Information for Health and Care Professionals
Welcome
You are very welcome here. We recognise that voluntarily stopping eating and drinking (VSED), a lawful choice, can raise legal, ethical, and professional questions and that many working in health and social care encounter uncertainty, inconsistency, or silence around this subject; often working in isolation.
We aim to provide an informational resource, not clinical or legal instruction. We want to support informed understanding of VSED within the current legal framework in England and Wales, acknowledge the limits within which health and social care professionals work, and reflect our experience.
Our objective is not to promote VSED. Rather, we seek to bring the subject into open and thoughtful discussion to address concerns, clarify misunderstandings and provide balanced background information.
Important note: This information should be read alongside the BMA guidance on Caring for patients who elect to voluntarily stop eating and drinking to hasten death (VSED).
Introduction
The following is intended for health and care professionals who may come here looking for clarity, reassurance, and thoughtful context when questions about VSED arise in real conversations with their patients and those close to them, or simply out of general interest to learn more. This information is relevant to healthcare professionals when they are being approached by a person who
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is seeking information about VSED
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has made the decision to elect to VSED
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requests support and symptom management during VSED.
It is increasingly important for health and care professionals to understand VSED because more people are raising questions about it, either explicitly or indirectly. People may ask about stopping eating and drinking, express a wish not to continue intake of food and fluids to hasten death, or quietly refuse food and fluids as their illness progresses. As awareness grows, VSED is becoming a subject that health and care professionals will encounter more often in everyday practice.
Whilst the BMA has recently published guidance on caring for patients who choose VSED, we recognise that it has not yet been widely publicised and awareness remains far from universal. Not all doctors are BMA members and may therefore be unaware of it; moreover, the guidance is addressed specifically to doctors rather than the wider range of allied health and care professionals who may be involved in supporting someone undertaking VSED.
In 2022, Compassion in Dying published a policy report calling for national guidance for healthcare professionals on VSED, as no such documentation then existed. Compassion in Dying states they are pleased that the BMA has listened and recognised this need for clarity for clinicians by the publication of their guidance.
As part of their policy report, Compassion in Dying commissioned YouGov to conduct research into health and care professionals’ understanding of VSED in July 2022. The report states:
‘The survey of over 500 professionals revealed that 50% of the respondents did not have correct information about the legal status of VSED – this included 14% who thought it was illegal and 36% who did not know. 40% of respondents said they would not feel confident having a conversation with a patient about VSED. Worryingly, of the 54% who said they were confident discussing VSED with their patients, 12% believed that it was illegal and 24% said they didn’t know.
94% of the respondents said it would be helpful for health and care professionals to have guidance on the legal and clinical aspects of VSED and 92% thought that individuals and their loved ones would benefit from similar information.’
The information that follows may be relevant to you if you work in any of the roles listed below; the list is not exhaustive.
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GPs and primary care clinicians
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Palliative care and hospice doctors
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Community, district and registered nurses
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Hospital doctors (especially geriatrics, oncology, and neurology)
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Specialist nurses (palliative care, cancer, progressive neurological conditions, long-term conditions)
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Allied health professionals — particularly occupational therapists, physiotherapists, speech and language therapists, and dietitians
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Mental health professionals involved in capacity or distress (social workers, psychiatrists, psychologists)
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Social workers and safeguarding professionals
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Care home managers, care workers
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End of Life Doulas, Soul Midwives and End of Life Companions
We have added more detail on this page for some health and care roles and settings.
This website is a work in progress. If you notice anything that could be clearer, more helpful, or better laid out, we would really value your feedback.
To help you find what you’re looking for, here are links to the topics covered in this section:
Some Background
BMA (British Medical Association) Guidance
Stances of Professional Medical Bodies
Implications for Professionals
Care Organisations / Agencies and Paid Care Professionals
End of Life Doulas / Soul Midwives / End of Life Companions
Exploring Options and Considerations Around VSED
Other Key Legal Issues
Mental Capacity Act, An Advance Decision to Refuse Treatment and An Advance Statement
Implications of an Advance Decision to Refuse Treatment and an Advance Statement for VSED
Medical Certificate of Cause of Death
Navigating the Law, Ethics and a Conscientious Objection
How is VSED Different from Suicide?
How is VSED Different from Assisted Dying?
Conscientious Objection in Relation to VSED
What is VSED in Summary
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Voluntarily stopping eating and drinking (VSED) is when a mentally capable adult chooses to hasten their death by refusing all food and fluids.
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It is not usually experienced as painful; thus, the focus is on comfort, calm, and symptom relief.
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It is a conscious, intentional, and informed decision.
