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Spain will become the sixth country worldwide to allow euthanasia and assisted suicide

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n147 (Published 15 January 2021) Cite this as: BMJ 2021;372:n147

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Complications with medication use during assisted suicide and/or euthanasia. A peaceful, pain free, dignified death is not guaranteed. Ireland aware? Response to: Spain will become the sixth country worldwide to allow euthanasia and assisted

Dear Editor,

Many healthcare professionals, politicians and members of the general public who support the introduction of assisted suicide and/or euthanasia may be under the impression that the method of dying they support would be achieved by the administration of ‘a pill'. This is not the case.

Awareness of assisted suicide deaths and/or euthanasia deaths that do not go according to plan would lead to opposition to the introduction of assisted suicide and/or euthanasia. The suggestion that assisted suicide and/or euthanasia are ways to achieve a complications free, dignified death for all would be questioned! Many promoters of assisted suicide and/or euthanasia often suggest that the use of medications during the assisted dying process results in a pain free, dignified death for all. This is not the case. Modern medicine cannot guarantee a pain free death (natural or intentional) for all. The as yet unrealised goals for ideal oral medication use during assisted suicide and/or euthanasia are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume in assisted suicide.

A so called ‘Dying with Dignity’ Bill is under review by the Committee on Justice of the Oireachtas i.e. The Irish legislature. The difficulties and complications of medication administration during the assisted dying process are rarely mentioned by those promoting the introduction of assisted suicide and / or euthanasia to intentionally end a human life. Studies in The Netherlands show that nonreporting of euthanasia is strongly related to the type of drugs used (1). The goals for ideal oral medications in assisted suicide are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume.

Many deaths during assisted suicide are prolonged. Patients may become unconscious relatively quickly but the dying process can take up to 30 hours or more. There are also reports of people re-emerging from a coma and sitting up during the dying process. it is important that the correct drugs are chosen. Failure to use the ‘correct drugs’ in the assisted suicide and/or euthanasia process may lead to traumatic situations such as an extended time to death or awakening of the patient, causing distress for the patient and the attending family and health care providers . One-third of cases identified in a study in 2013 involved the use of non-recommended drugs, mainly opioids or benzodiazepines (2). The authors suggested that (a) some physicians may over estimate the actual lethal effect of these drugs in persons at the very end of life and (b) some physicians use drugs that are not associated with the recommended euthanasia procedure but with ‘palliative sedation’ as a strategy to reduce cognitive dissonance, that is the mental discomfort experienced by a person with conflicting attitudes, as some clinicians find ‘palliative sedation’ emotionally less burdensome to perform than euthanasia.

There is currently an international scarcity of lethal drugs suitable for oral administration during an assisted suicide. On occasions when oral barbiturate drugs are administered there are reports of patients being unable to self administer a complex cocktail of lethal medicines. Family members have reported having to scrape powder from 100 plus capsules with toothpicks to produce bitter powder to be mixed with sugar syrup. Medication for nausea and vomiting must be consumed before and during the process. In some countries, lethal cocktails have been ‘experimented’ with due to difficulties sourcing licensed medicines for the purpose of assisted suicide and/or euthanasia.

A number of medicines used in assisted suicide and/or euthanasia were previously used in executions. Use of medicines during executions has been described as ‘inhumane’ with reports of people feeling ‘burning’ sensations throughout their bodies prior to death.

A scoping review of the 163 studies that included technical summaries, institutional policies, practice surveys, practice guidelines and clinical studies that describe assisted suicide and/or euthanasia provision in adults identified complications that may cause patient, family and provider distress (3). These included prolonged duration of the dying process, difficulty in obtaining intravenous access and difficulty in swallowing oral agents.

Since 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada (4). Oral assisted suicide is underutilized in Canada as there is no international consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for ‘optimal’ assisted suicide medications is low. It is recognised that any suggested recommendations can only be informed by the global but generally anecdotal experience. There are challenges for implementing oral assisted suicide in Canada (and elsewhere?) and include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration.

The process of assisted suicide and/or euthanasia cannot guarantee a peaceful, pain free, dignified death.

References:
1. van der Heide, A., et al., End-of-Life Practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine, 2007. 356(19): p. 1957-196
2. Dierickx, S., et al., Drugs Used for Euthanasia: A Repeated Population-Based Mortality Follow-Back Study in Flanders, Belgium, 1998 - 2013. Journal of Pain and Symptom Management, 2018. 58(4).
3. Zworth, M., et al., Provision of medical assistance in dying: a scoping review. BMJ Open, 2020. 10(7): p. e036054
4. Harty, C., et al., Oral medical assistance in dying (MAiD): informing practice to enhance utilization in Canada. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2019. 66(9): p. 1106-1112.

Competing interests: No competing interests

21 February 2021
Bernadette Flood
Pharmacist
Daughters of Charity Disability Support Services Dublin, Ireland.
St Joseph's Centre, DOC, Clonsilla ,Dublin 15