A legal end-of-life process, Voluntary Stopping of Eating and Drinking, is gaining traction in part because of local authors sharing experiences and information.
Ed.: This article contains a reference to suicide.
When Kate Christie’s mother first voiced her wish to die through Voluntary Stopping Eating and Drinking in 2016, the Bellingham resident was skeptical of the end-of-life process — or that her mom would even go through with it.
Diagnosed with Alzheimer’s after several years of cognitive impairment following a broken back, Christie’s mother had vowed not to die like her own mother: slowly fading away in a memory care facility as a “stranger among strangers.”
But Christie’s mother wasn’t eligible for Washington State’s Death with Dignity Act — also known as Medical Aid in Dying — because conditions like dementia and Parkinson’s disease aren’t covered under the law.
Christie and her family spent subsequent years exploring the legal and practical processes and implications surrounding the stopping of eating and drinking process, also known as VSED, as her mother’s condition worsened. Her mother finally went through with VSED over the course of 10 days in February 2020, dying peacefully at her home at age 75.
Christie’s experience led her to write “The VSED Handbook,” published in 2022 as both a memoir and self-help guide for exploring and understanding this end-of-life process, including its legal, logistical and emotional aspects.
Literature about VSED is growing, as death doula Nancy Simmers published her own book, “VSED Support: What Friends and Family Need to Know,” last year. These locally-authored volumes join other books – both academic and narrative – about the process.
In addition to their involvement with and authoring of VSED literature, Simmers and Christie are forever linked by the death of Christie’s mother: Simmers was one of her death doulas.
Who gets to die?
In Washington, MAID is only available to terminally ill adults expected to live less than six months and who can self-administer the prescribed lethal medication, which is often mixed into juice.
To qualify, a patient must be deemed of sound mind and make two separate requests, a week apart, to two different medical professionals. Two more people must also serve as witnesses to the patient’s signing of a MAID request, declaring them competent and to be acting voluntarily.
For Alzheimer’s patients like Christie’s mother, cognitive decline comes years before the disease takes their lives, rendering the law incompatible for their condition.
Nationwide, 13 states and Washington D.C. have legalized some form of MAID, and 13 more are considering it. But that leaves roughly half the nation’s population unable to seek such relief when faced with advanced stages of a terminal illness.
“Think of how many millions of people don’t have access to Medical Aid in Dying,” Simmers said. “Many haven’t heard about VSED, or their care providers haven’t heard about the guidelines, let alone the advance directives.”
Simmers has received messages from people in parts of the country in which MAID doesn’t exist. The messages, she said, are often from people who’ve clearly thought things through, whether they’re terminally ill or so old that they don’t wish to keep going. They’re excited to discover VSED, Simmer said, because some feel their only other recourse is to buy a gun.
MAID is also legal across Canada in a more robust form, offering patients the option to either self-administer a lethal substance or have nurses and doctors do it for them. The neurological conditions not allowed in Washington qualify for MAID in Canada.
Controversially, a further amendment to Canada’s MAID law will allow mental disorders to qualify beginning in March 2027.
How to stop living
The VSED process is, in simplest terms, what it sounds like: a patient’s choice to stop all forms of sustenance, causing dehydration resulting in death.
But it also requires careful planning and outside support, from both a patient’s loved ones and from professional medical providers and caregivers. Both Christie’s and Simmers’ books chronicle the multistage physiological processes, generally broken down into three parts.
The first involves the stopping of eating and drinking, with few activity-based limitations. Patients often experience hunger, anxiety, confusion, nausea and dry mouth during this phase, which usually lasts one to three days. Medications like morphine and lorazepam may be prescribed during this time.
The second phase sees symptoms of dehydration increase over the next one to three days, with increased thirst, agitation and weakness often present. Delusions and loss of balance can also occur. A patient can still call off the VSED process successfully in this phase by ingesting fluids again. In addition to aforementioned medications, fentanyl patches can also be used for pain management.
In phase three, a patient’s body shuts down over the final one to three or more days. They eventually lose consciousness, and may fall into a coma. Pain medications continue to be provided as needed, and the patient eventually takes their last breath.
Simmers’ book provides ample advice and information for loved ones accompanying a patient on their VSED journey, including how they can help a patient’s journey emotionally and spiritually, as well as how they can support the caregivers and themselves throughout the process.
While the process results in a natural, ultimately peaceful passing, it’s not for the faint of heart.
“It’s arduous,” Simmers said. “It’s arduous for the person doing it, it’s arduous for the support system and loved ones who are watching their loved one slowly dehydrate.”
