The Peaceful Pill EHandbook (August 2012)

Contents

Preface C h a p te r 1 - E n d o f L ite C o nsideratio ns C h a p te r 2 - S uicid e an d the L aw C h a p te r 3 - T h e P eaceful Pill C h a p te r 4 - T h e E xit ʻR P ʼ Test C h a p te r 5 - H y p o x ic Death & th e Exit Bag C h a p te r 6 - C arb o n M o n o x id e C h a p te r 7 - C y an id e C h a p te r 8 - D etergent Death C h a p te r 9 -

Introduction to Drugs

C h a p te r 10 - D ru g O p tio n s - M o rp h in e C h a p te r 11 - D ru g O ptio ns - P ro p ox yp hen e C h a p te r 12 - O th e r D ru g s & C o m m o n M yth s C h a p te r 13 - D ru g O p tio n s - N em butal C h a p te r 14 - O b tain in g N em b u tal C h a p te r 15 - U s in g N em b u tal for a P eaceful Death C h a p te r 16 - S y n th esis o f a Peaceful Pill C h a p te r 17 - T h e S w iss O ption C h a p te r 18 - A fter i t ’s O v er

Exit R P Table R eferences S u p p o rt E xit International

A bo ut Exit International Founded in 1996 by D r Philip Nitschke, Exit International (non-profit) is a global leader in the provision o f end o f life information to Seniors, people suffering serious illness and their families. At the heart o f Exit International's activities is the Safe Exit informa tion Workshop and Meeting Program. Safe Exit Workshops are held regularly in Nth America, the UK, Ireland, New Zealand and Australia. Exit International has offices in Bellingham (WA) and Darwin, Aus tralia. Exit operates chapters in towns and cities around the world. For more information about Exit International, please visit: http://www.exitinternational.net http://www.peacefulpill.com or email: contact@ exitinternational.net Phone: + 1 248-809-4435 (USA) +44 (0)20 7193 1557 (UK) 1300 10 3948 (EXI T) (within Australia) +61 407-189-339 (outside Australia)

C o n ten t R evised : 1 A u g u st 2 0 12

For D e re k H u m p h rу fo r h is c o u r a g e a n d c o m p a ssio n in sh o w in g th e w a y

“ F reed o m takes a lot o f effort ” A n n a S te p a n o v n a P olitkovskaya

In m e m o ry o f Caren J e n n in g

The Peaceful Pill eHandbook Dr Philip Nitschke with

Dr Fiona Stewart

E X IT IN T E R N A T IO N A L US

P u b lis h e d b y E x it In tern atio n al U S PO B ox 4250 B e llin g h am W A 9 8 2 2 7 USA

[email protected] P h ( + 1 ) 248-809-4435 T H E P E A C E F U L P IL L H A N D B O O K . N o v e m b e r 2011 C o p y r ig h t © D r P h ilip N its c h k e a n d D r F io n a S te w a rt 2011 T h e m o ral rig h t o f th e a u th o rs h a s b e e n asserted . A ll rig h ts re se rv e d . W ith o u t lim itin g th e rig h ts u n d e r c o p y rig h t re se rv e d a b o v e , n o p a rt o f th is p u b lic a tio n m a y b e re p r o d u c e d , s to r e d in o r in tro d u c e d t o a r e t r i e v a l s y s t e m , o r t r a n s m i t t e d , in a n y f o r m o r b y a n y m e a n s (ele ctro n ic , m e c h a n ic a l, p h o to c o p y in g , re c o rd in g o r o th e rw ise ), w ith o u t th e p r io r w ritte n p e r m i s s io n o f th e c o p y r ig h t o w n e r a n d p u b l i s h e r o f th is book.

First published by Exit International US Ltd, 2006 Cover design by Branden Barber, Twin Lizards T h e P e a c e f u l P ill e H a n d b o o k F irst p u b lis h e d b y E x it In tern atio n al U S L td , 2 0 0 8 T ec h n o lo g y s u p p lie d b y w w w .Y u d u .c o m P rin ted b y O rig in a l W ritin g L td N its c h k e , P h ilip H aig. T h e p e a c e f u l p ill h a n d b o o k .

IS B N 978 -0 -9 7 8 8 7 8 8 -4 -9 w w w .p e a c e fu lp ill.co m w w w . e x i t i n t e r n a t io n a l .n e t

W h a t th e C ritics sa id a b ou t

Killing M e Softly: Voluntary Euthanasia & the Road to the Peaceful Pill D r P h ilip N itsch k e & D r F io n a S tew art P en g u in - 2005

“The publication o f this book will probably prove to be a landmark in the history o f the reform o f the unenlightened laws that restrict Australians ’ end-of-life choices.” Canberra Times

“ A fascinating book about a curly issue ... it’s a compelling, moving and important book about a difficult subject.” Sunday M ail “ His passion screams from every page o f this book ... An informative read.” Launceston Examiner “For doctors especially, allow me to thoroughly recommend this book. The authors deliver a potent exposition o f the role o f medicine in this debate.” Australian Doctor "Killing Me Softly does represent, in a full and clear way, the issues surrounding voluntary euthanasia. To read it is to be better The West Australian informed in the matter.” "You ’ll either be for or against euthanasia but this book puts Nitschke and the debate in perspective.” H erald Sun “A fine new book”

The Mercury

“Nitschke has never been shy about speaking out against the establishment and w as already no friend o f the medical one.” The B ig Issue

D isclaim er

While every effort has been exercised to avoid errors in the information contained in this book, neither the authors nor the publisher warrants that the information is error or omission free.

The Peaceful Pill Forums M em bers o f Exit & Subscribers to the P eaceful Pill eH an d b o o k now have free access to the P eaceful P ill Discussion Forum s hosted by Exit International US.

This is an online space where you can ask your questions about issues covered in the eH andbook, and benefit from the com m ents, advice and experience o f experts, other subscribers and Exit members.

To jo in the Forum s, click the link and register. www.peacefulpill.com /forum

Preface T h e P e a c e fu l P ill e H a n d b o o k h a s b e e n c r e a te d a t a tim e w h en there are v e ry f e w p la c es w h e r e S en iors an d those w h o are serio u s ly ill can g et in fo rm a tio n a b o u t th eir en d -o f-life choices. In 1996, A ustralia p assed the w o r l d ’s first right to d ie law; the R ig h ts o f th e Term inally Ill A c t (R O T I). U n der R O T I, four o f my serio u sly ill p atien ts self-ad m in istered a legal, lethal o verdo se o f d ru g s; a P eaceful Pill i f y o u like. All d ied peacefully in their sleep, s u rro u n d e d b y p eo p le they loved. I k n o w this, b ecau se b ack then I w a s their tre atin g physician. I w a s the o n e w h o p u t th e n eed le into th eir veins. A n d I w a s the o n e w h o built th e ‘ D eliv eran ce M a c h in e ’ that th ey u sed to die. T h e D eliv eran ce M a c h in e w a s a laptop c o m p u te r an d p ro g ram that g ave these individuals the ultim ate control ov er their deaths. T h e ir d eath s tau g h t m e m u c h , b u t m o stly h o w im portant it is f o r people to be a llo w e d to h a v e control at th e end. O n each s e p a ra te o c c a s io n , th e c o m p u te r p re s e n te d a short series o f questions: 1. A re y o u a w a re that i f y o u g o a h e a d to the last screen and p ress th e ‘y e s ’ b u tto n y o u w ill be g iv e n a lethal d ose o f m e d ic a tio n s a n d die? 2. A re y o u certain y o u understand that i f y o u proceed an d press th e ‘y e s ’ button on the n ex t screen y o u w ill die? 3. In 15 se c o n d s y o u w ill be given a lethal injection . .. press ‘y e s ’ to proceed.

P reface

The Deliverance machine built by the author. Used by four people in the Northern Territory between 1996 - 1997. Now on display at the British Science Museum

The P eaceful Pill H andbook

A fter p ressin g the b u tto n fo r a th ird tim e, th e M ach in e w o u ld d e l i v e r a le th a l d o s e o f th e b a r b i t u r a t e , N e m b u t a l . T h e D eliverance M achine en ab led these four people to die peacefully an d w ith dig nity u n d e r a n e w law. M y ex p e rie n c e in th o se d a y s o f legal, a ssisted s u ic id e taught m e that the d ru g so d iu m pentobarbital - c o m m o n ly kn o w n as N em b u tal - provides o n e o f the m o st peaceful death im aginable. A n d it a lm o st n e v e r fails. T h a t is w h y it is u s e d in co u n tries like th e N eth erlan d s, B elgium an d S w itzerla n d a n d the U S S tates o f O reg o n a n d W ashin gto n w h e re a ssisted su icid e is lawful. In co u n trie s like A ustralia, C an a d a, th e U K a n d m o st A m erican s ta te s , w h e r e th e r e a r e n o e n d - o f - lif e la w s , th e m e a n s o f ach iev in g a p eaceful d e a th is next to im possible. In A ustralia - m y b irth p lace - fo r th e p a s t de cad e th e G o v e rn m e n t h as m ade it increasingly difficult for Seniors an d p eo p le w h o are seriously ill to access info rm ation a b o u t th eir end -o f-life choices. The A u stralian G o v e rn m e n t se e m s m o re c o n cern ed to k eep people in the d ark . T h e ir ratio nale is that i f p eo p le are k ep t in a state o f co m p le te ig norance th e y will live longer, h a p p ie r lives. N O T True! In m y e x p e rie n c e , o nce p e o p le h av e a c c e s s to in fo rm atio n that e m p o w e rs a n d en a b le s in fo r m e d d ecisio n s to be m ade, they ten d to s to p w orryin g. K n o w in g o n e ’s o p tio n s enables a p erso n to m ak e co n sid ered d e c is io n s as a m a tte r o f course. K n o w le d g e a b o u t o n e 's end-of-life ch o ic e s is e m p o w e rin g . It is this e m p o w e rm e n t that p ro m o te s a longer, happ ier life. N O T Ig n o ran ce.

Preface

The P e a c e fu l P ill e H a n d b o o k h as b een c re a te d to p ro v id e the m o st accurate, up -to -date inform ation a b o u t e nd-of-life choices p ossible. T h e o n lin e m e d iu m h as p ro v en the perfect format for d issem in atin g inform atio n in th is fast-ch an gin g field. The P e a c efu l P ill e H a n d b o o k is d eliberately p u b lish e d in th e US w h e re freedom o f sp eech is e n s h rin e d in the U n ited S tates B ill o f R ig h ts. O f co u rse, th e e H a n d b o o k co v ers so m e g re y a reas o f the law. It is the C onstitutional p ro te ctio n s offered by th e Bill o f R ights that allo w s these issues to be c a n v a s se d a t all. F in a lly, th e P e a ce fu l P ill e H a n d b o o k d ra w s on m o re than a d e c a d e ’s scientific research an d political a d v o c a c y in the fields o f A ssisted S uicide an d V oluntary Euthanasia. S ince its online p ub licatio n in O c to b e r 20 0 8 , it has b e c o m e the lead ing Internet reso u rce on end-of-life choices.

Acknowledgements The P e a c e fu l P ill e H a n d b o o k c o u ld n o t h a v e b een w ritte n w itho ut th e sup po rt o f m a n y people. First to thank are the m any E xit m e m b e rs w h o h ave c o n trib u ted th eir expertise, ideas and travel stories. T h is is truly a j o i n t effort. Secondly, o u r s ta f f a t E xit International w e thank very sincerely for all they d o d ay in, d ay out. O u tsid e o f Exit, special thanks to S teve H op es o f iK andy F ilm s in Sydney, B ran d en B arber in San F ra n c isco an d th e tech n ical s ta f f a t Y udu in th e UK. Finally, w e ' d like to thank o u r publisher, R ich ard West, for his c o n tin u ed su p p o rt an d w ith ou t w h o m n o n e o f this w o u ld have b een possible. D r Philip N its c h k e & D r F iona Stew art B ellingham , W ashington

The P eaceful P ill H andbook

A W ord o f C a u tio n T his b o o k is intended for Seniors and people w h o are seriously ill ( a n d th eir fam ilies). T h is bo o k is n o t in tend ed for y o u n g people o r a n y o n e su fferin g from p sy ch ia tric illness o r depression. As a u th o rs w e a c k n o w le d g e that there is a small risk th a t th is book m a y b e m isu s e d b y p eo p le f o r w h o m this inform ation is clearly n o t appropriate. T h e risk that info rm ation o f this n atu re m a y be m isu s e d w a s a fact a c k n o w le d g e d by th e ‘g o d f a t h e r ’ o f th e rig h t-to -d ie m o v e m e n t, fo rm e r British jo u rn a list, D erek H u m p hry . W h e n Derek first p u b lish ed F in a l E x it in 1991 he w a s c riticised for e n d a n g e rin g suicidal teen s the w o r ld over. H ow ever, a s he w o u ld later p o in t out, th e suicide statistics h ave failed to sh o w th e m u ch talk ed a b o u t ‘b lip ’. T h e re has b een n o rise in the su icide rate. P ro v id in g p eo p le w ith inform atio n d o e s n o t incite o r e n co u rag e p eo p le to die. A n d this is a critical point. R ath er, re lia b le , a c c u ra te in fo rm a tio n e m p o w e r s p e o p le to m ak e m a k e in fo rm e d d e c is io n s a b o u t th eir o w n e n d -o f-life c irc u m s ta n c e s . G o o d in fo rm a tio n s h o u ld n o t o n ly preven t grim , horrible d eath s o f g u n sh ot an d hanging (the m o st com m on causes o f suicide in the U S , U K an d A ustralia respectively) b u t it sh o u ld allay fears. It is paradox, perhaps. B y e q u ip p in g Seniors an d those w h o are serio u sly ill w ith k n o w led g e that em p o w ers an d retu rns con trol, th e se s a m e people arc m o re likely to stop w o rry in g a n d g et on w ith living. A n ecd o tal e v id en ce to this effect can be seen a t each an d e v e ry E xit m eeting. F ears are a d d re ss e d a n d participants feel b ack in control.

