March 24, 2005
Starvation is Not Painful, Experts Say
After suffering through cancer, the middle-age 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 her gradual decline, providing one of the most detailed clinical accounts of starvation and dehydration.
Instead of feeling pain, the patient experienced the characteristic 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 finally 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 slow and painful death from starvation has been a galvanizing force.
But medical experts say going without food and water in the last days and weeks of life is as natural as death itself. The body is equipped with its own resources to adjust to death, they say.
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."
Schiavo, who hasn't had any food or water since Friday, has been in a persistent vegetative state for 15 years that makes it impossible for her brain to recognize pain, doctors say.
"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 would be comfortable, 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."
Contrary to the visceral fears of humans, death by starvation 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 and suffering than those who had elected to die through physician-assisted suicide.
The average rating given by the nurses for the patients' quality of death was an 8 on a scale where 9 represented a "very good death" and 0 was a "very bad death."
Patients deprived of food and water will die of dehydration rather than starvation, unless they succumb to their underlying illness first.
Without fluids, the body loses its ability to maintain the proper balance of potassium, sodium, calcium and other electrolytes in the bloodstream and inside 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 tired and 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 stores of fat and muscle to get the carbohydrates and proteins it needs to make energy.
"If you mine too many proteins in the heart, it gets unstable," Sullivan said. 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 impact after a few days, Fine said.
They eventually descend into a coma and finally death. The entire process usually takes one to two weeks, although a patient who is otherwise healthy -- such as Schiavo -- could hold on much longer.
Throughout the process, the body 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, said Sullivan, a senior fellow at Duke's Center for the Study of Aging.
After 24 hours without any 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 back-up 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 a natural anesthetic.
The weakening brain releases a surge of feel-good hormones called endorphins.
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 administer morphine or other powerful painkillers.
Sullivan said doctors are likely to give some to Schiavo.