Simmers wrote her book in part as an update to Christie’s, she said, as several important updates had since taken place. The first was the publication of nationally recognized guidelines for VSED, comprised by a group of nationally known clinicians. The guidelines are especially significant, Simmers said, since many physicians have been hesitant to help families due to the lack of such guidelines.
Around the same time, a group of attorneys that include Bellingham’s Erin Glass composed the first-ever VSED-based advance directive. Simmers incorporates copies of both in her book.
Updates to MAID
In 2023, SB5179 was signed into law, helping expand the state’s Death with Dignity provisions for those who qualify for MAID.
The bill adds physician assistants and advanced practice registered nurses as medical providers a patient can consult to sign off on their use of MAID. Of the two providers used by a patient, however, must still be a physician.
The bill also reduced a 15-day waiting period for the patient’s MAID requests to seven days, in addition to prohibiting healthcare providers from stopping employees who participate in MAID cases outside the scope of their own employment.
Neither Simmers nor Christie, however, expressed much hope Washington’s MAID law will see further expansion to include conditions they’ve seen patients choose VSED for.
Getting the word out
Both authors faced an unforeseen challenge in distributing their VSED knowledge this January, when each received emails from Amazon Kindle Direct Publishing. The messages explained their books were in violation of the company’s content guidelines, and were now prohibited from being sold through Amazon.
Christie’s book had sold well through Amazon for nearly four years before being pulled. After unsuccessfully appealing the decision through phone and email support, Christie republished through a different distributer and assigned the book a new ISBN number to get it back on the site, but it was removed again this month.
For Simmers, who published her books just months ago, the prohibition was particularly discouraging, as she’d used much of her personal savings to write, edit and format her book, which Amazon had agreed to publish in the first place.
Simmers said she sees Amazon’s sudden policy shift as an attempt to absolve itself of potential liability by removing books associated with suicide. Emails shared with Salish Current show Christie was told only that her book violated Amazon’s guidelines, with no further explanation given.
Those guidelines explain the exclusion of content that promotes sexual abuse, rape or pedophilia, advocates for terrorism, is deemed hateful, along with “other material we deem inappropriate.”
Christie said her paperback and eBook versions continue to be available at Barnes & Noble’s website, Bookshop.org and locally through Village Books. Simmers, meanwhile, is republishing her book with a different company.
New copies should be available in April, she said.
The blessing of choice
Christie and her father struggled coming to terms with her mother’s choice to die by VSED before ultimately embracing it.
At one point during her mom’s passing, Christie sat on a boulder beneath a super moon on the shore of Lake Whatcom, and realized that her mother was taking years of slow suffering and compressing it into 10 days.
“That was a gift to herself, and a gift to the rest of us as well,” Christie said. “I know plenty of people whose family members have gone into (memory) care. And it’s devastating, and it’s retraumatizing every day and every week and every month. So I think my mom was really wise in saving the rest of us and herself from that.”
Another family member did not come around to the idea, calling police and getting Adult Protective Services involved. The move led to investigations by both protective services and PeaceHealth, both of which eventually concluded no laws or conduct were being broken by family members or her mother’s physician, who had prescribed palliative care medications for the VSED process.
“It actually relieved a lot of my nervousness around the gray legal area of VSED,” Christie said, “because it’s not explicitly authorized by statute, but it’s also not disauthorized by statute. It’s generally thought to be ethically and medically sound, and…granted by a Supreme Court decision that says people have the right to discontinue medical treatment and fluids. It’s generally believed to be legal.”
Christie’s father also chose VSED to end his life at age 80 in 2024, after suffering with Lewy body dementia initially misdiagnosed as Parkinson’s disease.
Writing a book that can help others with the hardest parts of what she and her parents encountered, she said, is a great way to honor their memory.
“I feel really fortunate to be the daughter of two people who fought so deeply about their end-of-life choices: what they were willing to go through, what they weren’t willing to go through. And they put so much care and attention into those decisions.
“Death is always going to be hard,” she continued. “But…when it is done with proper planning and proper palliative care, VSED can be peaceful and very suffering-free. And I think everyone should have the choice.”
By Matt Benoit
Also read in Salish Current:
• “Hospice of San Juan to expand caregiver respite program,” Sept. 24, 2025
• “How local chaplains attend to patient care,” Sept. 18, 2025
• “Local hospice stands out in shift away from nonprofits,” June 25, 2025
• “Proposed changes to state’s Death with Dignity Act spark debate,” Feb. 16, 2023
• “Possible hospice sale sparks concerns re changes in end-of-life care,” Nov. 13, 2020
• “Commentary: Coronavirus pandemic adds new twists to the ‘good death’,” June 4, 2020