Preface

A s p rincipal a u th o r I ask that u sers o f this e B o o k resp ect its integrity an d in ten d ed audien ce. S enio rs a n d people w h o a re seriously ill, deserve to be able to m ak e inform ed decisions about th eir futures. Ign oran ce is n o t a n accep tab le state o f affairs. It is a basic hu m an right to live an d die w ith o n e ’s dignity in tact. T h e P e a c efu l P ill e H a n d b o o k is one w a y o f help ing en su re that o n e 's passin g m ig h t be a s p ro u d an d stro n g a s o n e 's living.


H o w to G et th e M o st from y o u r eB ook T h e P e a cefu l P ill e H a n d b o o k b reak s n e w g ro u n d in th e socalled ' v o o k ' p u b lish in g p h en o m en o n . P art-book, part-video, th e Y udu te c h n o lo g y platform o f the P e a cefu l P ill eH a n d b o o k allo w s users to T urn th e P a g e in m u ch th e s a m e w a y they have a lw a y s done. T h e re is also a ‘N o te p a d ’ . B y clicking on this icon in th e to p m en u bar, a u s e r can m ak e notes a s th e y go. T h e n o tes are sto red a s y e llo w p age ico n s at vario us p laces in th e text. A n o th e r featu re is th e ‘B o o k m a r k ’ so p a g e s can be m ark ed for fu tu re reference. T h e traditional In d ex o f a H a n d b o o k h as been ab an d o n ed , and rep laced b y th e search function. F o r th is reason, an d because th e con ten t a n d size o f the e H a n d b o o k c h a n g e s as n e w m aterial b e c o m e s available, p ag e n u m b e rs are being gradually rem oved. W h e n quoted, p a g e n u m b ers refer to th e p a g e co u n te r a t the c e n te r to p o f th e digital display. Best o f all, how ever, an e B o o k by its n a tu re allo w s a u s e r to m o v e s id ew ay s a s w ell as forw ards o n th e p age. M an y o f the k e y co n cep ts in this bo o k are hyp e r lin k e d to external w e b pages. O th ers co ntain v id e o s that y o u can w a tc h as y o u read o r return to at y o u r leisure. Finally, i f y o u are h ard o f sight, y o u can click on the e H a n d b o o k 's built-in m ag n ify in g g lass that allo w s th e u s e r to zo o m an d rep osition text on th e screen with am a z in g customizability.

Preface

The eH a n d b o o k can also b e p rin ted , o r d o w n lo a d ed to a hard disc (size > 3 0 0 M b ), b u t it is d esig n ed to be read liv e o n lin e . T h is way, c h a n g e s an d u p g rad es a re im m ed iately av ailab le to all subscribers. I f a su b scrib er d o e s elect to d o w n lo ad , it is im p o rtan t to no te th e d o w n lo a d versio n w ill n eed to be trashed b efo re an y new , u p d a te d ed ition can b e a c cessed live. Finally, users are encouraged to refer th e eH andbook on to others o f like m ind. R oyalties from sales are u sed to u n d erw rite Exit's o n g o in g R & D (in c lu d in g th e n e w E xiT ech p ro g ra m ) w h ic h is w h e re m an y o f the issues c o v e re d in th e eH andbook h av e found th eir genesis. A s they n o w say in th e w o rld o f o n lin e b o o k s R E A D IT, W ATCH IT.

N o te : P u rc h a se rs o f th e P rin t ed itio n

P eaceful P ill H andbook are e n title d to a U S $ 10 cashback should th ey choose to elect to u p g ra d e to a subscription to th e online P eaceful P ill eH andbook. O n ce a r e a d e r u p g ra d e s b y ta k in g o u t a subscription at www.peacefulpill.com , email E xit w ith p r o o f o f p u rc h a s e a n d w e will credit $ 1 0 to y o u r P aypal account.

1 End o f Life Considerations D e v elo p in g an E nd o f L ife Plan People m ak e en d o f life plans for all sorts o f reasons. S om e p eo p le a re c o n cern ed that o n e d ay th ey w ill b e c o m e so sick and frail an d th eir qu ality o f life w ill b e c o m e so im p aired that death will b e c o m e the p referred option. O th ers w o rry th a t because c u rre n t g e n eratio n s are living lo n g e r th an th eir p a re n ts ’ an d g ra n d p a re n ts’ g en eratio ns, th ey w ill have to face that n e w set o f w o rries that c o m e from lo n g ev ity itself. S o m e eld e rly people are sim p ly ' tired o f l i f e '. T h e re a so n s that lead an eld e rly p erso n o r so m e o n e w h o is serio u sly ill to seek inform ation about th eir end-of-life choices are m a n y an d varied. All are in ten sely perso nal. R ew ritin g the w a y s in w hich s o c ie ty can plan for an d ex p e rien c e death and d y in g is th e ch allen g e o f o u r time. T h e d e v e lo p m e n t o f an e n d o f life plan is o n e sm all step that all o f us can take to pro tect those w e love fro m the rav ag es o f th e law. W h ile m o s t o f u s w ill n e v e r u se o u r p lan, w e can all d ra w c o m fo rt in k n o w in g that i f th ing s e v e r b e c o m e to o painful o r und ig nified (esp ecially in the con text o f seriou s illness and age), w e will h ave a plan in p lace that w ill a llo w us to m aintain o u r dign ity an d o u r independence.

E nd o f L ife C onsiderations

T h e W o n d ers o f M o d ern M ed icin e In an y d isc u s s io n o f en d o f life iss u e s th e role o f m o dern m edicine is param ount. W h ile n o o n e can be critical o f th e huge ad v a n c e s in m ed ical scien ce o v e r recen t d e c a d e s - im proving b e y o n d m easu re th e length an d qu ality o f o u r liv es th ere is also a flip side. In contrast to p rev io u s g e n eratio n s, w e are now f a r m o re likely to d ie o f slow er, deb ilitating co n d itio n s that are a sso ciated w ith o ld ag e a n d illness. Yet w e a re a lso m o re likely to be k ep t alive through an in creasin g ly so ph isticated arra y o f m ed ical technologies. A lo n g er life can be a w o n d erfu l thing, b u t sh o u ld w e be forced to live on, i f w e co m e to a point w h e re w e h av e s im p ly had e n o u g h ? S urely th e act o f b alan cin g o n e 's qu ality o f life against th e struggle o f daily living in o u r later years o r in illness, should b e each individual to arbitrate.

O u r A g ein g P o p u la tio n A century ag o w h en life expectancy w a s ap pro xim ately 25 years less than it is today, f e w p eo p le h ad the o p p o rtu n ity to reflect on h o w th ey m ig h t die. T h e n p eo p le w ere m u ch m o re likely to d ie q uick ly w ith little w arn in g . F o r ex am p le, o n e hundred y ears ag o infectious disease w a s co m m o n . P eople co n sid ered th e m se lv e s lucky i f th ey w ere still aliv e in th eir m id 50s. The w id e s p re a d in tro d u c tio n o f p u b lic h ealth m e a s u re s such as sew erage, w a te r reticu latio n, g o o d housing, a n d o f co u rse the introduction o f m o d e rn an tib io tics h av e all p la y e d a p a rt in g re a tly redu cin g th e toll o f infectiou s disease.


In m o d e m tim es, those livin g in th e d e v elo p ed w e s t h ave a life e x p e c ta n c y o f 75 to 80 y ears. N o w in industrialised countries, w e will be m o re likely to ex p erien ce d isea ses an d disabilities that w e re rare in earlier tim es. W hile o ld ag e is not in itse lf pred ictiv e o f s e rio u s p h y sica l illness, the g rad ual deterioration o f o n e ’s b o d y w ith ag e leads to a n a lm o st inevitable declin e in a p e r s o n 's q uality o f life. T h is is w h y w e see the issue o f control in d y in g a s being an in c re a sin g ly c o m m o n co n cern f o r m an y elderly people. E xit's w o rk s h o p p ro g ram is often b o o k ed out m o n th s a h e a d as elderly folk seek an sw ers to th eir practical q u estio n s a b o u t th eir e n d o f life options. A ltho ug h few w h o a tte n d th e se w o rk sh o p s have a n y intention o f d y in g in the n e a r future, m o st see a n eed to o rg an ise an d plan for this inevitable event. Just as m an y o f u s plan for o th er aspects associated w ith d ying (eg. w e all w rite a will, ap po int executors, an d som e o f us prepay f o r funerals), so it is c o m m o n sense to en su re that w e h ave a p lan a b o u t h o w w e m ig h t w ish to d ie. Yet to be in a position to p lan for o n e 's death, o n e m u st first k n o w o n e 's op tion s. A nd that m eans inform ation.


T he Q u e stio n o f S u icid e A n y o n e w h o m a k e s p lan s for th eir o w n d e a th can be said to be p lan n in g th eir o w n suicid e. W h ile for so m e people su icide is a ta in te d concept, for a g ro w in g n u m b e r o f o ld er p eo p le it is an issu e o f g reat interest an d discu ssion . In this con tex t, suicide is a w a y o u t o f a life th a t an individual m ight c o n s id e r is not w orth living. P eo p le w h o c o m e to E xit w o r k s h o p s are w e ll a w a re o f the im p o rtan ce o f m ak in g that ultim ate o f d ecisio n s, th e decision to die. T h e y are all a c u te ly a w a re o f the n e e d to get it right. In this C hapter, w e e x a m in e th e p h en o m en o n o f suicid e in the context o f the m o d e m life co u rse, an d w h y a c c e s s to the best in en d o f life inform ation is s o im portant.

A B r ie f H isto ry o f S u icid e O v er the years, th e w a y in w h ic h so ciety v ie w s the tak in g o f o n e 's o w n life h as v aried enorm ously. S u icide has n o t alw ays b een seen a s th e act o f a sick an d d e p re ss e d person. In ancient Greece, A thenian m agistrates kept a supply o f poison for anyone w h o w a n te d to die. You ju s t needed official perm ission. F o r the S toics o f ancien t tim es, su icide w a s c o n sid e re d an ap pro priate resp o n se, i f th e p ro b le m s o f p ain , g ra v e illn ess o r p hysical ab no rm alities b e c a m e to o great. W ith th e rise o f C h ristia n ity , h o w e v e r, s u ic id e c a m e to be v ie w e d as a sin (a violation o f th e sixth c o m m a n d m e n t). As L isa L ieb erm an w rites in h er b o o k L e a v in g You, all o f a sudden ' the R o m an ideal o f h ero ic in d iv id u a lism ' w a s re p la c e d ' w ith a p latonic co n cep t o f su b m issio n to d iv in e au th o rity '.


It w a s C hristianity that c h a n g e d s o c ie ty 's v ie w o f suicid e from th e act o f a re sp o n sib le person, to an in frin g em en t up o n the righ ts o f G od. O n e ’s d e a th b e c a m e a m atter o f G o d ’s will, n o t o n e 's o w n an d it w a s a t this point that p en alties w e re first esta b lish ed for those w h o a ttem p ted suicide. I f th e suicid e w a s su ccessfu l, it w a s the fam ily o f th e o ffe n d e r w h o w ere p un ish ed w ith fines an d social disgrace. W ith the em ergence o f m o d e m m edicine in the 19th Century, the m ean in g o f su icide c h a n g e d again a n d it is this u nd erstan d in g that p rev ails today. S uicide is n o w g en erally tho ug ht o f a s an illness. I f a p erso n w a n ts to en d th eir life, then th ey m u st be sick (psych iatric illness, w ith d ep ressio n th e usual diagnosis). The appropriate response, therefore, is m edical treatm ent (in the form o f p sy ch ia tric c o u n sellin g a n d /o r an ti-d e p ressan t m edications). A t Exit In te rn atio n al, w e q u e s tio n th e v ie w o f s u ic id e that au to m atically links a p e r s o n 's decision to d ie to d e p re ssio n and m ental illness. A re w e serio u s ly p o stu latin g that th e suicide b o m b e rs o f th e M iddle E ast are d ep ressed ? Rather, th e act o f suicid e m u s t be seen a s co n te x t dep en den t. F o r ex am p le, a person w h o is v ery eld e rly an d w h o is seeing frien d s die a ro u n d th em on a w e e k ly basis an d w h o m u st be w o n d erin g ' am I n e x t? ' is g o in g to have a very different outlook on d y in g than th e y o u n g person w h o h as their w h o le life in front o f th em . L ikew ise, w h en serio us illness is present. A p e rso n 's a ttitu d e to w a rd s death m u st b e u n d e rsto o d in th e con text o f that p e r s o n 's situation. In O reg o n , w h e re p h y sic ia n -a ssiste d s u ic id e (PA S) is legal, s y m p to m s o f d e p re ssio n h ave b een found in 2 0 p e r cent o f p atien ts w h o requ est PAS (Battle, 2003). A 1998 s tu d y by the


A ustralian B u reau o f Statistics rep o rted 15 p e r c e n t o f m en and 18 p er c e n t o f w o m e n w h o su icid ed h ad ' an a sso ciated or contributory d iag n o sis o f a m en tal d iso rd e r' (A B S , 2 0 0 0 ). At E xit w e argue that feelin g s o f sa d n e ss (as o p p o s e d to clinical dep ressio n ) are a norm al resp o n se to a d iag n o sis o f a serious illness. T h is is w h y s o m e stu d ie s co n tin u e to find a sadn ess associated w ith a s e rio u s illness. Y ou d o n 't n e e d to be a p sy ch iatrist to u n d e r s ta n d t h a t th is m ig h t b e a n o rm a l r e s p o n s e to an ex trao rdin ary situation (R yan, 1996). T o assu m e that suicide a m o n g st the elderly o r p eo p le w h o are serio u sly ill is the result o f depression o r other psychiatric illness, is to a d o p t uncritically a b io m ed ical w a y o f s e e in g the w o rld . W e can do better.