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It is lawful in the UK when chosen by an adult with mental capacity.
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It normally takes place at home (sometimes in a hospice if they support such a choice)
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Death usually occurs within one to two weeks, depending on health, hydration status and other factors.
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It can be a choice for people with an incurable illness, advanced frailty, or experiencing unbearable suffering from a chronic or progressive illness(es) who wish to avoid further decline.
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Medical support should be sought in advance and be accessible if needed to relieve symptoms and maintain comfort.
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Care support is required.
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It should involve Advance Planning for End of Life, including an Advance Decision to Refuse Treatment (ADRT) and an Advance Statement so that a person's refusals and wishes guide care if they later lose capacity.
Some Background
BMA Guidance – Caring for patients who elect to voluntarily stop eating and drinking to hasten death (VSED)
The guidance is very much welcomed. As the BMA itself explains, it was developed in response to requests from doctors and other organisations, reflecting a clear need for greater clarity about the law and ethics of VSED and for reassurance about how healthcare teams can lawfully support patients who have made this decision. In the BMA’s own words:
“It became clear that guidance is needed to provide clarification about the law and ethics of VSED [and] to provide doctors with the reassurance that they need to support patients who have made the decision to elect to VSED.”
However, as of September 2026, it is still early days. It remains to be seen how widely the guidance will become known across the healthcare professions and how consistently it will be translated into practice. Developing the confidence and competence needed to support a person who is considering, or has decided to exercise, their lawful choice to VSED will inevitably take time.
In the guidance, the BMA shares its understanding that:
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“Patients with capacity are entitled to make decisions about treatment refusals and about their nutrition and hydration, including to voluntarily stop eating and drinking in order to hasten their death;
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there is no requirement in the law that a patient needs to be ill or at the end of life to decide to voluntarily stop eating and drinking in order to hasten their death; and
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doctors face no criminal liability for providing advice about clinical care options, nor for agreeing in advance to provide symptom relief to patients who have elected to voluntarily stop eating and drinking to hasten their death, provided that it is appropriately managed. This is part of their duty of care as per General Medical Council (GMC) guidance.”
Lawfulness
A capacitous adult’s decision to VSED is lawful and should be respected.
We refer to the 2014 decision of the Supreme Court of the United Kingdom in the Nicklinson, Lamb and Martin case, which confirmed that:
“A person who is … mentally competent is entitled to refuse food and water, and to reject any invasive … treatment … even though without it he will die. … Medical practitioners must comply with his wishes.”
“The doctor is in no danger of incurring criminal liability merely because he agrees in advance to palliate the pain or discomfort involved should the need for it arise.”
This judgement underpins the understanding that VSED rests on an individual’s lawful right to refuse sustenance, while allowing professionals to continue providing appropriate symptom relief within their professional role.
The BMA guidance states:
“Doctors are not at risk of committing a crime (‘assisting or encouraging a suicide’) if they provide a patient with information and answer their questions when their patient has asked about the option to VSED or indicated their intention to elect to VSED. As part of their duty of care, doctors must always assess a patient who has started, or wants to elect, to VSED and, if appropriate and needed, palliate and treat the symptoms that arise. This is regardless of whether the doctor agrees with the patient’s choice, and regardless of whether the patient is terminally ill.”
“It is legal for doctors to agree in advance to provide symptom management for patients who have elected to VSED, should or when such symptoms arise. Doctors will not be penalised by the law for doing so.”
Stances of professional medical bodies
We have offered a description of where medical professional bodies appear to sit in relation to VSED and acknowledge that their positions may evolve. See here.
Who May Consider VSED
People choose VSED for different reasons. Broadly, there are two common situations:
Some people choose VSED because they are already suffering in ways that feel intolerable to them.
Others choose VSED to avoid what they fear may be a difficult or distressing final phase of life and to retain a sense of control before their condition worsens.
This may include, for example:
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Someone living with a progressive or terminal illness who has decision-making capacity
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Someone whose independence has been greatly reduced by frailty or long-term health problems, and who has decision-making capacity
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Someone with suspected or diagnosed early stages dementia, fearing a prolonged death from advanced dementia, who has the mental capacity to make the decision to VSED
VSED, as described above, applies to a deliberate end-of-life decision made by a person with mental capacity. It is distinct from reduced intake associated with eating disorders, including anorexia nervosa, or other psychiatric disorders, which require different clinical assessment and intervention.
VSED Process
The length of time it takes to die by VSED can vary significantly from person to person. It depends on factors such as the individual’s underlying health, for example, whether they are already frail or seriously ill, their physical reserves, and their hydration status. Where the person ceases the intake of food and fluids from the outset, the VSED process takes on average 7-21 days, most commonly 10-14 days. There is no predictable or guaranteed time frame.
