Hastening Death by Stopping Eating and Drinking: Hope Wechkin, Thaddeus Pope, & Josh Briscoe

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GeriPal - A Geriatrics and Palliative Medicine Podcast 51 min 2 speakers 8 chapters transcribed 9 hours ago

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What is Minimal Comfort Feeding (MCF) and why was it created?

Eric Widera 0:00

This episode of the JerryPal Podcast is CME eligible.

Alex Smith 0:04

To claim credit, please go to the CME tab on jerrypal.org.

Eric Widera 0:09

Welcome to the Jerry Powell Podcast. This is Eric Wadera. This is

Alex Smith 0:12

Alex Smith. And Alex,

Eric Widera 0:13

who do we have with us today?

Alex Smith 0:14

We have a very full house today. Hope Wetchkin brought this topic to us. Thank you, Hope, for bringing a topic to us. We love it when our guests suggest things. Hope is a palliative care doc and hospice medical director at Evergreen Health up near Seattle, Washington. Hope, welcome to the Jerry Powell podcast.

Hope Wechkin 0:31

Thanks. Great to be here.

Alex Smith 0:32

And one of Hope's collaborators, Thaddeus Pope, is a lawyer and a bioethicist and professor of law at the Mitchell Hamlin School of Law in Saint Paul, Minnesota. Thaddeus, welcome to the Jerry Powell podcast.

Thaddeus Pope 0:46

Thank you.

Alex Smith 0:48

And we're delighted to welcome back Josh Briscoe, who's a palliative care doc at the Durham VA Medical Center in Duke, and blogs at Notes from a Family Meeting. Josh, welcome back to Jerry Powell. Thanks, y'all. And finally, Theo Slomoff, who is a palliative care fellow at UCSF and is joining us as a guest host. He was gonna jump in there and ask questions, try to get in s edgewise, but Eric has so many questions to ask. So jump in there. Oh yeah, you gotta jump in.

Eric Widera 1:16

Take it over. So we got a lot to tell you. Cause we're gonna be talking about feeding, nutrition, hydration at the end of life, particularly this idea of minimally comfort feeding, visa, medically aid and dying, how they all potentially combine or if they don't. So a ton to talk about. But before we talk about this subject, but nutrition, hydration at the end of life. People with advanced illness or maybe not so much. Does somebody have a song request for Alex?

Hope Wechkin 1:45

I do.

Eric Widera 1:46

Yes. What is it, Hope?

Hope Wechkin 1:50

Hungry like the wolf. By Duran Duran.

Eric Widera 1:54

Why did you choose this song? Very apro title.

Hope Wechkin 1:58

Well, gotta think about hunger, but most importantly, I wanted to hear something from junior high.

Alex Smith 2:06

And um Yeah, when did this song come out?

Hope Wechkin 2:10

It came out in nineteen eighty two. And I and just this morning I looked up the video. It was actually the video that came out with this. It is hilarious. The hair is amazing. Um And Simon LeBon, I mean he's still going, but He just tears it to shreds. So

Eric Widera 2:33

Let's see if Alex tears it to shred.

2:39

Dark in the city, night is a wire. Steam in the subway, the earth is afire Doot.

2:52

Well when you want me, give me a sign And catch me breathing even closer behind Do.

3:07

Touch with the ground, I'm on the hunt, I'm after you. I smell like a sound, I'm lost in a crowd, and I'm hungry like the wolf. Straddle the line in discord and rhyme. I'm on the hunt, I'm after you. Mouth is alive, the juice is like wine, and I'm hungry like the wolf.

Eric Widera 3:37

Thank you, Alex. So we got a lot to cover. I'm gonna start off with you, Hope. Uh you wrote a paper not too long ago titled, Mr. Smith has no meal times, minimal comfort feeding for patients with advanced dementia. Why did you write this paper?