S u icid e & D ep ression T h e link b e tw e e n s u ic id e a n d d e p re ss io n r e m a in s a v e x e d issu e w ith m illions o f d o lla rs in g o v e rn m e n t fu n d in g devoted to ra isin g th e c o m m u n ity 's a w a re n e s s o f su icide, esp ecially a m o n g st th e y o u n g a n d s o m e m in o rity g ro u p s (eg. farm ers). A n d there can be n o d oubt. P eople w h o suffer from clinical d epression are clearly a t risk o f suicide.

S ev ere d ep ressiv e

states can rob a p erso n o f th e ability to m a k e rational decisions and these p eo p le n eed care an d treatm en t until th ey are once again able to resu m e control. Yet illness o f this severity is not co m m o n a n d needs to b e d istin g u ish ed fro m a larger g roup o f p eo p le w h o s h o w o ccasion al sig n s o f d epression but w h o are in full control o f th eir actions.


T h e re is a s ig n ific a n t d iff e r e n c e b e tw e e n a p e rs o n h a v in g m o m en ts o f feeling d o w n o r h av in g a transitory feelin g that th eir life h as lost p u rp o se an d the person w h o h as severe clinical d epression , w h e re ev en the m o st basic d aily d e c is io n s o f life b e c o m e problem atic. T h is is quite different from an eld erly o r serio u sly ill p e rso n 's d esire to form ulate an en d o f life plan; a p lan w h o s e sole aim is to m ain tain control o v e r their final days. P eople w h o like to b e p rep ared an d w h o are n o t d ep ressed sh o u ld n o t b e v iew ed in p sychiatric term s.

E nd o f L ife D e cisio n s & th e R o le o f P a llia tiv e C are Critics o f Voluntary Euthanasia and A ssisted Suicide often argue that i f palliative care is av ailab le a n d o f g o o d en o u g h standard, patients w ill never n eed ask fo r assistance to die. T his is untrue, b u t to u n d erstan d the claim , o n e needs to loo k a t the b ack g ro u n d o f the p alliative care speciality. P alliative c a re w a s th e first b ran ch o f m e d ic in e to sh ift the focus aw ay from ' cure at all c o s ts ' an d to focus in stead upon th e treatm en t an d m a n a g e m e n t o f sy m p to m s (fo r p eo p le w h o h ave a life-threatening illness). In this s en se, p alliative c a re 's aim has n e v e r b een ' c u re '. Rather, p alliative m e d ic in e is about s y m p to m control. It is a b o u t im p ro v in g the q u a lity o f life o f th o se w h o are serio u sly ill an d dying. To date, palliative care h as been m o st successful in th e treatm ent o f p ain. Indeed, it is often c la im e d - p erhap s ex ag g erated ly that p a lliativ e care can su c c e ssfu lly add ress pain in 95 p er cent o f all eases. W h a t is m u ch less sp o k en about is th e sp eciality 's lim ited ability to alleviate so m e o th er c o m m o n sy m p to m s o f seriou s disease; sy m p to m s su ch a s w e a k n e ss, b reath lessn ess or nausea. Or. q u ite sim p ly to gu aran tee a g o o d death.


Angelique Flowers at Oscar Wilde's grave at Pere Lachaise cemetery in Paris in 2006.

N o w h e r e can th e s h o rtc o m in g s o f p a llia tiv e c a re b e m ore o b vio us than in th e tragic death in A u g u st 20 0 8 o f 3 1 y e a r old M e lb o u rn e w riter, A n g eliq u e F low ers. A t the ag e o f 15 years, A n g eliq u e w a s d ia g n o se d w ith painful C ro h n 's D isease. O n 9 M a y 2 0 0 8 , sh ortly b efo re h er 31st b irth d ay sh e w a s d iagnosed w ith S tage 4 c o lo n cancer. A s A n g eliq u e said, in o n e o f the several v id eo s sh e m ad e in the w eeks leading up to h er death, there is no Stage 5. A t Stage 4 and u p o n diagnosis, the can cer h ad already sp read to h er liv er and ovaries. A n g ie ’s doctors told h er then, h er d ay s w e re num bered. T h e y also told h er that there w o u ld be v e ry little th e y c o u ld do to ensure that h er death w a s p ain -free an d dignified. A s history n o w tells A n g e lique 's story, this co u rag eo u s, clever, beautiful y o u n g w o m an d ied in the m o s t difficult an d unpleasant way. A s a patient in A u s tra lia 's p rem ie re palliative care unit at M o n a sh M edical C entre in M elb o u rn e, A n g e lique 's care w a s th e best that m o d e m m edicin e can p rov id e, a n d that m o n ey

E n d o f L ife Considerations

can buy. D espite s o m e hiccups, A n g e liq u e 's pain control w as d e s c rib e d a s reasonable. W h a t w a s n o t so g o o d an d w h a t the law prevents m e d ic in e fro m ad d ressin g, w a s h er death. A n g e l i q u e F l o w e r s d i e d v o m i t i n g u p f a e c a l m a t t e r a f te r e x p e rie n c in g an acute bo w el blo ck age. Just as h er d o c to rs h ad w arn ed , h er death w a s s im p ly aw ful. T h e y h ad told h er that it c o u ld be sho ck ing , an d it was. T h is y o u n g w o m a n w a s terrified o f this p ossib ility w h ic h is w h y sh e p u t o u t a call f o r N e m b u ta l, on th e Internet. A lthough A n gie w a s successful at o b tain in g N e m b u ta l, b e c a u s e o f the law sh e kept th e d rug h id d en at h e r p a re n ts' hom e. W h e n the bo w el blo ck ag e o c cu rred , A n g eliq u e w a s in the h o sp ice yet h er N e m b u ta l w a s at hom e. S h e lost h er ch an ce to take control. S h ortly b efo re sh e d ied, A n g ie m ad e a v id e o diary. In it she p le a d e d w ith A ustralian P rim e M in is te r Kevin R u d d to once again, legalise v o lu n ta ry euth an asia in A ustralia. A n g e liq u e 's trag ic s to r y s h o w s m a n y th in g s, in c lu d in g w h y a m o d e m , civ ilised society n e e d s th e best p a lliativ e c a re a n d voluntary euth an asia / assisted suicide. At Exit, w e are frequently ap p ro ach ed b y people w h o tell us that their palliative care is s e c o n d to n o n e b u t w h o , like A ngelique, still w ish to be in control o f th eir death. T h e y say that w h ile they m ig h t n o t n o w be in p ain , the q u ality o f th eir life is n on eth eless serio u sly effected by th eir illness. T h e y k n o w that there is often n o th in g that m o d e m p alliative m e d ic in e can d o about it.


S o m e o f th e se p e o p le a r e so w e a k that they c a n n o t m o v e u n a s sis te d . O th e rs h a v e s h o rtn e s s o f b reath w h ic h m a k e s in dep en dent livin g im possible. F o r a significant n u m b e r o f p eo p le, it is n o n-m ed ical issues that h ave m o s t im p act upon the q u a lity o f th eir life. O n e recent m em o rab le case con cern ed a m iddle ag ed m a n called B ob. B o b w a s suffering fro m lu ng cancer. H e w a s in cred ibly sad that his favourite p a s t tim e - a ro u n d o f g o ld with his m ates - w a s no lo n g er possible. T h is p erso n w a s clear. It w a s his frustration a t b e in g h o u s e -b o u n d an d d e p en d en t on visits from frien ds an d family, rather th an the p hysical sy m p to m s o f the cancer, th a t m ad e h im c h o o se an elective death. P alliative care is no u n iv ersal p an acea. W h ile this branch o f m edicine d oes h ave a v alu ab le contribution to m ak e, especially in th e field o f pain co ntro l, it is u n h elp fu l to u se sy m p to m m a n a g e m e n t as the b en ch m ark again st w h ich a p e rs o n ’s quality o f life is m easured. Rather, p eo p le rate their q uality o f life in different w a y s with no tw o in d iv id u als’ a sse ssm e n t th e sam e. W h ile a life w ith ou t p ain is clearly b e tte r than a life w ith pain , this is n o t alw ays th e m o s t im p o rta n t issu e. I n s te a d it is that p e r s o n ’s o w n com plex a sse ssm e n t o f their life ’s w o rth that is th e key. The physical sy m p to m s o f an illness are often on ly o n e o f m any considerations. Just ask A ngelique.

E n d o f L ife Considerations

T h e T ired o f L ife P h en o m en on In recen t y ears, a n e w tre n d h as beg un to em erge; o n e that has cau sed E xit to rethink o u r ap p ro a c h to d e a th an d dying. Increasingly at o u r w o rk sh o p s , w e m e e t eld erly people w h o are lit an d health y (fo r th eir ag e), b u t fo r w h o m life h as becom e in c re a sin g ly b u rd e n s o m e .

S u ch p e o p le a r e n o t dep ressed .

R ather, th e s e n tim e n t e x p re ss e d is that ‘ I h av e lived en ough o f the g o o d life an d n o w it’s tim e to g o .’ T h e action s o f A ustralian c o u p le, S id n ey an d M arjo rie C roft, ex p lain this p h en o m en o n well. In 2 0 0 2 , th e C ro fts s e n t E xit International th eir su icid e note e x p lain in g w h y th ey h ad d e c id e d to g o together. Exit h ad no p r io r k n o w led g e o f th e c o u p le 's plans. W e k n e w on ly that they h a d atten d ed several E xit w o rk sh o p s w h e re th ey sat at the back, h old ing h a n d s an d a sk in g questions. T h e C ro fts d id n o t n eed to w rite this n ote y e t th e y w a n te d u s to understand. A n d in return they a sk e d for o u r respect. To W h o m it M a y C o n cern P lease d o n 't co n d em n us, o r feel b a d ly o f us for w h a t w e h ave done. We h a v e th o u g h t clearly o f this fo r a lo ng tim e an d it has taken a lo ng tim e to g et th e d ru g s needed. We are in o u r late 8 0 s an d 9 0 is on th e horizon. A t this stage, w o u ld it be w ro n g to ex p ect no deterio ration in o u r health? M o re importantly, w o u ld o u r m ental state be bright an d alert?


In 19 7 4 w e both lost o u r partners w h o m w e loved very dearly. F o r tw o a n d a h a lf y ears M arjo rie b e c a m e a reclu se w ith her grief, a n d S id b e c a m e an alcoholic. W e w o u ld n o t like to go thro u g h that tra u m a tic ex p e rie n c e again. H e n c e w e decided w e w a n te d to go together. W e h ave n o children an d n o o n e to consider. W e h ave left in structio ns that w e b e c r e m a te d an d that o u r ashes be m ix e d together. We feel that way, w e will be together forever. Please d o n 't feel sad, o r g riev e for us. But feel g la d in y o u r h eart as w e do. S id n ey a n d M arjorie C roft T h e C ro fts are th e p riv ate face o f an in c re a sin g ly co m m o n sen tim en t a m o n g a m in o rity o f o ld er peop le; that is that a good life sh o u ld be a b le to be b rou gh t to an e n d w ith a g o o d death, w h en a n d i f a person so w ishes. T o su gg est, a s m a n y in the m ed ical p rofessio n have do n e, that th e C ro fts w ere ' d ep ressed ' is to trivialise a n d patronise th em for th eir actions. A n o th e r person w h o ev o k ed th is ' tired o f life' p h en om en on w a s retired French a c a d e m ic , Lisette N ig o t. In 2 0 0 2 , Lisette N ig o t a lso took h er ow n life, c o n s u m in g lethal d ru g s sh e had sto ckp iled o v e r th e years. L isette's reaso n fo r d y in g ? S h e said sh e d id n o t w a n t to turn 80.