Some people choose to gradually reduce food or fluid intake before beginning VSED. This can help with psychological adjustment and may also reduce bowel activity, discomfort, urgency, or incontinence in the early days. Some may stop eating but continue drinking for a period before starting VSED. Others may begin the VSED process by stopping both eating and drinking from the outset. These choices vary and are a matter of personal preference.
The changes seen during VSED are similar to those commonly observed in the final stage of life, characterised by reduced oral intake, progressive dehydration, increasing somnolence and a gradual decline in physiological function, with care focused on comfort and symptom management.
Contrary to what some people may imagine, VSED is not usually experienced as painful. Discomfort can occur, particularly a dry mouth, weakness, or restlessness, but these are commonly relieved with symptom management.
VSED typically involves three stages:
Early stage (1 to 3 days, but variable): In the initial stages of VSED, the person is alert and oriented, able to interact with their circle of support, can tolerate hunger pangs, and experiences increasing thirst and dryness of mouth. Common features include:
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awareness and ability to communicate largely intact
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hunger sensations that often diminish within the first few days and reduce as ketosis develops
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dry mouth rather than true thirst; oral discomfort is usually related to mucosal dryness rather than fluid deficit and responds to good mouth care
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increasing fatigue and reduced activity
Middle stage: With increasing dehydration, the person becomes weak, fatigued, lightheaded, and begins to sleep for longer periods of time. The patient may experience agitation, confusion and hallucinations. Delirium is not uncommon as dehydration progresses. Common features include:
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dry mouth
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weakness and somnolence increase
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reduced urine output
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intermittent confusion or delirium may occur
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periods of reduced consciousness alternate with wakefulness
Final stage: This stage is marked by loss of consciousness as organ systems fail and is similar to the late dying process in other settings. Common features include:
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the person is largely unconscious or minimally responsive
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verbal communication is absent
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pre-recognition responses may persist (response to voice, touch, or familiar presence)
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respiratory pattern changes (periodic breathing, shallow respirations)
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multi-organ failure progresses
Anticipatory medicines ("just in case" box/bag/pack) should be provided for symptom management and typically include medications for pain, breakthrough pain, nausea, constipation, delirium, sleeping, anxiety and sedation.
Implications for Professionals
We believe that every healthcare professional has a responsibility to understand VSED sufficiently to respond to a person seeking support in an educated and considered way, grounded in evidence-based information and with reference to professional guidance. Unfortunately, our experience is that this is not always the case: responses may on occasion be shaped by personal views, misinformation and misunderstanding or an initially dismissive stance towards the person’s choice. We therefore urge healthcare professionals to inform and educate themselves about VSED and to approach each person with an open mind, professional curiosity and a willingness to listen.
GPs
Our experience of GP responses to a person wanting to discuss VSED as a choice has been mixed. Some GPs already have an understanding of VSED and respond with empathy, support and a person-centred approach. At other times, we have encountered reluctance or refusal to engage, including instances where concerns were expressed about professional or regulatory risk. In some cases, individuals have been referred to a mental health team despite no indication of an underlying psychiatric disorder. We have also often encountered GPs who have little prior experience of VSED but are open to learning, seeking insight, and engaging constructively when space is created for informed discussion.
When a capacitous adult decides to VSED, this represents a lawful refusal of food and fluids. GP involvement is not about initiating or promoting VSED; it is about continuing to support a patient within the bounds of professional duty.
Supporting a patient to VSED is consistent with professional expectations set out by the General Medical Council, including respect for patient decisions and provision of appropriate end-of-life care. It also aligns with the British Medical Association’s emphasis on patient-centred, proportionate care. Involvement means:
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respecting autonomy
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respecting the person’s right to refuse treatment
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proactive symptom control
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timely anticipatory prescribing
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referrals to palliative care or specialist services where appropriate
The BMA guidance states:
“... doctors have a professional duty to provide palliative care and symptom relief to their patient. The doctor’s role is not to consider whether the patient’s decision is rational, reasonable, or sensible. It is not for doctors to decide whether the patient should be permitted to end their life in this way.”
Considerations for offering support
The clinician should check that the:
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patient has the capacity to make the decision
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patient’s decision is not a symptom of a mental disorder
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patient’s decision is free from coercion
Considerations when thinking of refusing support
While each of the responses below may arise in complex situations, they are not sufficient grounds for refusing clinical support where a patient has capacity and is requesting engagement.
