A review analyzing current practices used in assisted dying suggests methods may inadvertently or unintentionally result in “inhumane” death. Publishing their work in the journal Anaesthesia, a team of researchers argue for more concise ways to measure when a person is unconscious before administering fatal doses of certain drugs in order to prevent unintended consequences.
“A common humane aim [of assisted dying] is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress,” write the authors. “However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10 percent), prolongation of death (up to 7 days), and re-awakening from coma (up to 4 percent),” which raises the concern that some deaths might unintentionally be inhumane.
Ethical questions aside, the analysis “dispassionately examines” whether current practices of assisted dying effectively achieve the level of guaranteed unconsciousness needed to ensure death is free from pain and distress. To do so, they compared US capital punishment practices with two forms of legally assisted death used in the Netherlands.
Generally speaking, the same methods used in US capital punishment cases are the same as those in assisted deaths. Both are meant to be “humane” and without unnecessary distress. A high-dose intravenous drug first induces unconsciousness, followed by a long-acting neuromuscular blocking drug that causes respiratory paralysis and stops muscle spasms, before a third drug, potassium chloride, is given to induce rapid fatal ventricular fibrillation.
Of the benefits associated with assisted death, there are some horror stories. There have been reports of prisoners waking up in distress during the final moments of their execution. In other instances, a patient may experience accidental awareness during general anesthesia, waking up but being paralyzed to the point of death. For those who opt to swallow oral drugs, about two-thirds of cases will fall asleep within five minutes, followed by death within 90 minutes. Others, however, may have difficulty swallowing (9 percent), vomiting afterward (10 percent), and waking up from a coma (2 percent).
So, what constitutes an “optimum” way of inducing unconsciousness? That depends on who you ask. In some US states and European countries where voluntary assisted dying is legal, a common method is to self-administer barbiturate ingestion with death resulting slowly from asphyxia. In the Netherlands, where more than half of all deaths now involve an end-of-life decision, physicians often either administer injections of anesthetic and neuromuscular blockages or conduct hypoxic methods that involve rebreathing helium.
“Any decision by society to sanction assisted dying should go hand in hand with defining the method or methods to be used,” said senior author Jaideep Pandit to journalist Ingrid Torjesen in an opinion piece published in BMJ. “It should also define by what means unconsciousness should be induced to facilitate a humane death, and which assistants or practitioners should be involved.”
Regardless of the method, the authors conclude that ensuring better unconsciousness to the point of death requires three things: continuous drug infusions at very high concentrations, scanning of the brain, and clinical confirmation by lack of response to external stimuli. Only after unconsciousness is achieved should other methods of death be employed, depending on which route a physician or patient decides to take.