E nd o f L ife C onsiderations Lisette N ig o t insisted that s h e h a d led a g o o d a n d full life. S h e s a id she h a d always k n o w n that she w o u l d not want to b e c o m e ' too old.' ' I d o not take to old ag e v e r y w e ll' she told film-maker Janine Hosking w hose feature docum entary M a d e m o ise lle a n d th e D o cto r tra c e d the last m o n t h s o f he r life. In late 20 02, sh ort ly bef ore her

Mademoiselle Lisette Nigot

80th birthday, Lisette N igot e n d e d he r life. Intelligent a n d lucid to the end, Lisette k n e w her o w n mind. A fiercely in d ep en d en t w o m a n , it is not surprising that she e x p ected control in he r dying, j u s t as she h a d in he r o w n life. In M a d e m o ise lle a n d th e D o c to r she explained: ' I d o n ' t like the deterioration o f m y bo d y ... I d o n ' t like not b e i n g able to d o the things I us ed to be able to do ... a n d I d o n ' t like th e discrepancy the re is b etw een the m i n d which r e m a in s w h a t it a l w a y s w as , a n d the bo d y which is sort o f physically deteriorating. Perhaps m y m in d will g o a n d I w o u l d hate that. A n d certainly m y bo d y will g o a n d I w o u l d n 't be very hap py with that either. S o I might as well g o w h ile the g o i n g is g o o d '. W h e n details o f the C r o f t's a n d Lisette N ig o t's death w e r e made public, m a n y tried to med icalise their situations. A n assortment o f diseases a n d conditions w e r e su ggest ed a s r e a so n s for their decision to e n d their lives. U n d er p in n in g all o f this w a s the b e l i e f that ‘w e l l ’ peop le d o n ot take their o w n life.


Then A ustralian P rim e M in ister Jo hn H o w ard , co m m en tin g on Lisette N ig o t's actio ns, stated, ' I h a v e a stro n g b e lie f that w e sh o u ld not be en co u rag in g w ell p eo p le to take th eir ow n life, I 'm app alled.' At E xit w e do not e n co u rag e anyone, sick o r w ell, to take their o w n life. W e do, how ever, believ e that a decision to e n d on e's life can be rational. Such a d ecision can o c c u r ju s t a s m u ch in th e co n te x t o f age as in th e co n te x t o f serio us su fferin g and disease. T h is is w h y all eld e rly p eo p le s h o u ld h av e access to relia b le en d o f life in form ation; inform ation w hich is critical i f m istak es are to be prevented. E x it W ork sh op s In recen t y ears, E x it's w o rk sh o p s h ave g row n in popularity s p re a d in g o v e r A ustralia, N Z , U K , U S A a n d C an a d a. From their c o m m e n c e m e n t in 19 9 7 , this flagship E xit p ro g ram now p ro v id e s factual, accu rate info rm atio n to o v e r 4 0 0 0 people e v e ry year. T h e w o rk s h o p idea w a s first c o in e d in 1997 after th e w o r ld ’s first en d o f life law - th e R ig h ts o f th e T erm inally III A c t - w a s o v e rtu rn e d b y th e A ustralian parliam ent. A t that tim e, the V o luntary E u th a n a s ia R ese a rc h F o u n d a tio n - a s E x it w a s then kn o w n - w a s ap p ro a c h e d b y in creasin g n u m b e rs o f older p eo p le w h o w a n te d to k n o w th eir en d o f life op tion s. T hese p eo p le w e re not ill. Rather, th ey w a n te d to k n o w w h at their o p tio n s w ere, sh o u ld they e v e r b e c o m e ill. U n ab le to visit these rational, eld e rly a d u lts o n a o n e-o n -o n e basis, E xit D irector Philip N itsch k e began w o rk sh o p s, initially w ith a ro u n d 2 0 p eo p le at a tim e. H eld in local co m m u n ity ce n tre s, th e w o r k s h o p s p r o v id e d a p e rfe c t o p p o rtu n ity to co rre c t m isinfo rm atio n an d an sw er questions.

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S in c e th a t tim e w o r k s h o p s h a v e o n l y g o tte n b ig g er, n o w attracting o v e r 10 0 particip ants at each m eetin g . B ec au se Exit c an still n o t k e e p u p w ith p e o p le 's d esire to obtain en d o f life inform ation, this bo o k h as b een created . W elcom e to E xit's n e w global w o rk sh o p . C o n clu sio n I f o n e is to su g g e st that the eld erly an d serio u sly ill h a v e the right - for g o o d an d so u n d re a so n s - to e n d th eir lives earlier th an n atu re w o u ld h ave it, then the pro v isio n o f accurate, upto-date inform ation is an im portant first step. I n f o r m a t i o n is th e m a i n r e a s o n w h y p e o p l e j o i n E x it International. Inform ation is certainly the m ain reason w h y our w ork sh op s are b o o k ed o u t m o n th s ahead. People w an t to know h o w to en d th eir lives peacefully, relia b ly an d w ith dignity. M o s t p eo p le k n o w th a t they m a y n e v e r u se this inform ation. All are com fo rted, how ever, in k n o w in g that i f thin gs ' turn b a d ' a s th e y put it, th e y h av e a plan in place. R em em ber, s u ic id e is legal, y et assisting a su icide is illegal. T h is is w h y ev e ry o n e sh o u ld d ev elo p an en d o f life plan . An en d o f life plan will k eep o n e 's fam ily an d loved o nes safe from th e law. A n en d o f life plan is the re sp o n sib le th in g to do.


T h e n A u stralian P rim e M in ister Jo hn H o w a rd , c o m m e n tin g on Lisette N ig o t's actio n s, stated, 'I h ave a stro n g b e lie f that w e should n o t be en co u rag in g w e ll p eo p le to take th eir o w n life, I 'm a p p alled .' A t E xit w e d o not e n co u rag e anyone, sick o r w ell, to take their ow n life. W e do, ho w ev er, believe that a d ecision to e n d o n e 's life can be rational. Such a decision can o c c u r ju s t a s m u ch in the co ntext o f ag e as in th e co ntex t o f seriou s su fferin g and disease. T his is w h y all elderly p eo p le s h o u ld h ave access to reliable en d o f life in fo rm atio n ; inform atio n w h ic h is critical if m istak es are to b e prevented.

E xit W o rk sh o p s In recen t y ears, E x it’s w o rk sh o p s have g ro w n in p op ularity spreading o v e r A u stralia, N Z , UK, U S A an d C an ad a. From th eir c o m m e n c e m e n t in 1997, this flagship Exit p ro g ram now p ro v id e s factual, accu rate in fo rm atio n to o v e r 4 0 0 0 p eo p le every year. T h e w o rk sh o p idea w a s first c o in ed in 1997 after th e w o rld 's first e n d o f life law - the R ig h ts o f th e T erm inally Il l A c t - w a s o v e rtu rn e d by th e A u stralian p arlia m e n t. A t th a t tim e, the V oluntary E u th an asia R esearch F o u n d atio n - a s Exit w a s then k n o w n - w a s ap p ro ach ed b y increasing n u m b ers o f o ld er people w h o w a n te d to k n o w th eir en d o f life op tio ns. T h e se people w ere not ill. Rather, th e y w a n te d to k n o w w h a t th e ir options w ere, s h o u ld th ey ever b e c o m e ill. U nable to v isit these rational, eld erly adu lts on a o n e-o n -o n e basis, Exit D irector Philip N itsch k e b egan w o rk sh o p s, initially w ith a ro u n d 2 0 p eo p le at a tim e. H eld in local co m m u n ity ce ntre s, the w o rk sh o p s p ro v id e d a perfect o p p o rtu n ity to correct m isin fo rm atio n a n d a n s w e r questions.


S in c e th a t ti m e w o r k s h o p s h a v e o n l y g o tte n b ig g e r, n o w attracting o v e r 100 particip ants at each m eeting. B ecause Exit can still n o t k eep u p w i t h p e o p le 's d esire to o b tain en d o f life inform ation, th is b o o k h as b een c re a te d . W elco m e to E xit's n e w global w orkshop.

C o n clu sio n I f o n e is to su g g e st that th e eld erly an d serio u sly ill h av e the right - for g o o d an d so u n d reason s - to en d th eir lives earlier th an n atu re w o u ld h ave it, th en the p ro v isio n o f accurate, upto-date in fo rm atio n is an im p o rtan t first step. I n f o r m a t i o n is t h e m a i n r e a s o n w h y p e o p l e j o i n E x i t International. Inform ation is certainly th e m ain reaso n w h y o u r w o rk sh o p s are b o o k e d o u t m o n th s ahead. P eople w a n t to k n o w h o w to end th eir lives peacefully, reliably an d w ith dignity. M o st p eo p le k n o w that they m a y n e v e r u se this inform ation. All are com forted , how ever, in k n o w in g that i f things ' turn b a d ' a s th e y p u t it, they h av e a p lan in p la c e . R em em ber, su icide is legal, y et assisting a suicid e is illegal. T h is is w h y ev e ry o n e s h o u ld d e v e lo p an e n d o f life plan. An e n d o f life plan will k eep o n e ’s fam ily a n d loved o n es safe from th e law. A n en d o f life plan is the respo nsib le th in g to do.

2

Voluntary Euthanasia, Suicide & the Law In m o st w estern co u n tries, suicid e is legal, y et assisted suicide is a crim e, attractin g harsh legal penalties. W h ile a person w h o tak es th eir o w n life c o m m its n o crim e, a person fo u n d guilty o f assisting an o th e r can face a lon g jail term. T h in k a b o u t it. T h e law m ak es it a crim e f o r a p erso n to assist an o th e r person to do so m eth in g that is lawful. T h ere is no other e x a m p le o f this in m o d e m w estern legal sy stem s. T h is is w h y an y p erso n w h o ch o o s e s to be invo lved in th e d e a th o f an oth er - h o w e v e r tang en tially a n d for w h a te v e r reason s - n e e d s to be very careful indeed. T h is is especially true w h e n friends and fam ily are inv olved an d em o tio n s m a y cloud o n e ’s ju d g em en t.

L egal D efin itio n s & P en alties T echn ically sp eak in g Voluntary E u th an asia is the term used to d escribe the situation w h e n a m edical professional m ight a d m in ister to a p a tie n t a lethal injection. Voluntary euthanasia is legal in co u n tries such a s th e N e th e rla n d s an d B elgium .


B y contrast, P hysician A ssiste d S u icide (PA S) is the term that d escrib es w h e n a m edical professional m ight prescribe, b u t not adm inister, a lethal d rug to a patient. A n e x a m p le o f this is the U S states o f O reg o n a n d W ashington. Finally, the term A ssiste d S u ic id e d e s c rib e s th e situ ation in S w itzerlan d w h e re th e pro v isio n o f lethal d ru g s to p eo p le w h o are su fferin g h as lon g been decrim inalised. G e n e ra lly sp eakin g, assisting a suicide is legally defined as ' a d v isin g ,' ' c o u n s e llin g ' o r ' a s sis tin g ' a p erso n to en d their life.

S o m e tim e s the w o rd s ' a id a n d a b e t ' are a lso used.

In

m o st co u n tries assisting a suicid e carries sev ere legal penalties. In Australia, th e penalty ranges from 5 years to life imprisonment, d e p e n d in g up o n the ju risd iction . In Britain (a n d C an a d a) the p e n a lty ex ten ds to 14 years. In 20 0 9 , the UK d ire cto r o f public p ro secu tio n s, K eir S tarm er, issued n e w g u id elin es on assisted suicid e follow ing a successful cam p aig n b y M S sufferer Debbie P urd y to seek clarification o f th e law. S ee: http://www.cps.gov.uk/n ews/press_releases/144_09/ In the U S , assisting a suicide is illegal in ju s t o v e r h a lf o f all states, w ith th e rem ain d er tre atin g it th e sam e as the c rim e o f m u rd e r o r m anslaughter. In the US, th e penalties for assisted suicid e v a ry from state to state. T h e o n ly ex cep tion s are the states o f O reg o n , W ashington an d M o n ta n a w h e re Physician A ssisted S uicid e (PA S) is legal in s o m e circum stances. In M ic h ig a n , th e la te D r J a c k K e v o rk ia n w a s in c a rc e ra te d for a lm o s t a d ecad e fo r the assisted suicid e o f his term inally ill p atien t, T h o m a s Y ouk. In M a rc h 1999, K e v o rk ia n w a s c o n v ic te d o f s e c o n d d eg ree m u rd e r an d s e n te n c e d to 10 to 25 y ears jail.

Suicide a n d th e Law

D efin in g A ssiste d S u icid e So w h at is a ssisted su icid e? A t the current tim e, argu m en t a b o u t w h a t a c tu a lly c o n stitu te s ' a s sis te d s u ic id e ' s h o w s no sign o f casing. A significant g re y a re a c o n tin u e s to ex ist at the bo u n d aries, w ith law y ers u n ab le to g ive clear an d concise a n sw ers to m an y q u estio n s a b o u t this issue. T h e d earth o f case law leaves it u n c le a r a b o u t w hether, for exam ple, g iv in g a p erso n the info rm atio n th e y need, o r even sitting w ith a person w h ile they take th eir ow n life, is assisting w ith th eir suicid e. O n th e o n e h an d there is the a rg u m e n t that the m ere act o f sitting w ith so m e o n e a b o u t to s u ic id e provides p s y c h o lo g ic a l e n c o u r a g e m e n t ? O r d o e s it? P e r h a p s th o se p resen t h ave a d u ty o f care to prev en t that p erso n from harm ing th em selves? Perhaps o n e sh o u ld leap fro m o n e 's ch air an d grab the g lass o f lethal d ru g s from the p e rso n 's lips? But w o u ld n 't that be an assault? T h e law reg ard in g assisted suicide is ill defined an d murky.