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disagreement with the person’s decision
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experiencing the situation as uncomfortable or unfamiliar
Where a capacitous adult chooses to refuse food and fluids, their decision should be recognised as a lawful refusal, and they may reasonably expect appropriate care and support in response. If a clinician refuses, they should:
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provide a clear explanation of the basis for any refusal to support the person. This should ordinarily be based on evidence that the person lacks the relevant mental capacity, supported by a decision-specific mental capacity assessment; detection of coercion; or a diagnosed mental disorder that materially affects the person’s decision-making identified through an appropriate mental health assessment.
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document the reason for the decision and make this available to the person
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ensure the patient is not abandoned
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make arrangements for alternative support and care
GP Practice Policy
We recognise the considerable time pressures on GPs and believe that having an agreed policy would save time and mental energy by reducing the need to work each case out from first principles.
A policy supports clarity, consistency, and confidence when responding to patient enquiries. It will help clinicians understand the lawful right of a capacitous adult to refuse food and fluids and set out how this sits within existing legal and ethical frameworks.
It can clarify appropriate clinical responsibilities, including:
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assessment and review of mental capacity
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exploration of coercion or untreated distress
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how anticipatory care and a care plan will be developed
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symptom management
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documentation
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referral to palliative service
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clear arrangements for out-of-hours support
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completion of ReSPECT form, Treatment Escalation Plan and other Emergency Care and Treatment Plans
Without an agreed approach, responses can vary between clinicians, leading to confusion and distress for patients and families and potentially unnecessary escalation to safeguarding or mental health pathways.
A practice policy supports person-centred care, promotes safe and ethical decision-making and demonstrates that the GP Practice has taken a considered, lawful, and compassionate approach.
Hospices
Our experience within the hospice movement suggests that there is limited experience of supporting a person who has chosen to die by VSED and that such requests are not frequently made. We cannot be sure this is the case, though, as the perception may be influenced by issues of confidentiality and by hospices not wishing to be seen as promoting VSED. We are, however, aware of some individuals who have been supported by a hospice through this process.
Overall, our experience is that in the UK, hospices do not generally have a stated position on VSED nor would they raise it as an end-of-life choice if it had not been raised by the individual in the first instance. Hospice involvement in VSED varies, and in our work as Talk VSED, we have found some hospices are willing to support comfort and symptom relief once a person has made a clear, capacitous decision, while others may feel unable to be involved because of local policy, commissioning, or lack of national guidance.
Publicly known examples of hospice support in the UK exist for Wendy Mitchell and Emma Bray. See Resources.
The following outlines our shared understanding of what good practice could include within a hospice setting.
When a hospice is approached about VSED, obviously, the starting point is to listen carefully and without judgement. A person with mental capacity has the right to refuse food and fluids, and this is lawful.
The hospice’s role, where appropriate, is to consider whether it can offer comfort-focused palliative care rather than to influence the decision itself. Support does not equal recommendation; it reflects respect for a person’s choice and a commitment to compassionate care.
Each request should be considered on a case-by-case basis, considering referral criteria, service capacity, and governance arrangements. Some hospices will be able to offer inpatient or hospice at home involvement.
Where a hospice cannot be involved, they should explain this clearly and compassionately, avoid language that suggests illegality or wrongdoing and help ensure that care continues through other services.
When a hospice is approached about VSED, there may be times when the situation feels complex, uncertain, or challenging for staff. In these circumstances, it can be appropriate to refer the case to the hospice’s ethics committee or ethics forum.
At Talk VSED, we believe it is good practice for all hospices to have a policy on VSED because it provides clarity and consistency to ensure enquiries are handled lawfully, compassionately, and without delay. A clear policy supports good governance, helps prevent inadvertent abandonment of patients and families, and ensures decisions are transparent and aligned with the hospice’s values rather than dependent on individual views.
If a person is to be supported in relation to VSED, there should be a process of checking out staff views in advance before the situation becomes live. Where a member of hospice staff has ethical objections to supporting VSED, the first response should be calm and respectful, acknowledging their position without judgement. The reasons for refusal should be gently explored to understand whether this relates to ethical beliefs, uncertainty, lack of confidence, or a need for additional support. Any refusal should be documented, and responsibility for the person’s care should be formally handed over to another appropriate individual or team to ensure continuity. Staff should not be pressured to act against their conscience; however, the hospice must ensure that refusal does not result in abandonment.
Care Organisations / Agencies and Paid Care Professionals
Our experience is that care organisations and agencies providing paid carers can play a key role in supporting a person who has chosen VSED, particularly in providing continuity, comfort, and day-to-day care. Care can be delivered through a shared approach, with paid carers working alongside family members and the wider support network to provide practical support and respite.
