Challenges and Issues Associated With Death Certificates After Voluntary Stopping of Eating and Drinking.

In recent years, health care providers and the general public in the United States have gained a greater awareness of Voluntary Stopping of Eating and Drinking (VSED) as a last resort option to escape from unbearable suffering, thanks to a growing number of publications, books, and documentaries. However, the challenges and issues that can arise in completing a death certificate after VSED are not well described in literature. In this article, we first present an example case of VSED in which the death certificate was issued listing suicide as the manner of death by the medical examiner. Then, we describe the challenges and issues related to death certificates in VSED cases. Because there is no consensus on whether VSED is natural death or suicide, the death certificate may need to be referred to a medical examiner in many jurisdictions, potentially resulting in suicide being designated as the manner of death. Such designations can cause reticence in providers and institutions that might otherwise support patients who choose VSED but are concerned about the legal or reputational implications of enabling a "suicide" at their facility. A suicide designation may also contribute to moral distress in health care staff and impose emotional and practical burdens on the patient's surviving loved ones. In contrast, in some of the jurisdictions where Medical Aid-in-Dying (MAiD) has been legalized, there are laws that require the physician to list natural death as the manner of death without involving medical examiners. We suggest that there are 3 approaches to addressing challenges and issues associated with death certificates after VSED: (1) navigate the existing system with guidance developed by professional organizations, (2) make a legal exemption, and (3) change the death certification system. Debate involving a wide variety of experts is warranted.