V E L eg isla tio n - W h a t T y p e o f L a w is N eed ed ? O v e r th e y ears, legislation has a tte m p te d to bring clarity and o rd er to th e A ssisted S uicide debate. B y defining the c lass o f person w h o can be h elp ed to die an d by stipulating the m an n er in w h ich this h elp can be prov ided , law s su ch a s th e R ights o f th e T erm in a lly Il l A c t (N o rth e rn Territory) - th e w o rld 's first righ t-to-die law - w e n t a lo ng w a y to w a rd s estab lishin g u n iform ity an d equity. T o m ak e use o f the law a p erso n had to be ' term inally i l l ' an d this w a s d efin ed in th e Act. T h e p erso n also h ad to satisfy a n u m b e r o f o th e r strict criteria.


I f t h e y q u a lifie d , th e y o b ta in e d th e r ig h t to r e q u e s t lawful assistan ce fro m a d o c to r to die. O th e r law s (O reg o n , H olland etc) h ave also set o u t to define e x a c tly w hich g ro u p o f people can h av e help to die. In all cases, eligibility is tightly controlled. Yet ev en w h e re V E law s w o rk w ell, there is o n e significant d ra w b a c k . T h e v e r y strict set o f co n d itio n s m e a n s th a t the p ro c e ss o f e sta b lis h in g elig ib ility is d e m a n d in g a n d can be h u m iliatin g to th o se involved. B esides, there are so m e p eo p le (th o se w h o fit th e ' tired o f life' d escrip tion ) w h o will sim p ly n e v e r qualify. In the N orth ern Territory, a te rm in a lly ill p erso n h ad to o b tain tw o m edical op in ion s, a palliative care rev iew an d a psychiatric consultation b efo re th ey c o u ld qualify to u se th e law to die. In practice, this m e a n t th a t s o m e very sick p eo p le h ad to b eg the m edical p rofessio n in o rd er to qu alify to die. In the course o f m y involvem ent with this law, it q uick ly b ecam e ap p aren t that no n e o f m y four patients w h o u sed th e R O T I A c t w o u ld h ave both ered w ith th e ex h au stiv e a sse ssm e n t p ro c e ss if they h ad access to a P eaceful Pill a t h o m e in the cupboard. W h y w o u ld a p erso n su b je c t th e m se lv e s to a co m p u lso ry p sychiatric e x a m in a tio n , i f th e y a lr e a d y h a d th e m e a n s to a p e a c e fu l, dignified death? T h e y w o u ld sim p ly h av e w a ite d till th e tim e w a s rig h t a n d then taken th e Pill. T h e v ery law s th a t w e re s u p p o se d to e m p o w e r these sick an d frail people s eem ed to d o the exact opposite. T h e law d en ied th e se in d iv id u als' control. Instead, control w a s p laced in th e h ands o f those d o c to rs task e d w ith establishing eligibility.

Suicide a n d th e Law W h il e s o m e p e o p le m a y w i s h to in v o lv e d o c to r s in th e ir deaths, o th ers do not. O u r point at Exit is that death n eed not be a m ed ical event. It is also arg u ab le w h e th e r th e m edical profession s h o u ld b e given th e role o f arbiter, o f w h o gets the rig h t to d ie w ith dignity, an d w h o d o e s not. (A n e x te n s iv e d iscussio n o f E x it's p h ilo so p h y o f d e a th and d ying can be found in K illin g M e S o ftly: V E a n d th e R o a d to th e P e a c efu l P ill, P en g u in , 2 0 0 5 - republished in 2011 b y Exit U S an d av ailab le fro m Exit). T h is m e d ic a l m odel o f death an d d ying h a n g s o v e r u s an d n e e d s to be challenged. T h is is, in part, w h y this bo o k h as b een p rod uced. T h e Internet A g e h as proven p erfect fo r the de m o cratisatio n o f inform ation.

C o n clu sio n T here are m a n y u n d e rsta n d a b le re a so n s w h y a serio u s ly ill person ( o r an eld erly p erson ) s h o u ld be en c o u ra g e d to m ake an en d o f life p lan. E xit do es n o t accep t the p ro p o sitio n that serio u sly ill p eo p le w h o p lan f o r the en d o f th eir life are either d ep ressed o r m en tally ill. R ather, a p e r s o n 's right to en d -o f-life in fo rm atio n is better u nd ersto o d a s critical to e m p o w e rin g that p erso n to m ak e their ow n c o n sid e re d d ecisio n s a n d choices, j u s t a s th ey h ave done all th eir life. B y im p le m e n tin g la w s th a t re s tric t a n d w ith h o ld th is inform ation, the State is b eh avin g in a w a y that is n o t only cruel, b u t inequitable an d unjust. T h o s e w ith m o n e y an d co nn ectio ns w ill alw ay s be better resourced, better able to g et th e necessary info rm ation an d better a b le to access th e restricted drugs, than those w h o are less w ell off. th e balance.

T h is b o o k is in ten ded to restore

3

W hat is a Peaceful Pill? In tro d u ctio n The P eacefu l Pill is a pill o r drink th a t p ro v id e s a peaceful, pain-free death a t a tim e o f a p e rso n 's individual choosing; a pill that is o rally in gested an d av ailab le to ‘m o s t’ people. D r Philip N its c h k e It w a s th e late D u tch S u p rem e C o u rt Ju d g e H u ib D rion w h o first called for th e in troduction o f a Pill. In a letter to th e ed itor o f th e D u tc h n e w s p a p e r N R C /H a n d e ls b la d , D rio n o p e n ly b e m o a n e d th e fact th a t w h ile his d o cto r frien ds knew w h a t to d o an d h o w to access the rig h t d ru g s for a p eacefu l death, a s a law y er he d id not. D rion q u e stio n e d the logic o f w h y he, a retired ju d g e , should not h av e the sam e re a d y access to a d i g n i f i e d d e a th a s his d o c to r friends. A cco rd in g to Drion, all people o v e r a certain ag e sh o u ld h ave the right to die at a tim e o f th eir cho osing . A pill, he argued, w o u ld co n fer this right. Fig 3.1: Professor Huib Drion

W h a t is a " P e a c e fu l P ill"

E lderly an d ailing p eo p le often realize that, at s o m e tim e in the future, they c o u ld w ell find th e m se lv e s in an u n accep tab le an d u n b e a ra b le situation, one th a t is w o rsen in g . A pill to en d life a t o n e 's o w n discretion c o u ld alleviate s o m e o f th eir anxiety. N o t a pill for now , but fo r the u n fo reseeab le future s o that the en d can be h u m a n e (H uib D rion, D ikk ers cited in N itsch k e and Stew art, 2 005) F o llo w in g Drion, E xit research h as c o n firm ed that a Peaceful Pill p rovides peace o f m in d fo r its seriously ill o r eld erly ow ner, g iv in g that p erso n a sense o f control o v e r th eir life an d death. U nlike en d o f life law s that d e p e n d so lely upon a p e r s o n 's state o f health ( o r illness), D rio n 's ' universal m o d e l' h as only one criteria, th a t o f age. Drion s u g g e ste d that a ll p eo p le o v e r th e ag e o f 65 y ears sh o u ld h ave access to a Pill. W h ile th e ag e is arg u ab le, th e p o in t rem ain s th e sam e. T h e ' D rion P ill' o r ' P eaceful P ill' s h o u ld be a ccessib le to th e serio u sly ill as w ell a s th e elderly.

T h e H isto r y o f the S u ic id e P ill T h e idea o f a P eaceful Pill - that is, a lethal s u b sta n c e o r liquid that can b e o rally ingested - is n o t new. In A then ian tim es, the h erb H em lo ck w a s th e d rug o f ch o ice fo r su icide an d it w a s taken a s a drink. T h e m o s t fam o u s H em lo ck s u ic id e w a s that o f the G re e k critical scholar, Socrates. In m o re m o d e m tim es, the ch e m ic a l c o m p o u n d C y a n id e has been w id ely em p lo y e d as a suicid e pill. O n e recen t w ell know n death from C y an id e w a s that o f S panish qu adriplegic R am on S am pedro.


In 1998, S a m p e d ro end ed h is life by d rin k in g cy an id e th a t had b een prov id ed an d p rep ared b y h is friends. T h e aw ard -w inn ing 2 0 0 4 film The S ea In sid e p ro v id e s a rem a rk a b le a c c o u n t o f his life an d death. F o r m u ch o f th e 20 th C entury, cy an id e w a s ro u tin ely issu ed to intelligence ag en ts a s part o f th eir jo b . H itle r's h ead m an in the SS an d th e G estapo, H ein rich H im m le r, e s c a p e d interrogation upon arrest by th e British, b y sw a llo w in g a capsule o f cyanide. H erm an n G oering, h ead o f th e Luftw affe, av o id ed the hangm an by ta k in g p o ta s s iu m c y a n id e th e n ig h t b e fo re th e p la n n e d execution. W h e re th e p u rp o se is to a v o id interrog ation and torture, s p e e d o f action is essential an d c y a n id e fitted th e bill.

T h e B est P eacefu l Pill F ifty y e a r s o n a n d it is p e n to b a r b ita l ( N e m b u ta l ) t h a t is fav ou red as an ideal P eaceful Pill. N em b u tal is a m e m b e r o f th e barbiturate fam ily o f d ru g s that are m a d e fro m th e salts o f barb ituric acid. T h e se a c tiv e b arb itu rate salts h a v e b een used m e d ic a lly fo r m a n y y e a r s , m a in ly a s se d a tiv e s o r slee p in g tablets. In the 1950s, for ex am p le, there w e re m o re than 2 0 m ark eted form s o f b arbiturate slee p in g tablets. E arly e x a m p le s included V eronal, A m ytal, S econal, S o n e ryl, and, o f c o u rs e , N em b u tal. F ifty y e a r s a g o , N e m b u ta l w a s a w id e ly p r e s c r ib e d d rug , rec o m m e n d e d even to h elp b ab ies sleep, an d to calm aching teeth (S ee Fig 13.1)

W hat is a "P eaceful P ill"

O v e r the last 30 years the barbiturates h a v e s lo w ly d isappe are d from the market. T h e fact that in o v e r d o se they c aus ed death, either ac cidentally o r deliberately, a n d the availability o f newer, safer sleeping d r u g s has led to their decline. N em b u tal was r e m o v e d from the Australian prescribing schedule in 1998. The last barbiturate sleeping tablet, Am ytal, w a s r e m o v e d in 2003.

P erceiv ed B en efits o f a P e a cefu l Pill Th ere ar e m a n y m e a n s by w h i c h a seriously ill person can end their life, al though relatively few o f these m eth o d s ar e reliable, dignified a n d peaceful. In m o s t w es tern countries, ha nging and gun s h o t rem ain the m ost c o m m o n m e t h o d s o f suicide. Yet f e w p e o p l e w o u l d r e s o r t to s u c h m e a n s i f t h e y h a d a n y real c h o i c e . M o st s e r i o u s ly ill o r e l d e r ly p e o p l e w h o are c o n s id e r i n g death, s e e k a m e t h o d that is peaceful, dignified a n d p a i n free. C o m m o n l y this is e x p r e s s e d as, 'I s i m p l y w a n t t o g o to sleep a n d die'

In 2 0 0 4, Exit International undertook a m ajor study o f our supporters' attitudes to v a r i o u s m e t h o d s of dignified dying ( n = 1163). Fig 3.2; Survey of Exit Members Methods of Self Deliverance


W h a t w e found w a s a strong an d significant p reference f o r a Pill o v e r all o th er m eth o d s. Indeed, 8 9 % o f respo nd en ts (av erage a g e 72 years) said th a t they w o u ld p refer to take a Pill than use a plastic Exit bag, a c arb o n m o n o x id e g e n e ra to r (C O G e n ie ) o r seek h elp fro m a d o c to r to p rov ide th em w ith ' s lo w e u th a n a s ia '. A ‘ P ill’ w a s defined as so m eth in g that c o u ld be taken a s a single oral d ose (b y m o u th ) in either tablet form o r a s a small drink. T h e reasons behind the respo nd en ts’ preferences b ecam e clear as m o re o f th e data set w a s ex am in ed . M o st o f those surveyed saw the Peaceful Pill a s an im portant w a y o f p roviding independence (91 %). It w a s seen a s an adv antag e i f one d id n o t have to d epend on frien ds an d fam ily fo r assistan c e w h e n th e tim e cam e. A P eaceful Pill w a s also seen to p ro vid e ' p e a c e o f m i n d ' (90% ), w a s relia b le (8 8 % ) an d , u n lik e th e E xit B a g o r th e C arbon M o n o x id e G enerator, th e Pill w a s e a s y -to -a d m in iste r (8 7% ) sin c e it req u ired n o eq u ip m en t a n d n o technical know -how . In this w ay, the P eaceful Pill w a s seen a s a m e th o d that w a s accessible an d usable, even b y th e m o st frail.

