling a "suicide" at their facility. A suicide designation may also contribute to moral distress in health care staff and impose emotional and practical burdens on the patient's surviving loved ones. We suggest that there are 3 approaches to addressing challenges and issues associated with death certificates after VSED: (1) navigate the existing system with guidance developed by professional organizations, (2) make a legal exemption, and (3) change the death certification system. Debate involving a wide variety of experts is warranted.
近年来，由于越来越多的出版物、书籍和纪录片，美国的医疗保健提供者和公众对自愿停止进食和饮水（VSED）作为逃避无法忍受的痛苦的最后手段选项有了更高的认识。然而，文献中并未充分描述VSED后填写死亡证明时可能出现的挑战和问题。在本文中，我们首先介绍一个VSED的实例，其中法医将死亡证明上的死亡方式列为自杀。然后，我们描述VSED案件中与死亡证明相关的挑战和问题。由于对于VSED是自然死亡还是自杀没有共识，在许多司法管辖区，死亡证明可能需要提交给法医，这可能导致死亡方式被指定为自杀。这样的指定可能会使原本可能支持选择VSED的患者但担心在其机构促成“自杀”的法律或声誉影响的提供者和机构保持沉默。自杀指定也可能导致医护人员的道德困扰，并给患者在世的亲人带来情感和实际负担。我们建议有三种方法来应对VSED后与死亡证明相关的挑战和问题：（1）在专业组织制定的指导下驾驭现有系统，（2）进行法律豁免，（3）改变死亡证明系统。有必要让各种各样的专家参与辩论。
