Ceasing Food and Fluid Can Be Painless

After suffering through cancer, the middle-aged woman decided her illness was too much to bear. Everything she ate, she painfully vomited back up. The prospect of surgery and a colostomy bag held no appeal.

And so, against the advice of her doctors, the patient decided to stop eating and drinking.

Over the next 40 days in 1993, Dr. Robert Sullivan of Duke University Medical Center observed the woman’s gradual decline, providing one of the most detailed clinical accounts of starvation and dehydration.

Instead of feeling pain, the patient experienced the sense of euphoria that accompanies a complete lack of food and water. She was cogent for weeks, chatting with her caregivers in the nursing home and writing letters to family and friends. As her organs failed, she slipped painlessly into a coma and died.

In the evolving saga of Terri Schiavo, the prospect of the 41-year-old Florida woman suffering a painful death from starvation has been a galvanizing force.

But doctors say that going without food and water in the last weeks of life is not traumatic, and that the body is equipped to adjust to such conditions.

In fact, eating and drinking during severe illness can be painful because of the demands it places on weakened organs.

“What my patients have told me over the last 25 years is that when they stop eating and drinking, there’s nothing unpleasant about it -- in fact, it can be quite blissful and euphoric,” said Dr. Perry G. Fine, vice president of medical affairs at the National Hospice and Palliative Care Organization in Arlington, Va. “It’s a very smooth, graceful and elegant way to go.”

Doctors say Schiavo, who hasn’t had food or water since Friday, has been in a persistent vegetative state for 15 years, which they say makes it impossible for her to recognize pain.

“Her reflexes with respect to thirst or hunger are as broken as her ability to think thoughts or dream dreams or do anything a normal, healthy brain does,” Fine said.

But even if her brain were functioning normally and she were aware of her condition, she still would not be conscious of pain, doctors say.

“The word ‘starve’ is so emotionally loaded,” Fine said. “People equate that with the hunger pains they feel or the thirst they feel after a long, hot day of hiking. To jump from that to a person who has an end-stage illness is a gigantic leap.”

For those fighting to have Schiavo’s feeding tube reinstated, the issue is not merely one of pain but of her right to live.

Though people may fear death by starvation, it is the norm in nature -- and the body is prepared for it.

“The cessation of eating and drinking is the dominant way that mammals die,” said Dr. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center in New Hampshire. “It is a very gentle way that nature has provided for animals to leave this life.”

In a 2003 study published in the New England Journal of Medicine, 102 hospice nurses caring for terminally ill patients who refused food and drink described their patients’ final days as peaceful, with less pain than those who elected to die through physician-assisted suicide.

The average rating given by the nurses for the patients’ quality of death was eight on a scale in which nine represented a “very good death” and zero was a “very bad death.”

The process of dying is usually gradual. Patients deprived of food and water will die of dehydration rather than starvation -- if they don’t succumb to their underlying illness first.

Without fluids, the body loses its ability to maintain a balance of potassium, sodium, calcium and other electrolytes in the bloodstream and cells.

The kidneys react to the fluid shortage by conserving as many bodily liquids as possible.

The brain, which relies on chemical signals to function properly, begins to deteriorate. So do the heart and other muscles, causing patients to feel lethargic.

“Everything in the body is geared toward trying to maintain that normal balance,” Fine said. “The body will do everything it can to maintain this balance if it’s working well.”

Meanwhile, the body begins mining its muscles and stores of fat to get the carbohydrates and proteins it needs to make energy.

“If you mine too many proteins in the heart, it gets unstable,” said Sullivan, a senior fellow at Duke’s Center for the Study of Aging. That can give rise to an irregular heartbeat, which can cause the patient to die of cardiac arrest. Or, if the muscles in the chest wall become weak, the patient can end up with pneumonia, he said.

Patients already weakened by disease begin feeling the effects after a few days, Fine said.

They eventually descend into a coma and finally death. The entire process usually takes one to two weeks, though a patient who is otherwise relatively healthy -- such as Schiavo -- could hold on for much longer.

Throughout the process, the body also strives to suppress the normal feelings of pain associated with deprivation.

That pain of hunger is only felt by those who subsist on small amounts of food and water -- victims of famine, for instance, or concentration camp inmates. They become ravenous as their bodies crave more fuel, Sullivan said.

Patients who are close to death don’t get hungry or thirsty like healthy people, said Byock of the Dartmouth-Hitchcock Medical Center.

“If you ask people who have stopped eating and drinking if they’re hungry, they will say no,” Byock said.

The lack of pain is part of a protective mechanism developed over millions of years, Sullivan said.

After 24 hours without food, “the body goes into a different mode, and you’re not hungry anymore,” he said. “Total starvation is not painful or uncomfortable at all. When we were hunting rabbits millions of years ago, we had to have a backup mode because we didn’t always get a rabbit. You can’t go hunting if you’re hungry.”

After a few days without food, chemicals known as ketones build up in the blood. These chemicals cause a mild euphoria that serves as an anesthetic.

The weakening brain also releases a surge of feel-good hormones called endorphins -- the same chemical that prompts the so-called “runner’s high.”

Doctors also have a host of treatments to ameliorate acute problems, such as sprays and swabs to moisten dry mouths, and creams to moisturize flaky skin. They can also give morphine or other painkillers.

Sullivan said doctors were likely to give painkillers to Schiavo, but added: “Frankly, I think they might as well give it to each other, because it will probably be more painful for them than it will be for her.”