W hat is a "P eaceful P ill"

C o n clu sio n E x it's s u rv e y h as e sta b lish ed a stro n g p referen ce f o r a reliable an d effective P eaceful Pill a s the best m e a n s o f p ro v id in g the option o f a peacefu l death a t th e tim e o f o n e 's cho osing . M uch o f th e re m a in d e r o f this b o o k fo c u se s on the v a rio u s fo rm s a P eaceful Pill m ig h t take. In p ro v id in g this inform ation w e are fo llo w in g the ag en d a set by lo n g-stand ing m e m b e rs o f Exit International.

4 The E xit RP Test

M a n y e n d o f life op tion s are d iscu ssed in this b o o k a n d it can be a d au n tin g p roject try in g to distinguish o r c o m p a re the relative a d v a n ta g e s o r sh o rtc o m in g s o f o n e o v e r th e other. T o sim plify th e p rocess, w e h ave d e v elo p ed a sim p le ratin g system that can be ap p lie d to all en d o f life m eth o d s. We call this the R eliability & P eacefu ln ess T est - th e ‘E xit R P T e st’.

P r im a ry C riteria T h e ' E xit R P T est' p ro v id e s a b en ch m ark again st w h ich all end o f life optio ns can be co n sid ered . T h e v a lu e s ad d ressed b y the test cam e to E xit's attention thro u g h specific research on the n o tio n o f a P eaceful Pill an d also th ro u g h person al accou nts a n d an ecd o tes o v e r the past d e c a d e . T h is feed back co n tin u es to identify tw o principal factors in p e o p le 's p referen ces for en d o f life m eth o d s. T h e se factors are ‘ R eliability ’ an d ‘P eacefulness’. In th e R P Test, R eliability a n d P eacefu ln ess are each given a sc o re o f 1 to 10. T h e h ig h er the num b er, th e m o re reliable an d peaceful the m eth o d in qu estion . F o r e x a m p le , N em b u tal ach iev es a high overall score, h an g in g a v e ry lo w score.


R elia b ility (R - 10) R eliability h as b een consistently identified a s a m a jo r im portant fa c to r in assessin g en d o f life m eth o d s. A serio u sly ill person w a n tin g to en d th e ir life n e e d s to k n o w th e m e th o d w ill work. N o o n e w a n ts to take c h a n c e s w ith a m e th o d that m ig h t w ork. R eliability is essential. P e a c e fu ln e ss (P - 1 0 ) P eacefu ln ess is th e s e c o n d m a jo r criteria identified b y Exit. T h e r e is a lm o s t n o i n t e r e s t in m e t h o d s th a t a r e v io le n t, irrespective o f h o w reliable they m ight be. T h e m o st c o m m o n ly expressed w is h b y serio u sly ill an d elderly p eo p le is that th e y b e able to die in th eir sleep. S e co n d a r y C rite r ia T h e re are a n u m b e r o f lesser, b u t n ev erth eless highly-desired, characteristics f o r a m e th o d o f dying. Six additional secon dary factors a re listed below: A vailability (A) Preparation an d A d m in istration (Pr) U n d etectab ility (U) S p eed o f Effect (Sp) Safety to O th e rs (S a) S torage - S h e l f Life (St) In th e R P test, a score o f 1-5 is given fo r each o f these seco nd ary characteristics.

T h e E x it R P Test

A v a ila b ility (A - 5) To be o f an y u se th e m e th o d m u s t b e a v a ila b le . T h e m o s t p eacefu l an d reliable d ru g is o f n o u se i f it is unavailable. P r ep a ra tio n a n d A d m in istr a tio n (P r - 5) S im plicity o f preparation an d adm inistratio n is an im portant factor. N o o n e w a n ts to use co m p licated eq u ip m en t that is difficult to asse m b le o r d ru g s that a re hard to use. U n d ete cta b ility (U - 5) M eth o d s that leave n o o b v io u s tra ce are strongly preferred. In reality, this m ig h t m ean that an atten d in g physician will be m ore likely to assu m e that th e death h as been cau sed b y a know n u n d e rly in g disease. In this situ ation , the question o f suicide d oes n o t arise. S p eed o f E ffec t (Sp - 5) S p e e d o f d e a th is a fu rth e r sig n ifican t factor. S p e e d lim its th e lik e lih o o d o f d i s c o v e r y a n d a n y p o s s ib le in te rf e r e n c e (resuscitation). S a fety to O th ers (S a - 5) M o st serio u sly ill p eo p le d o n o t w a n t to die alone. M ethods that present a d an g er to o thers are u n p o p u la r for this reason. S to ra g e - S h e lf life (S t - 5) T h e re is a stro n g p reference for m eth o d s that u se su b sta n c e s, drugs o r item s that do n o t d eteriorate with tim e. T h is m e a n s the p erso n sh o u ld be able to asse m b le the required item s o r obtain


the req u ired d ru g s in ad v an ce, an d not h ave to w o rry about lin kin g th e p o ssib le tim in g o f o n e 's passin g to the acq uisition o f th e item s. All o f th e m eth o d s d escrib ed in this b o o k have b een given an E xit R P Test score. T h e m a x im u m p o ssib le is 50 po in ts, th e h ig h er th e sc o re th e ‘ b e tte r ’ th e m eth od . S om e c r i te r i a w ill v a r y o f c o u r s e d e p e n d i n g on an in d iv id u a l's p artic u la r circu m stan ces. The R P Test rating sh o u ld only ever b e u se d a s a g en era l guide. Take th e e x a m p le o f the E xit B a g w h en u sed in con jun ctio n w ith H eliu m (see C h a p te r 5). Test F a c to r

Score

Reliability: T h is is g o o d , b u t tech n iq u e is im portant

R =8/10

Peacefulness: T h e re is s o m e sh o rt term a w aren ess an d alarm

P=7/10

Availability: N e c e s sa ry item s are readily available

A = 5 /5

Preparation: Item s req uire a sse m b ly an d coo rdination

Pr=l/5

U ndetectability: I f item s rem oved, totally undetectable,

U=5/5

e v en in th e e v e n t o f an au to p sy Speed: U n co n scio u sn ess an d death o c c u r qu ickly

S p = 5 /5

Safety: T h e m e th o d p resen ts n o risk to o th ers present

Sa=5/5

The E xit R P Test

Storage: E q u ip m en t do es n o t d eteriorate an d testing readily available T otal fo r H eliu m a n d a n E xit B ag

S t= 5 /5

41 (82% )

N o w c o m p a re th e RP Test result fo r th e E xit B ag + H eliu m w ith the U se o f S o diu m C y a n id e (see C h a p te r 7). T est F a cto r Reliability: T h is is v e ry high

Score R =10/10

Peacefulness: P atchy reports, h ard to assess

P=5/10

Availability: D ifficult to obtain o r m a n u factu re

A=2/5

Preparation: T h is is straig htfo rw ard

Pr=5/5

U nd etectab ility : S o m e clinical changes m a y be n o te d , certain ly noted on autopsy

U=3/5

Speed: P ro d u ces a rap id death

Sp=5/5

Safety: T h e re m a y b e so m e slig ht risk to those present from possible H C N g as production

Sa=3/5

Storage: Well p ackaged , s h e lf life indefinite

St=5/5

T otal for S o d iu m C y a n id e

3 8 (76% )


A N o te o f C a u tio n T h e R P T e s t s c o r e s e r v e s o n l y a s a g u i d e . I n d iv i d u a l c ircu m stan ces an d p referen ces will alw ay s influence a p e rso n 's d ecision. T h e re are p e o p le for w h o m a plastic E xit b ag o ver th eir h ead will n e v e r be a v iab le o p tio n , n o m a tte r h o w peaceful an d reliable th e m etho d. T h is m a y b e b ecau se o f an in d iv id u a l’s p artic u la r aesthetic c o n c e r n a n d h a v e n o t h i n g to d o w it h th e m e t h o d 's high reliability physiologically. N evertheless, if this is a real concern, th e m eth o d w ill n o t be co n sid ered , irrespective o f th e high RP Test s c o re . Similarly, the ‘availability ʼ o f a p artic u la r m eth o d can differ fro m individual to individual. T h e co m p ariso n a b o v e suggests that h eliu m w o u ld b e preferred ab ov e cyanide. H o w e v e r, i f an individual h as recen tly b e c o m e s o d isabled th r o u g h i lln e s s t h a t th e u s e o f an E x it B a g is p h y s ic a lly im possible, an d y e t that sam e person h as access to cy an id e pow d er, th e final ch o ice w ill clearly n o t b e d e te rm in e d b y the high est R P Test score. See Table 1 w h ic h p ro v id e s th e o verall R P Test s c o re s for the six a p p ro a c h e s d e s c rib e d in this book.

5

H ypoxic Death & the Exit Bag

In tro d u c tio n T h e plastic Exit B ag p ro v id e s p eo p le w ith th e m eans to obtain a sim p le, effective a n d p eaceful death. W h ile E xit research has fo u n d that relatively f e w p eo p le w o u ld p r e fe r to u se a Plastic B ag o v e r th e sim p le ingestion o f a P eacefu l Pill, it rem ain s one o f the m o s t accessible m e th o d s available. T h e re is m u ch m isin form ation , h o w ev er, a b o u t h o w a plastic E xit B a g w o r k s a n d w h y it is s o effe c tiv e . T h e c o m m o n assu m p tio n is that th e b ag cau ses death by ' su ffo catio n '. Suffo catio n o ccu rs w h en a person c an n o t easily take a breath. E x a m p le s o f th is in c lu d e ty in g a rop e a r o u n d th e n eck , or p u s h in g a p illo w into o n e 's face. T h e act o f m e c h a n ic a lly b lo ck in g o n e ’s b reath in g is te rrify in g , an d p eo p le will struggle w ith th e last o f th eir strength to clear th e obstruction. W h e n used properly, th e plastic E xit B a g cau ses a peaceful death; o n e that c o m e s from (freely ) b reath in g an atm o sp h ere w h e re there is n o o xygen (h yp o xia ). W ith an Exit Bag, a person b reath es easily an d p eacefully; the b ag e x p a n d s an d contracts with each breath b u t there is v ery little o xygen present in the gas. T h is is in stark c o n trast to th e te rro r o f su ffo cation an d is w h y it is im p o rtan t n o t to c o n fu se th e p eaceful h y p o x ic death th a t is p o ssib le w h e n an Exit b ag is u sed properly, w ith th e g rim death that results fro m an obstru ctio n to th e airways.

H ypoxic D eath & th e E xit Bag

A n d th is is w h y w e s h o u ld b e w a ry o f m e d ia r e p o r ts that rein fo rce this confusion. F o r ex am p le, w h en referrin g in 2001 to th e im portation o f C an adian Exit b ag s, th e M u rd o ch press ( The A u stra lia n n ew sp ap er) rep o rted these bags as ' rem in iscent o f th e K h m e r R o u g e 's s h o p p in g b ag ex ecu tion s in C a m b o d ia 's killing f i e l d s '. Such rep orts s h o w a lack o f u n d erstan d in g o f the p ro c e ss a n d h ave d a m a g e d the im ag e o f th e Exit Bag.

T he H y p o x ic D eath H y p o x ia is th e term m ean in g ‘ lo w o x y g e n ’, an d a death that results from inhaling insufficient o x y g en is a hy p o x ic death. W h ile th ere are several w a y s this m ight occur, th e c o m m o n m e th o d u s e d by th o se seek ing a peacefu l death is to sud denly im m erse o n e s e lf in a n o n -o x y g e n en v iro n m en t. T h e sim plest w a y to ach iev e this is b y filling a plastic b ag w ith an inert gas and then to quickly place this bag o ver o n e 's head. T o understand w h y th e plastic E xit b ag p ro v id e s an easy an d reliable w a y to die, a basic u n d erstan d in g o f h u m a n p hy sio lo g y is helpful. In norm al ev e ry d a y life, w e live in an atm o sp h e re that is 21% oxygen. Interestingly, w h en there is a d e c lin e in th e level o f o xygen in the air w e are breathing, w e d o n o t ex p erien ce any p artic u la r alarm o r concern. A s long a s o n e can breath e easily, th e sensation o n e e x p erien c es a s the o x y g en level d ro p s is one o f diso rientation, co n fu sio n , lack o f coo rdination an d eventual loss o f consciousness. T h is ex p erien ce is so m etim es likened to b e in g d ru n k (alcohol intoxication). I f the o x y g en level is to o lo w death w ill result. A ccid en tal h y p o x ic d eath s a re n o t u n c o m m o n an d there are a n u m b e r o f scen ario s that can b rin g th em about.