Hope Wechkin 3:56

Well The short version is I had no idea what I was getting myself into. I was part of a writing group that wrote clinical guidelines for V set for voluntarily stopping eating and drinking. And after we were done with that, we thought, you know We should define what comfort feeding only is. And just to make sure everybody knows what that is and how that's different. And I thought, oh, how hard can that be? Like that's pretty easy. That'll take It an after I had an afternoon when I could like Write that up. And lo and behold, I started looking into it and I started to find out that Actually comfort feeding only is not very well described at all. It's not very well defined at all. And then actually what happened was right around that time

Hope Wechkin 4:49

I'm a hospice medical director and I And of course it was a Friday afternoon and I got a call from our intake department about a patient and I knew it was a matter of time before this came along. There was a patient who was living in Seattle at a skilled nursing facility. And she was from Oregon, of course, and in Oregon in twenty twelve she had completed an advanced directive. for stopping eating and drinking once she had advanced dementia.

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Chapters

8 chapters

1 What is Minimal Comfort Feeding (MCF) and why was it created? 0:00–6:02 2 How does the case of the Seattle patient illustrate the compromise between VSED and comfort feeding? 6:02–12:33 3 What are the key differences between Comfort Feeding Only and Minimal Comfort Feeding? 12:33–19:10 4 How can Minimal Comfort Feeding serve as a bridge to Medical Aid in Dying (MAID)? 19:10–25:16 5 What legal and ethical challenges arise when using VSED to qualify for MAID? 25:16–31:46 6 How do capacity assessments affect decisions about eating, drinking, and MAID in dementia? 31:46–38:01 7 What legislative changes are needed to align MAID eligibility with VSED and dementia care? 38:01–44:34 8 What practical steps and research are needed to implement Minimal Comfort Feeding widely? 44:34–51:24

Speakers

2 identified

Eric Widera 8 min Alex Smith 6 min

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Topics in this episode

Washington 1 California 1 Spain 1 Seattle 1 Alex Smith 3 dementia 1 Quebec 1 Chris Jones 1 Ed Martin 1 Elizabeth Chung 1 Harry Hahn 1 Susan Nelson 1

Source

Recorded20 Mar 2025

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Show notes

Eric and Alex have featured discussions about complex bioethical concepts around caring for people at the end of life, including voluntarily stopping eating and drinking (VSED), and multiple episodes about the ethical issues surrounding medical aid in dying (MAID). Recently, discussion has emerged about how these issues intertwine in caring for patients with advancing dementia who have stated that they would not want to continue living in that condition: for those with an advanced directive to stop eating and drinking, how do we balance caring for their rational past self and their experiential current self? Should these patients qualify for medical aid in dying medications? And is there a middle path to provide some degree of comfort while also hastening the end of life? To delve into these questions, we spoke with Hope Wechkin, medical director of EvergreenHealth home hospice, who authored an article describing a process of Minimal Comfort Feeding (MCF) for patients who have expressed an interest in not wanting to live with advanced dementia. MCF, which Hope implemented for one of her hospice patients, serves as a middle way between the discomfort to the patient and caregivers of completely withholding food and fluid, and the current practice of comfort feeding only in which food and fluid are routinely offered to patients even in the absence of a symptomatic benefit. We were also joined by Thaddeus Pope, JD and Dr. Joshua Briscoe, to discuss the topic of voluntarily stopping eating and drinking as a potential bridge to access medical aid in dying medications and their respective articles on the topic. We discussed what makes an illness "terminal", what goes into assessing capacity for an action as simple as requesting something to drink, and whether the TV show Severance illuminates any of these answers. -Theo Slomoff, UCSF Palliative Care Fellow 2024-25 (guest host) Articles referenced in this discussion: "Mr. Smith Has No Mealtimes": Minimal Comfort Feeding for Patients with Advanced Dementia by Hope Wechkin et al in JPSM Medical Aid in Dying to Avoid Late-Stage Dementia by Thaddeus Pope and Lisa Brodoff in JAGS Law not loopholes: Medical aid in dying for those with dementia also in JAGS by Joshua Briscoe and Eric Widera Past GeriPal Podcast Episodes on MAID: MAID podcasts https://geripal.org/what-is-going-on-with-maid-in-canada-bill-gardner-leonie-herx-sonu-gaind/ https://geripal.org/conscientous-provision-of-maid-and-abortion-robert-brody-lori-freedman-mara-buchbinder/ https://geripal.org/assisted-dying-podcast-with-lewis-cohen/ https://geripal.org/dilemmas-in-aid-in-dying-podcast-with/ Past GeriPal Podcast Episode about VSED: https://geripal.org/tim-quill-vsed/

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