We believe a care organisation can play an important part in caring for a person who has decided to VSED. Their role is to provide continuity, dignity, and compassionate care, not to judge end-of-life decisions. VSED is a lawful refusal of food and fluids, and supporting someone does not mean initiating or encouraging that choice; it means continuing to meet personal care and comfort needs.
However, when requests related to VSED arise, they can be met with understandable nervousness by the agency/organisation. This usually reflects uncertainty about role boundaries, legal responsibilities, staff confidence, or organisational policy, rather than a lack of willingness to care. This uncertainty can be addressed through clear policies.
A VSED policy would explain purpose and scope, set out core principles such as respect for a capacitous person’s right to refuse food and fluids, the discussions required with other clinicians for guidance and support, non-abandonment, and a focus on comfort-centred care. It would clearly define staff roles and boundaries, including that staff do not initiate or promote the choice to VSED. The policy should outline how capacity and consent are understood and recorded, how staff views and ethical concerns are checked in advance and managed and how handovers are arranged to ensure continuity of care. It should also set out escalation routes for senior or ethics advice.
It may be that a care agency has been supporting a person for some time, and the person later decides to pursue VSED. Where an agency feels unable to continue involvement, it should explain this clearly and respectfully, document the reasons, and help ensure continuity of care by arranging handover, shared care, or referral to other services. Care should not be withdrawn abruptly, and staff should not imply that the person’s decision is illegal or wrong.
End of Life Doulas / Soul Midwives/ End of Life Companions
End of Life Doulas, Soul Midwives and End of Life Companions may sometimes be alongside a person who has chosen VSED, but their role is non-medical and non-directive. Their focus is on advocacy, continuity, coordination, presence, emotional support, practical comfort and holding space for the person and those around them. To work safely and responsibly, they need to be well informed about the legal framework around VSED, as well as familiar with the process and its potential impacts.
Exploring Options and Considerations Around VSED
See also this section relating to considerations for offering or refusing support.
A person’s wish to pursue VSED often emerges through open, careful conversations with those in their close network. Where such conversations have already taken place, the person is likely to have thoughtfully explored the questions below and understood the implications of their decision. This enables their values, concerns, and motivations to be articulated clearly to professionals. Careful, attentive listening is therefore essential. In some cases, a person may be approaching a professional in order to explore VSED for the first time; in these situations, the same depth of exploration, active and reflective listening is required. The BMA guidance provides detailed advice under the heading ‘Conversations with patients about VSED’. In summary, and in our experience, conversations should include:
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Why is continued living intolerable?
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What has the person anticipated may happen in the future to choose this way to die?
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What research and information has been explored?
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How could circumstances be different to result in a change of mind?
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Who has the person spoken to in their close network, and do they have their support?
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Timing - does the person wish to
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Commence VSED immediately or as soon as practicable?
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Commence VSED at a specified future date?
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Have it recorded on their medical records as a future option contingent on defined circumstances?
Preparation for VSED
Again, the BMA provides guidance on what the conversation can cover and in summary, we have found from experience that this can include:
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Has the mental capacity to make the choice to VSED been established? (see more below)
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Are there attorney(s) for Health and Welfare in a Lasting Power of Attorney who support the decision?
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Is there an Advance Decision to Refuse Treatment (ADRT) and an Advance Statement in place?
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Has the support of the GP / Hospice at home been sought? If not, when?
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Availability of anticipatory medications ("just in case" box/bag/pack)?
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Is there a video with the person expressing their wishes?
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Who is the lead person(s) to be involved in the person’s care?
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Are these people supportive of the decision?
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Who is the lead person(s) who will advocate for the person with health and social care professionals? This may be an appointed spokesperson and/or an attorney appointed in a Lasting Power of Attorney for Health and Welfare.
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When will VSED start?
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Medications the person may want to continue taking or stop taking?
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If certain medications are to be continued for comfort, it is helpful to discuss how they might be prescribed so they can be taken without the need for fluids
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What care support is available?.
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Care and comfort items to be obtained?
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Has a care plan been established with the relevant health care professional?
Other key legal issues
Mental Capacity Act, An Advance Decision to Refuse Treatment and An Advance Statement
The Mental Capacity Act 2005 (MCA) enshrines the Advance Decision to Refuse Treatment (ADRT) by providing a statutory, legal framework that makes valid and applicable refusals of medical treatment legally binding in England and Wales. It moves beyond common law, ensuring that if a person over 18 with capacity makes an ADRT, healthcare professionals must follow it, even if it results in the person's death.