O n e e x a m p le is th e su d d en dro p in o x ygen level that occurs w h e n an aero p lan e dep ressurizes a t high altitude. T h is can lead to a rap id loss o f co n scio u sn ess an d th e d e a th o f all th o se in th e plane. W h e n th e plane d e p r e s s u r i zes, o n e can still breath easily but there will b e little ox ygen in th e in haled air. T h is w ill c a u se a sudden dro p in the d iss o lv e d o x y g en in th e b lo o d reach in g the b rain, leading to loss o f co n scio u sn ess an d death. It is not u n co m m o n for planes that h av e su dd en ly d e p r e s s u riz e d to travel on a u to p ilo t until th ey run o u t o f fuel w h ile every on e a b o ard h as died. W itnesses (from p lan es sent to investigate) say that it often ap pears as though ev e ry o n e o n board h as ju st go n e to sleep. P n eu m o n ia is a m o re c o m m o n cause o f a h y p o x ic death. Its peaceful reputation led to its c o m m o n description a s th e ' old p e rso n 's frien d '. W h ile the a ir inh aled m a y contain th e full 2 1 % o f o x y g en , the inflam m ation o f the lungs (cau sed by the p n eu m o n ic infection) m a k e s it im p ossib le fo r th e necessary o xygen to b e extracted. T h e b lo o d reach in g the brain w ill have less o x y g en th an that required fo r life, an d a p eaceful death often results. T h e p r e s e n c e o f a n in ert g as like H e liu m in th e E x it B ag d ram atic ally sp eed s th e process. W h e n o n e ex hales fu lly and then p u lls d o w n the E xit bag p r e f i l l e d w ith H eliu m an d takes a d eep breath in o n e 's lungs are filled w ith a g as in w h ic h there


is v e ry little o x y g en . B loo d p assin g th e lungs on th e w a y to the brain finds no o x y g en av ailab le an d w h en this b lo o d with a lo w o x y g en level reaches th e brain, co n scio u sn ess is rapidly lost, w ith in one o r tw o breaths. It is this lack o f o x y g en in the in haled g as that cau ses death. It is im portant to note that th e inert g a s do es n o t interact w ith the body. H eliu m , A rgo n o r N itro gen h ave n o taste o r sm ell and q u ic k ly dissipate after death. W hile H eliu m can be d etected at autopsy, there is no test that can reveal th e u se o f a N itro g e n filled Exit bag, m ak in g it particu larly useful for folk w h o d o n 't w is h th eir c a u se o f d e a th to e v e r be estab lished. ( O f co u rse this p resu p p o ses th a t th e e q u ip m e n t will b e re m o v e d b e fo re the b o d y is ' d isc o v e re d '.

Fig 5.1: 420 litre disposable Helium cylinder


T h e R o le o f C a rb o n D io x id e (C O 2) In n o rm a l respiration, th e h u m an b o d y uses ox ygen an d produces a s w a s te th e g as, c a rb o n d io x id e .

C a r b o n d io x id e is then

re m o v e d from the bo d y as w e exhale. W h ile th e hu m an b o d y is relatively insensitive to falling levels o f o x y g en , it is very sen sitive to a n y rise in the level o f carbon dio xide in in h aled air. W h e n th e b o d y d etects a sligh t increase o f carbon d io x id e in the a ir that w e breathe, a w a rn in g m essag e fro m th e brain alerts the person. T h e y w ill be ro u sed a n d m a y react by gasping. I f the p erso n is u sin g a plastic Exit bag, an y rise in th e level o f carbon d iox ide w ith in the b ag m a y result in the person struggling to pull the b ag from their head. T h is reaction is know n as a H ypercapnic (high carbon d io x id e) A larm R esponse. Sleep A p n e a p ro v id e s an ex am p le o f h yp ercapn ic alarm . Here the person w ith sleep a p n e a sn o res so h e a v ily that th e y den y them selves the o xygen they need. However, it is not the lowering o f the o x y g en level that a la rm s an d w a k e s th e p erso n , b u t the a c c o m p a n y in g rise in th e level o f c arb o n dioxide. I f th e fall in o x y g en w ere n o t acco m p an ied b y this rise in carbon d iox ide, th e S leep A p n e ic w o u ld b e far m o re lik ely to die. In the d ep ressu rized aircraft, the o x y g en level d ro p s but there is no a c c o m p a n y in g rise in c arb o n dioxide, h e n c e a p eacefu l death is the c o m m o n outcom e.


A e sth etic and O th er C o n cern s T h e im ag e o f a bag tied tightly a ro u n d o n e ’s n eck cau sing a grim death b y o b stru ctin g the airw ay h as turned m a n y aw ay fro m the plastic Exit Bag. Even at Exit International w o rk sh o p s, it is c o m m o n fo r p articipan ts to voice th eir d isg ust a t the E xit Bag, s ay in g ‘I d o n 't like th e th o u g h t o f b e in g found like th a t.’

L isette N ig o t rejected this m e th o d (see M a d e m o ise lle a n d the D o cto r, C h a p te r 1). Lisette likened the plastic E xit B ag to being ' w ra p p e d like a p ie c e o f h a m .' F o r L isette an d others, the m ain co n cern w a s o n e o f aesthetics. D espite such con cern s, i f used correctly, th e E xit B ag p rovides a sim ple, reliable an d peaceful w a y o f e n d in g o n e ’s life.

A P eacefu l D eath T h e best m eth o d o f u sin g an E xit B a g involves the u se o f an inert g as, such a s H eliu m , N itro g e n o r A rgo n. In A ustralia, the U S an d o th er countries, H eliu m an d A rg on can be purchased in d isp o sab le con tainers. H eliu m is m a rk e te d in disp osable con tain ers so that b allo o n s can be filled a t h o m e fo r parties (Fig 5.1), A rg on in disp osable fo rm , for u se in w e ld in g applications ( se e fig 5.5). T h e re is n o n e e d to hire a h e a v y c y lin d e r o f c o m p r e s s e d g a s th a t n e e d s r e tu rn in g . A lte r n a tiv e ly e m p ty cylinders can be pu rch ased an d filled w ith an appropriate am ount o f a re a d ily a v a ila b le c o m p re s s e d g a s like N itro g e n . T h e se cy lin d ers can then be sto red indefinitely.


T h e use o f an inert g as is a d v o c a te d b ecau se o f its ability to create a sp a c e d ev o id o f o x y g en . T h is m a k e s a peaceful death from h y p o x ia - lack o f o xygen - possible in a relatively short sp a c e o f tim e. T h e p erso n only h as the E xit B a g o v e r their head fo r a m atter o f seco nd s until u n co n scio u sn ess o ccu rs, an d there is a lm o s t no risk o f a person e x p e rie n c in g an ad verse reaction to a risin g level o f carbon d iox ide w ithin th e Bag. A n d this is w h y the Exit B ag, w h en c o m b in e d w ith a g as like H eliu m o r N itrog en, is s o effective. T h e in troduction o f a flow o f g as into th e B ag, disp laces a n y o x y g en an d flushes aw ay th e e x h a le d carbon dioxide. O n e d o e s n o t n eed to w a i t for the o xygen level inside the b ag is u s e d b y the person, an d there is no a sso ciated build up o f c arb o n dioxide. T h e re is n o th in g particularly special about the inert gas. Indeed, a n y g as that do es n o t react w ith th e body, is o d o u rle ss and av ailab le in a co m p re ss e d fo rm w o u ld do. M o s t c o m p r e s s e d g ases are o n ly a v a ila b le in high pressure cy lin d ers w hich are re n te d fro m g a s su p p ly co m p an ies (like B O C G ases). H igh p ressu re g as n e e d s to be co ntro lled w ith a regu lato r in o rd er for a u sab le stream o f g as to be produced. T h e se cy lin d ers are av ailab le for lease ONLY, either short term o r for an annual fee. T h e d raw b ack w ith accessing a co m p ressed g as this w a y is th e p a p e r trail that is generates. T h e re is no anonym ity.


A s e c o n d issu e o f c o n c e rn is th e s iz e o f th e se c o m m e rc ia l c y lin d e rs. C o m m e rc ia l c o m p r e s s e d g as cy lin d e rs a re often large, h e a v y an d difficult to transport. S u sp icio n m ight arise if an elderly o r v e ry sick p erso n is seen leasing a c y lin d e r from th eir local B O C g as outlet. I f so m e o n e else w e re to collect the cy lin d er for th em , this o th er p erso n m a y w ell b e c o m e legally im plicated in a ssistin g in a suicide.

T h e se c o n c e rn s turned

m a n y p eo p le a w a y fro m u sin g high pressure, c o m p re s s e d inert g as w ith an E xit bag. T h e in troduction o f lo w pressure disp osable cy lin d ers a n d m ore recen tly light w eig h t hig h p ressu re a lu m in iu m cy lin d ers has m ean t th a t g ases like H eliu m a n d A rgo n, an d m o re recently N itrog en h av e b e c o m e viable g ases fo r u se w ith an E xit Bag. A s a result, th e E xit B ag h as u n d erg o n e a significant rise in use a s an en d -o f-life choice.

T h e O p tim a l G a s F lo w R a te T o achiev e a p eaceful h y p o x ic death w ith an inert g as an d an Exit Bag, th e op tim al g as flo w is o n e that flushes a w a y ex h aled c arb o n dio xid e s o this g as d o e s n o t accu m u late w ith in th e bag. T his optim al g as flow also prevents the b ag from heating up, but is slow enough so that useful flow w ill continue for > 2 0 m inutes. T o d e te rm in e the op tim al flow E xit ca rrie d o u t ex p erim en ts w h e re d ifferen t flow rates o f air w ere ad m itted to a bag o v e r a s u b je c t's head. T h e level o f c arb o n d io x id e w ith in the b ag w a s m o n ito re d using an RKI sa m p lin g g as detector. R esults for an 80 K g m a le taken o v e r a 5 m inute p erio d f o r tw o g as flow rates (5 & 15 l/m in) are sh ow n in Fig 5.2


F o r 15 l/min g as flow the level o f carbon dio xid e in the b ag d o e s not rise a p p reciab ly ov er the 5 m in u te period. W ith the low flow rate carbon diox ide level ap p ro a c h e d 5% , en o u g h to m a k e the su b ject u n c o m fo rta b le an d alarm ed . A flow rate o f ~ 2 0 l/min w a s seen a s optim al. W h e n u sin g disp osab le B alloon T im e cy lin d e rs as a so u rce o f helium it can be difficult to control th e flow o f gas. T h e nylon tap p ro v id e d w ith th e c y lin d e r is d esig n e d to fill p arty balloons. T h e tap is n o t d esig n e d to a llo w a m o re subtle g as flow rate. For use w ith an E xit bag, E xit re c o m m e n d s that the n y lo n fitting be d isca rd ed an d replaced w ith E x it's brass j e t flo w fitting. U s in g th e E xit flow con trol kit on a stan d a rd 4 2 0 litre helium cylinder gives a useful operating tim e o f ~ 20 m inutes. T his sam e fitting can be m o dified to control th e flow o f nitrogen from the filled L P G cy lin d er (F ig 5.6). W ith high p ressu re alu m in ium cy lin d ers, th e click reg ulato r can b e set to give a c o n sta n t flow o f 2 0 litres/m in (F ig 5 .9 .2 ) lasting f o r > 30 m in.

Fig 5.2: Exit Bag CO2 &O2 concentration levels for the first 5 minutes

H ypoxic D eath & th e E xit Bag T he G a s S o u rce (H e liu m , A r g o n o r N itrog en ) 1. H elium D isposable, c o m p re s s e d H elium c o m e s a s part o f a B alloon Kit m a n u fa c tu re d in the US. T h e se kits are d esig n e d to p ro v id e an instant system to fill helium p arty b allo o n s an d con tain a lightw eig h t cy lin d er o f helium , a p ack et o f p arty b allo o n s (3 0 o r 50 d ep en d in g u p o n the size cy lin d er) an d tie ribbon. T h e K its can b e p u rch ased outright, w ith cash, leavin g n o p a p e r trail. In N th A m e r i c a , B a llo o n T i m e c a n i s te r s a r e a v a il a b l e a t A m azo n ' s onl i ne store

( h ttp ://w w w .la tim e s.c o m /n ew s/n a tio n w o rld /w o rld /

la-fg -m e x ic o -re h a b -a tta c k 4 -2 0 0 9 se p 0 4 ,0 ,5 4 2 5 7 7 0 .sto ry ) .

In the U K , B alloon T im e can isters are av ailab le a t th e online st o r e U rb a n J u n k ie

( h ttp ://w w w .u r b a n ju n k ie .c o .u k /p r o d u c t.p h p /1 8 4 /0 /

d isp o sab le -he liu m -ta n k -w ith -p a rty -b a llo o n s-3 0 ---5 0 -p ac k )

a s w ell as C linton

C ards an d T escos h o m e stores. In A ustralia an d N e w Z e a la n d m any, b u t n o t all, Spotlight stores stock B alloon T im e canisters. There are tw o sizes o f cy lin d er available, a larger cylinder which contains 4 2 0 litres (1 4.9 c u b ic feet) o f c o m p re s s e d helium at a pressure o f ~ 1500 k P a o r a s m a lle r c y lin d e r that contains 250 litres (8 .8 cubic feet) o f co m p re ss e d h eliu m at a sim ilar p ressure. (F ig 5.3).

Fig 5.3: Packages disposable Helium containers: Left - 420 litre, Right - 250 Litre


W hile there is en o u g h H elium in a sm all cy lin d er for a peaceful death, close control o f th e g as flow rate in th e sm all cylinders is essential. T h e larg er 4 2 0 litre cy lin d e rs giv e g re a te r m arg in fo r erro r a n d are p referred for this reason. T h is cy lin d er w ill pro d u ce a u sab le stream o f g as that will run for ap p ro x im a te ly 20 m inutes; m o re than en ough tim e for a peaceful death to occur. Useful flow rates are o b tain ed fro m either cy lin d er (>5 litres/m in for 15 m in u te s w ith the sm all cylinder, an d 25 m inu tes w ith the larger - see F ig 5.4).

