BMA guidance on patients who elect to VSED

The British Medical Association (BMA) has developed guidance for doctors and healthcare professionals on decision making regarding caring for patients who elect to voluntary stop eating and drinking to hasten their death (VSED). The guidance covers the legal and ethical aspects of the decision making.

What is VSED?

VSED describes the situation where a person with mental capacity makes an informed and voluntary decision to refuse food and fluids with the intention of ending their life. Unlike a loss of appetite arising from illness, VSED involves a deliberate choice made free from coercion and with an understanding of the consequences of that decision.

Scope of the guidance

What the guidance covers

The guidance applies to patients who explicitly choose VSED and who:

• are aged 18 and over (whilst mental capacity legislation in all four jurisdictions applies to people over the age of 16, this guidance relates to adults aged 18 and over. If the patient is under 18, independent legal advice should be sought);

• have the mental capacity to make decisions about their nutrition and hydration;

• express a wish to engage in VSED (not just those with a terminal or progressive illness); and

• live in the UK.

It applies in any setting where a patient chooses VSED, including at home, in hospital, or in a hospice.

What does the guidance does not cover

The guidance does not apply in the following circumstances:

• Patients who consciously stop eating and drinking but are not explicit that the intention of doing so is to hasten their death, for example patients at the end of life who are experiencing a natural loss of appetite;

• Patients who lack capacity to make decisions about the oral intake of nutrition and hydration at the time that doctors become aware that they have voluntarily stopped eating and drinking to hasten death (if the patient has an Advance Decision Refusing Treatment or Advance Directive);

• Patients who have stopped eating and/or drinking for reasons other than doing so with the sole intention of hastening their death, such as those on hunger strike or those refusing food for a political or other purpose;

• Patients whose decision to elect to VSED is a symptom of a mental disorder, such as anorexia nervosa; and

• Clinical information about VSED or symptom management.

What you’ll find in the guidance

The guidance provides practical advice on the legal framework on VSED, how to apply it, creating care plan and record keeping and reporting the death and wellbeing resources for doctors.

How the guidance is structured

It is divided into sections covering:

• Section 2: Information about the law on VSED in the UK.

• Section 3: How to proceed in accordance with the law and accepted principles of medical ethics in the UK when deciding whether it is legally permissible to provide symptom relief to patients who elect to VSED.

• Section 4: Guidance on creating a care plan with patients who elect to VSED, including particular topics of importance.

• Section 5: Information about record keeping and reporting the death.

• Section 6: Resources for doctors’ wellbeing.

Key points from the guidance

Central to the guidance is a detailed explanation of the legal position on VSED. It outlines when it may be lawful to provide symptom relief and supportive care to a patient who has made a clear and capacitous decision to stop eating and drinking and highlights the need to act in accordance with both the Mental Capacity Act 2005 and, where relevant, the Mental Health Act 1983. The guidance also includes practical advice on developing an appropriate care plan in partnership with a patient who has chosen VSED.

Two particularly useful flowcharts accompany the guidance. The first, on page 16, helps clinicians assess the legal permissibility of supporting a patient who has explicitly chosen VSED. The second, on page 27, provides a framework for responding where a patient experiencing delirium makes a request that appears to conflict with their previously expressed wishes and goals of care.

Together, these visual tools translate complex legal and ethical principles into a practical framework for clinicians navigating these increasingly common requests.

Questions around VSED often sit alongside wider issues relating to mental capacity, mental health and patient autonomy. Our team has extensive experience advising on these issues, including acting for the Integrated Care Board in the recent Court of Protection case, Patricia. The decision re-emphasised that a refusal of nutrition driven by anorexia nervosa is a manifestation of mental disorder and may justify compulsory intervention under the Mental Capacity Act or the Mental Health Act.

To discuss any of the issues raised in this blog, please contact Neil Ward and Isobel Matthews or find out more about our mental capacity and mental health work.

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