Under the Mental Capacity Act, a person who has mental capacity is entitled to make their own decisions about care and treatment, even if those decisions may hasten death.
An Advance Decision to Refuse Treatment (ADRT) is a legal document in England and Wales where a person aged 18 or over, while still having the mental capacity, specifies treatments they refuse to have in the future if they lose the ability to make or communicate decisions. Also known as a "living will," it is legally binding if valid and applicable, telling doctors to withhold specific treatments like artificial feeding, ventilators, or CPR in certain future situations, ensuring their wishes are respected.
An Advance Statement can accompany an Advance Decision to Refuse Treatment (ADRT); together, they help ensure that a person’s wishes are understood and respected if they lose mental capacity. The Advance Statement provides the context for the refusals by setting out the person’s values, priorities, and what matters most to them. While it is not legally binding, it must be taken into account when decisions are made in the person’s best interests.
Implications of an Advance Decision to Refuse Treatment and an Advance Statement for VSED
An ADRT cannot be used to refuse basic care. In the Mental Capacity Act Code of Practice, it says:
"An advance decision cannot refuse actions that are needed to keep a person comfortable (sometimes called basic or essential care). Examples include warmth, shelter, actions to keep a person clean and the offer of food and water by mouth. Section 5 of the Act allows healthcare professionals to carry out these actions in the best interests of a person who lacks capacity to consent (see chapter 6). An advanced decision can refuse artificial nutrition and hydration."
We believe here that the word offer is key in the above quotation from the MCA Code of Practice. If a person without mental capacity is actively refusing, resisting, or becoming distressed by spoon-feeding, continuing to feed them may amount to unlawful restraint. Lack of capacity does not give blanket permission to override a person’s expressed resistance, and persistent refusal would be a significant factor indicating that spoon-feeding and oral hydration via a cup may not be in their best interests.
We were heartened to see the reference in the BMA guidance, which says:
“Patients should also be informed that they can create an ADRT (or Advance Directive in Scotland) if they wish to do so and this could include their refusal of CANH [clinically assisted nutrition and hydration] (which would be legally binding in England, Wales, and Northern Ireland or potentially legally binding in Scotland). Additionally, they may wish to include their decision to elect to VSED with instructions to refer to any care plan regarding VSED, including comfort measures they would prefer (see section 2.7). Although this may not be legally binding, it would be a strong indication of the patient’s wishes and should be taken into account. It might also be helpful to document whether or not the patient wishes to be taken to hospital.”
Talk VSED is lobbying for greater clarity in relation to the ambiguity that exists around the classification of basic care and spoon-feeding in the context of VSED. In the meantime, Talk VSED works on the basis that where a person has made an Advance Statement (to accompany their ADRT) expressing their wish to refuse oral feeding and hydration, this should be explicitly referred to and respected when best-interests decisions are made.
Establishing Mental Capacity
The BMA guidance clearly states that when a person has made the decision to choose VSED, “The doctor’s initial responsibility is to assess the patient…” and that “there is a presumption of capacity ‘unless it is established that they lack capacity‘”.
The assessment includes determining whether the person has capacity, but also includes whether the decision is not a symptom of a mental disorder, and whether it is free from coercion. The guidance states that a mental capacity assessment will usually be required for a decision as significant as VSED.
Assessing capacity for VSED is typically conducted by qualified health and care professionals or an independent, expert mental capacity assessor. In the past, we have found that in practice some GPs will undertake a capacity assessment; some GPs agree to perform these assessments privately at a fee, others may feel the risks of doing so are too high or that the time needed to perform an adequate assessment is not available to them. In light of the BMA guidance, we hope that GPs will feel able and appropriately supported to carry out the necessary mental capacity assessments when a person is considering or wishes to undertake VSED.
We would like to bust some myths:
Myth: A mental capacity assessment for VSED must be done by a psychiatrist.
Fact: Capacity assessment is not a specialist task. Any appropriately skilled clinician, including a GP or other health and care professionals, can assess capacity under the Mental Capacity Act. Psychiatry input is only required where there is evidence of a mental disorder affecting decision-making.
Myth: If the GP disagrees with the decision, the patient must lack capacity / A patient only has mental capacity if a GP agrees with their decision.
Fact: Capacity is about the ability to understand, retain, weigh, and communicate information — not whether the decision is wise, comfortable, or professionally agreed with.
Myth: VSED automatically raises safeguarding or suicide concerns.
Fact: A capacitous adult’s refusal of food and fluids is a lawful exercise of autonomy. A decision to VSED does not by itself raise a safeguarding concern. Concerns such as coercion, abuse or a mental disorder should be considered only if there is a reason to suspect them.
