I read with great interest the article by Judith K. Schwarz, "Stopping Eating and Drinking" (September 2009), which gave an overview of clinical practices associated with hastening death. It was eye-opening to see that hospices now serve not only patients with a terminal diagnosis, but also those with chronic illnesses (such as cardiovascular and respiratory diseases, diabetes, and dementia) for whom a "good death" is often an unrealized goal.

The article mentions that sometimes patients forget they've made the decision to stop oral intake, a consequence of early dementia or an electrolyte imbalance that can cause confusion. Caretakers should gently remind the patient of her or his previously made decision to hasten dying in this manner, according to the author. Yet this reminder is conveyed when the patient is in a weakened, dehydrated, and possibly sedated state.

I suspect that more research needs to be done about how to handle this crucial decision, particularly the point at which the patient may realize and question the serious consequences of a fast. She or he may have second thoughts, spurred on by hunger and thirst, and it may be necessary to have an objective third party present who can assist in facilitating the patient's wishes.

Michael J. Sclafani, MS, MEd, RN

Whitehouse Station, NJ