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Assisted dying methods can lead to “inhumane” deaths

BMJ 2019; 364 doi: (Published 21 February 2019) Cite this as: BMJ 2019;364:l797

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  1. Ingrid Torjesen
  1. London

Methods for assisting death in countries where the practice is legal do not reliably achieve unconsciousness at the time of death to ensure that the patient experiences no pain or distress, a review published in the journal Anaesthesia has found.1

An argument made in support of assisted dying is that it minimises patients’ pain and distress and allows them to die with dignity at a time and place of their choosing. This argument assumes that the methods used are always effective in their aim of producing unconsciousness and death quickly, but an international group of researchers reviewed the mechanisms used in countries where assisted death is legal and discovered that this is not always the case.

Heterogeneity in methods

Complications related to assisted dying methods were found to include difficulty in swallowing the prescribed dose (≤9%), a relatively high incidence of vomiting (≤10%), prolongation of death (by as much as seven days in ≤4%), and failure to induce coma, where patients re-awoke and even sat up (≤1.3%).

“This raises a concern that some deaths may be inhumane,” the researchers said. They had expected to find a single technique being used but said that “the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined.”

The method commonly used to induce unconsciousness in European countries where assisted dying is legal is self administration of barbiturates (usually orally but sometimes through a nasogastric tube), and death results slowly from asphyxia due to cardiorespiratory depression. Although patients usually lose consciousness within five minutes and cardiopulmonary collapse occurs within 90 minutes in two thirds of cases, in a third of patients death can take as long as 30 hours.

Some countries, such as the Netherlands, allow a doctor (often an anaesthetist) to administer drugs to ensure that the patient is unconscious at the time of death, if the method of self ingestion of sedative by the patient fails. Physician administered injections (a combination of general anaesthetic and neuromuscular blockade) are recommended in the Netherlands if self administered barbiturates do not cause death within two hours. This injection is similar to that used for executions in the US states that still use capital punishment.

Jaideep Pandit, consultant anaesthetist and senior author of the review, said, “Any decision by society to sanction assisted dying should go hand in hand with defining the method or methods to be used. It should also define by what means unconsciousness should be induced to facilitate a humane death, and which assistants or practitioners should be involved.”

A failure to achieve an adequate state of unconsciousness during assisted dying has “clear parallels with the problem of ‘accidental awareness during general anaesthesia’ (AAGA), where the patient awakens unnoticed and paralysed during surgery,” said the researchers, and lessons can be learnt from the mechanisms put in place to avoid this. For example, the use of continuous infusion of an anaesthetic agent and electroencephalography monitoring could achieve unconsciousness more reliably and maintain it to the point of death.


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