Distinct Legal Frameworks: The Mental Capacity Act and the Mental Health Act
The Mental Health Act (MHA) is not generally relevant to VSED because VSED is understood in law as a refusal of food and fluids, not as a manifestation of mental disorder requiring compulsory treatment. The MHA applies where a person has a mental disorder of a nature or degree that justifies detention and treatment for that mental disorder and where the statutory criteria are met.
In contrast, VSED typically arises in the context of end-of-life decision-making and is within the Mental Capacity Act (MCA) framework: if a person has capacity, their refusal must be respected; if they lack capacity, decisions must be made in their best interests, taking into account any Advance Decision to Refuse Treatment (ADRT) and/or Advance Statement. This is why discussions about VSED properly sit within capacity and consent and not mental health detention powers.
The BMA guidance states:
“The fact that the patient has decided to elect to VSED is not, in and of itself, evidence of a mental disorder, or a cause for referral for a mental health assessment. Nor does the fact that a patient has a mental disorder provide evidence that they lack capacity to make a decision about VSED. Low mood (in response to the patient’s medical condition or circumstances) is also not an indication of a mental disorder.”
Safeguarding
Safeguarding becomes relevant where there are concerns that the person’s choice is not truly voluntary, not properly understood, or not being responded to safely. For example, VSED raises safeguarding concerns if there is coercion, pressure, or undue influence from others; if a person’s decision is shaped by neglect, poor symptom control, loneliness, or fear that has not been addressed. However, where a person has clearly and lawfully chosen to refuse food and fluids, the act of not feeding a person in response to that refusal is not, in itself, a safeguarding concern.
Medical Certificate of Cause of Death
The BMA guidance states:
“Doctors in charge of their patient’s care must ensure that the death is properly certified and reported, following established procedures. In England and Wales, where death has been caused or hastened by VSED, it should be reported to the Coroner. The Coroner will then assess whether an investigation is required.”
Navigating the Law, Ethics and a Conscientious Objection
Legal Concerns
We recognise that some healthcare professionals may worry that supporting a patient who has chosen to VSED could be interpreted as unlawfully assisting suicide or committing a criminal offence. However, misunderstandings about the law and an overly cautious interpretation of legal risk can lead to patients who have chosen VSED being left without appropriate symptom management and comfort care. This can result in avoidable distress at the end of life.
The law does not specify that a patient needs to be at the end of life to choose to VSED.
How is VSED Different from Suicide?
There are individual opinions and ethical perspectives on how VSED should be understood. Exploring all of these is beyond the scope of this section. There is no detailed statutory definition of suicide in UK law. Under the Suicide Act 1961, suicide itself is not a crime.
At Talk VSED, we recognise that some people view VSED as a form of suicide because it involves an intention to hasten death. However, we believe VSED is distinct in several important respects.
VSED is lawful because it is grounded in a person’s established legal right to refuse food and fluid. So VSED sits within the broader framework of autonomy and bodily integrity.
VSED is a passive process as it does not involve the administration of a lethal substance or external intervention. Death occurs as a consequence of declining intake, often in the context of advanced illness, frailty, or cumulative suffering.
VSED can be described as a process of “letting go” rather than a sudden or violent act. Clinically and experientially, it is a gentle and natural dying process when appropriately supported.
We therefore frame VSED as standing in its own category. It does not fit neatly within existing definitions. Regardless of whether an individual personally considers VSED to be suicide or not, it is generally understood to be a considered, intentional decision made by a person with mental capacity and who is not experiencing mental illness that impairs judgement.
VSED is a purposeful act taken with awareness and presence. It is a thoughtful decision to exercise control by refusing food and fluid at the end of life. As such, it is recognised as part of the wider spectrum of lawful end-of-life choices in the UK.
How is VSED Different from Assisted Dying?
VSED is sometimes mistakenly classified as assisted dying. However, it is not the same: VSED involves a person exercising their right to refuse food and fluids, whereas assisted dying involves another person actively helping to cause death.
The intention of professionals in this context is not to cause death, but to respect the autonomy of a competent adult who has chosen to refuse food and fluids. The decision belongs to the person themselves, and professionals are not responsible for that choice or death; their role is to respect the refusal and provide appropriate care within the law.
VSED, with the right safeguards, is a legal option for individuals, yet there is currently no national regulatory guidance or legal precedent specifically about the role health care professionals can play in supporting their patients who are contemplating VSED.
