VSED bridge to MAID: Spotlighting better end-of-life options

We thank Jaggard and Sams for their thoughtful comments on our article and on increasing patient access to person-centered palliative and hospice care.^{1, 2} Here, we respond to their critiques of Medical Aid in Dying (MAID) and we expand our analysis of when voluntarily stopping eating and drinking (VSED) could be used as a bridge to MAID.

In our article, we explained that patients with dementia are not eligible for MAID based solely on their dementia diagnosis.² Because of their dementia, these patients would no longer have decision-making capacity by the time they were determined to have a terminal illness, defined as six months from death. Yet, because many of these patients want access to MAID, we defended a path to eligibility by bridging VSED to speed the diagnosis to a less-than-six-month terminal condition.² Jaggard and Sams oppose not only this combination but also other expansions of MAID and even MAID itself. We now address all three of their opposition points.

Jaggard and Sams are correct that access to MAID has been expanding. MAID states have: (1) shortened or permitted waiver of waiting periods, (2) authorized APRNs and PAs as prescribers, and (3) eliminated residency requirements.^{3, 4} Jaggard and Sams describe these advances as “harmful expansions.”² But they cite no evidence, nor is any available, that any of these changes adversely impact patient safety. Instead, Jaggard and Sams commit the is/ought fallacy by abruptly moving from statements of fact to statements of value without explanation. The bare fact that MAID numbers are increasing cannot tell us whether those increases should be celebrated or avoided.

We celebrate expanded access to MAID because it promotes value-concordant care. Recent changes in most MAID states were carefully vetted through the state legislative process.³ They were enacted in response both to robust evidence of impediments and to demand by constituents for broader availability. For example, because many patients do not explore MAID until late in their illness trajectory, they cannot survive the original 15-day waiting period. That led six MAID states to shorten or waive the waiting period.^{3, 4}

The basis of Jaggard and Sams's opposition to expanded access is not patient safety but value-based opposition to MAID itself. They argue we “should not legalize this practice in the first place” and “doctors should not prescribe death.”² While we respect that minority position, we note that all MAID laws permit both individual clinicians and entities to opt out of participation.³ Most religiously affiliated facilities have declined to offer MAID.

Jaggard and Sams confuse matters when they state that “there are alternatives” to MAID and that patients “need” hospice. This implies a false either/or choice. In fact, almost all patients get both. Each state's Department of Health collects and annually reports data on MAID usage. Nearly 100 years of cumulative data show that over 90% of patients who get MAID are already in hospice.⁵ These patients hope that expert palliative care can alleviate their suffering, and it often does. One-third of patients never ingest the MAID medications they were prescribed.⁵

In our article, we showed how VSED could be used as a bridge to MAID for people with dementia who are terminally ill but who have longer than six months until death. VSED would be used to shorten the terminal diagnosis during the time when the patient still has decisional capacity.⁶ Indeed, because patients with dementia are otherwise unable to access MAID, some states have begun exploring making dementia a separate eligibility category.³

We then called for “guidelines and standards” that would extend the VSED bridge to other patients with “serious, irreversible, intolerable conditions.”² Jaggard and Sams argue that this bridge should be withdrawn. Instead, we now advocate for further extension of the VSED bridge.⁷ It should also be extended to patients who are seriously ill with a terminal diagnosis of two years or less and who would be encouraged by clinicians to document end-of-life decisions with a POLST (Figure 1). Guidelines widely recommend POLST for patients with “advanced chronic illness whose deaths within the next year or two would not surprise those persons' physicians.”^{8, 9} These same patients should be given the option of VSED to MAID with clinical support.

We look forward to future discussions with providers and patients on developing clinical guidelines and standards for using VSED as a bridge to MAID and hope to expand on what we learn in future articles.

All authors contributed to conceptualization, research, design, and drafting.

The authors declare no conflicts of interest.

No sponsor.

The authors received no funding in the creation of this manuscript.