There is guidance from the GMC entitled “When a patient seeks advice or information about assistance to die“
Respecting a capacitous refusal to VSED and providing symptom control, where the intention is comfort and good clinical care, is not Assisted Dying. Clear documentation of capacity, informed discussion and ongoing review are key.
A clinician, therefore, plays an important part in assessing the patient, checking that safeguards are in place, supporting them and providing high-quality clinical care, including prescribing appropriate medication to alleviate pain and distressing symptoms.
Clinicians caring for patients expressing a desire to consider VSED, who are uncertain about how a particular action might be viewed, may wish to seek advice from their defence organisation and professional association. We suggest that when making the approach, instead of asking a general question about VSED, it may be more constructive to explain the particular circumstances and the practical steps already taken and those being considered, in supporting the person.
Conscientious Objection in Relation to VSED
This refers to a professional not wanting to be directly involved in aspects of care related to a patient’s choice to refuse food and fluids, based on personal ethical or moral beliefs. Health professionals should ensure that their personal views do not influence the way they discuss the patient's wishes. Exercising a conscientious objection does not alter the lawful nature of a capacitous patient’s decision, does not imply that VSED is illegal, and does not remove professional responsibilities. Where a clinician objects, they must communicate this respectfully, avoid delay or distress, and ensure appropriate handover so that continuity of comfort-focused and palliative care is maintained. In the case of a handover/transfer, all appropriate support and care and support should continue to be provided until appropriate arrangements have been put in place, as is supported by GMC and BMA guidance.
The BMA guidance states:
“Doctors exercising a conscientious objection must follow professional guidance and ensure that there is someone else available to take over the detailed assessments and the patient’s care without delay or detriment to the patient. This means that, with the patient’s consent, doctors must pass on their assessment and care to another doctor who is willing to provide that support. Doctors should ensure that their personal views do not influence the way in which clinical information is presented or affect their attitude towards those - including the patient, family members, and other healthcare professionals - who do not share their views. All appropriate care and support must continue to be provided until arrangements have been put in place for the patient’s care to be transferred. This is supported by GMC and BMA guidance.”
Support for Professionals
We appreciate that supporting someone undertaking VSED may be psychologically or emotionally challenging for health and care professionals, particularly where the person is younger or does not have a terminal or progressive physical illness. However, this does not alter the person’s legal rights or the clinician’s professional responsibilities. We encourage professionals to seek appropriate professional or collegial support and hope that, as knowledge and experience of VSED grow across professional networks, experiences can be shared and mutual support more readily offered.
Resources
BMA guidance: Caring for patients who elect to voluntarily stop eating and drinking to hasten death (VSED)
Compassion in Dying Report on VSED
Compassion in Dying is a UK charity whose work is focused on supporting people to understand and exercise their lawful rights at the end of life, particularly through advance care planning. The report explores VSED as a lawful issue arising from a capacitous adult’s right to refuse food and fluids.
https://compassionindying.org.uk/resource/voluntarily-stopping-eating-and-drinking-vsed/
Also see their webpage 'Why we’ve created clear, accessible information about voluntary stopping eating and drinking (VSED)'.
https://compassionindying.org.uk/blog-post/clear-accessible-information-vsed/
The New England Journal of Medicine
Nurses' Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death
According to the nurses' reports, most deaths from voluntary refusal of food and fluids were peaceful, with little suffering, although 8 percent of patients were thought to have had a relatively poor quality of death.
https://www.nejm.org/doi/full/10.1056/NEJMsa035086
KNMG – Guide: Caring for people who stop eating and drinking to hasten the end of life
The Royal Dutch Medical Association (KNMG) is the national professional body representing doctors in the Netherlands. This KNMG guideline provides practical and ethical guidance for clinicians caring for adults who choose to VSED to hasten death. It includes useful information on care planning, symptom management, and continuity of care. The guidance distinguishes VSED from assisted dying and positions clinical support within good palliative practice.
https://www.thaddeuspope.com/images/KNMG_-_VSED_Guidelines_2024_English_.pdf
Wendy Mitchell’s use of VSED is often referenced because it brings together dementia, mental capacity, advance planning, and end-of-life choice. Wendy is a well-known British author, campaigner, and former NHS professional who lived with young-onset dementia and became a powerful public voice for people affected by dementia.
https://whichmeamitoday.wordpress.com/2024/02/22/my-final-hug-in-a-mug/
Emma Bray’s VSED case is used to show that VSED can be a lawful, considered end-of-life choice, while also underlining the urgent need for clearer guidance, better education, and shared understanding so that people are supported with confidence, dignity, and compassion when such decisions arise.
https://www.manchestereveningnews.co.uk/news/real-life/brave-mum-who-plans-end-31765052