Fig 5.4: Flow Rate, Pressure and Volume of Helium with Time for 420 & 250 litre Cylinders using the Exit Gas Control Jet Assembly

H ypoxic D eath & th e E xit Bag 2 . A rg o n S m all n o n-refilla ble b o ttles o f c o m p re s s e d A rg on fo r use in w e ld in g ap plication s are av ailab le (see fig 5.5). T h e cylinders are small ( ~ 1 litre) a n d light ( ~ 1K g ) an d the A rg on is sto red at relativ e ly high p ressu re ( ~ 6 0 0 0 kPa o r 9 0 0 psi). A reg ulato r d esign ed for use w ith the cy lin d ers is av ailab le an d allo w s good flow control. It is im p o rtan t to note though that w ith a flat rate o f g as flow o f a ro u n d 8 litres/ m in th ere is on ly a useful p erio d o f 8 to 10 m inutes. O n ce th e A rgon g a s fills the E xit b ag there is little tim e for reflection!

Fig 5.5: 60 litre disposable Argon cylinder


3 . N itrogen N itrog en is a v e ry c o m m o n gas, m a k in g up ~ 8 0 % o f the air w e breath. T h e g as is cheap, in no d an g er o f ru n n in g out, an d readily available. It is not restricted an d no q u estio n s are a sk e d about w h y o n e w o u ld w a n t a so u rce o f this gas, altho ug h o n e m ig h t say, i f asked, that y o u are w o rk in g o n a nitrogen g as sy stem for y o u r h o m e b e e r b re w a n d w a n t to achiev e th e fine b u b b le s an d c ream y h ead a sso ciated w ith G u in n e ss stout (N itro g en is used to aerate G u in n e ss stout) A lthough disposable cylinders filled with nitrogen are n o t readily av ailab le, th is will c h a n g e in 2 0 1 2 w i t h th e re le a se o f high p ressure cy lin d e rs c o n tain in g 6 5 0 litres o f nitrogen.

Fig 5.6: Filling a 4Kg LPG cylinder with 400 psi of Nitrogen


Prior to 20 1 2 , E xit s u g g e ste d the u se o f L P G (liquid petroleum g a s ) c y lin d e rs a s a p o s s ib le c o n ta in e r to sto re c o m p re s s e d nitrogen. T h e se cy lin d ers, w hich are d esig n e d to ho ld 4 K g o f L P G , are easily o b tain ed n e w an d can be filled w ith nitrogen to a pressure o f 3.3 M P a ( o r 4 80 psi). A t ~ 4 0 0 psi there is ~ 2 5 0 litres o f n itrogen in the tan k an d useful flow rates can be m a in ta in e d for 15 to 20 m in u te s (F ig 5.6) However, there are p rob lem s filling these cylinders. G a s vendors (such a s B O C in th e U K o r A ustralia, o r A ir G a s in th e U S and C an a d a) w ill n o t fill the cylinders. O n e can re a d ily re n t a high p ressu re o f n itro g en (1 5 0 b a r/ 2 0 0 0 p si) an d w ith a suitable regu lator d ecan t g as into th e L P G cylinder. T h is requires a great deal o f care, an d an accu rate p ressu re re g u la to r o r the LPG cylinder c o u ld rupture. I f this is to be carried out, a solid safety b a rrier s h o u ld su rro u n d th e L P G cylinder.


A b e t t e r s t r a t e g y is to p u r c h a s e an e m p t y h i g h p r e s s u re alu m in ium cylinder. W hile so m e g as outlets will fill this typ e o f cylinder w ith nitrogen fo r you, others will not. T hese alum inium cy lin d ers (see F ig 5 . 6 .1) are av ailab le in the U S by mail order from the B everag e Factor) at: http://bit.ly/jp A 5 9 Z T h e 2 2 cu ft (6 5 0 litre) cy lin d er pictured has a rated se rv ic e pressure o f u p to 22 0 0 P S I/1 5 0 BA R.

R eg u la tin g th e F lo w o f N itrogen T h e easiest w a y to regulate the flow o f nitrogen is v ia a suitable regulator. A regu lator w ill g iv e e a s y control o f flow rate an d can b e set to d e liv e r ~ 2 0 litre/m in. A full cy lin d er w ill g iv e a steady flow o f nitrogen fo r a ro u n d 30 m inutes. T h e re is no n eed for th e E xit flo w fitting that is u s e d w ith the h eliu m B alloon T im e system . T h e d elivery ho se to take the n itrogen to the E xit Bag fits d ire ctly o n to the regu lator outlet. To set the flow rate, a sim p le flow g a u g e can be m a d e by u p e n d in g a 2-litre so da bottle filled w ith w a te r an d allow ing th e nitrogen flo w in g th ro u g h the h ose to displace th e w ater. T h e req u ired flow ra te o f ~ 20 litres/ m in sh o u ld e m p ty the bottle in ~ 6 sec. O n e useful aspect o f the N itro g e n S ystem is the fact that the cy lin d ers can be to p p e d u p i f th ere is leakage o f n itrogen o ver tim e (the d ispo sab le H elium a n d A rg on cy lin d ers c an n o t be refilled). N ote: the p ressu re m e a s u re m e n t n eed ed to establish that a cy lin d er is full is p ro v id e d b y the g a u g e on th e regulator.


Fig 5.6.1 (a) 650 litre Al cylinder (b) Nitrogen regulator (c) Gas cylinder ready to connect to Exit Bag


T he Exit Bag T h e Exit plastic b ag is th e b ag w h ich is filled w ith th e inert g as. T h e b a g is d e s ig n e d to e n a b le s im p le filling w ith no co n tam in atio n w ith o xygen, p ro v id in g a straight fo rw ard w a y for o n e to su d d e n ly im m erse o n e s e lf in inert gas.

1. M a k in g an Exit Bag W hile different people m ak e slightly different bags, th e standard Exit B ag in v o lv es a plastic b ag of: a re a so n a b le size a suitable s o ft plastic a n eck b an d o f elastic that allo w s th e bag to m ak e a snug, b u t n o t tight, fit a ro u n d a p e rso n 's neck In th e p a s t, E xit B ag s h ave been able to be p u rch ased from o rganization s such as R ight to Die C anad a.

A s the original

in v en to rs o f the Bag, R ight to Die C an a d a w ere activ e for m an y y ears in th eir m an u factu re an d sale an d fo r a w h ile p ro v id e d a m ail o rd er se rv ic e for their m em bers. F o r a sh o rt p erio d in 2001 an d again in 2 0 1 1, E xit International also s o ld Exit bags. H o w ev er, w ith th e ex p e rie n c e o f Sharlotte H y d o rn o f the GLADD organisation in California in early 2011 (her h o m e w a s raided b y th e p o lice an d FBI w h o s e iz e d all m an n er o f p ro p erty ) fresh in o u r m in d s Exit h as re v ise d its position for the tim e being a t least. See: h ttp ://b it.ly/q u n U q 0

In recen t y ears, it h as b een N u rse B etty w h o h as tau g h t readers o f th is b o o k h o w to s ta y safe in th e law an d m a k e th eir own E xit bags.


T o m ak e an E xit Bag, several item s a re n eed ed (se e Fig 5.7) Plastic • b ag - p o ly ester ' o v en b a g ' av ailab le in su perm ark ets is a g o o d size (L arg e 3 5 cm x 4 8 c m ) ' A & B' •1m etre o f 10 m m w id e elastic, ' D' •1toggle to ad ju st elastic length •1 roll o f 2 0 m m stick y tape ‘C ’ (M ic ro p o re o r equivalent) 1• sm all roll o f ~ 35 m m plastic du ct tape •Pair o f sh a rp scissors

Fig 5.7 Items used to construct an Exit Bag


C o n stru c tio n

(S ee Fig 5.8 & D o it w ith Betty video)

1. L a y th e b ag o u t on a flat surface an d folded b ack ~ 25m m (1 ”) a ro u n d the o p e n en d (A-B) 2. M ak e a 2 5 m m cu t in th e fo ld e d po ly ester 3.

L a y the elastic ( C ) inside th e fold an d h ad th e tw o e n d s exit

4.

through this cut Tape c o m p le te ly along th e fo ld e d e d g e o f the plastic with

5.

the stick y tape Place a cut in a ~ 6 0 m m p ie c e o f du ct tape an d fold this ov er

6.

7.

the ex iting clastic to strengthen this part o f the bag T h re a d a small w ire tie through tw o cuts in an o th e r p iece ( ~ 5 0 m m ) o f du ct tape an d stick this to th e inside o f the bag ~ 15cm u p fro m th e e lastic (E). T h is can be u s e d to secure the plastic helium h ose inside the bag. T h e to g g le (D ) is th en th re ad ed onto th e tw o e n d s o f the clastic to co m p le te th e b a g (F ig 5.9)

Fig 5.8: Exit Bag Manufacture

Fig 5.9: The completed Exit Bag

G a s F lo w C o n t r o l N o m atter w h ic h g as is u s e d a flo w v e lo c ity o f ~ 15 1/min is n e e d e d to p re v e n t th e a c cu m u latio n o f C 0 2 in the Exit bag. Exit has investigated several m eth o d s o f c o n tro llin g g as flow.


F o r disposable ‘Balloon T im eʼ helium cylinders a t pressures o f 1700 kPa, Exit h as d esig n e d g as flow control fittings e x p re ss ly for this purpose. T h e se fittings are av ailab le at:

http://bit.ly/9swOxk F o r high pressure cylinders o f nitrogen o r helium , regulation is essential. Regulators can be purchased from g as providers. T h e re g u la to r s h o w n in F ig 5.9.2 g iv es th e p ressu re o f n itrogen in the cylinder, an d allo w s th e o u tp u t flow rate to b e set at 15 o r 2 0 litres/ m in. U s in g this regulator, flow rate is constant thro u g h o u t th e hy p o x ic death. F o r th e low -p ressure n itrogen system d e s c rib e d (F ig 5.6) w ith filling p ressu res o f 2 8 0 0 k P a (4 0 0 p si), a suitable flow rate can b e o b ta in e d u sin g a s ta n d a rd L P G re g u la to r to restrict the outlet p ressu re to ~ 2.8kPa. A je t (size ~ 2 m m ) w ill allow a constant flow o f n itrogen at the appropriate rate. T h e regu lator a sse m b ly w ith 2 m m j e t is s h o w n in Fig 5 . 9 . 1

Fig 5.9.2 High pressure nitrogen regulator with click flo w rate output

Fig 5.9.1 LPG regulator and 2mm jet used to control nitrogen flow


Fig 5.10: Fittings purchase page at peacefulpill.com


Fig 5.11: The Exit Helium flow control fitting

Fig 5.12: Pressure gauge used to check if gas cylinder is full


Fig 5.13: Helium cylinder with pressure gauge attached to flow control assembly

Fig 5.14: Positioning, Inflating & Using the Exit Bag with Helium


Testing th e P ressure o f th e G a s in th e C y lin d er W ith th e Exit b ag m eth o d , it is im portant to establish that there is sufficient g as av ailab le fo r a p eaceful h y p o x ic death. For co m p ressed g a s in c y lin d e rs, the easiest w a y o f en su rin g this is to m easu re th e pressure. T h is is p articu larly im p o rtan t for cylinders that h a v e b een kept in sto rag e fo r lon g periods. F o r B alloon T im e h eliu m cy lin d ers a pressure g au ge th a t fits the flow control m akes testing the pressure sim ple. A full cylinder sh o u ld h ave a pressure o f > 1700 k P a (25 0 psi). S o m e o f these cylinders h av e b een found to h ave faulty ta p s an d to be n ear em pty on purch ase. A su itab le p ressu re g a u g e is av ailab le from h ttp ://b it.ly /9 s w O x k (see F ig 5.10). W h e n u sin g a high p ressu re nitrogen sy stem , th e p ressu re will b e s h o w n b y the re g u la to r an d s h o u ld b e ~ 1 2 ,0 0 0 k P a (1 700psi). F o r a L P G cylinder, the p ressu re s h o u ld be ~ 2 8 0 0 k P a (400psi). I f a regu lator an d large j e t are to be u s e d w ith th e L P G cylinder, p ressure m easurem en ts m u st be m ade up stream o f the regulator.

G as P u rity E xit o ccasio n ally receiv es repo rts o f failures b y p eo p le using Exit Bags. A lthough this information is sketchy, the reports arc o f p eo p le breathing the g as inside th e bag for so m e m in u tes w ith no loss o f co n scio u sn ess. In all c ases th e g as inv olved w a s helium . C o n tam in atio n o f th e g as h as b een su g g ested as an explanation. T h e o n ly p o ssib le co n tam in atio n that could p ro d u c e this effect w o u ld be th e addition o f a significant q u an tity o f o xygen to the helium . T h e introduction o f 10% o f ox ygen w o u ld have no effect on the m ark eted u se o f the g as - b alloons filled w ith this m ixture w o u ld float - b u t this g as w o u ld fail in an Exit bag.


E very y e a r, Exit tests n e w B alloon T im e helium cylinders. T h e resu lts o f these tests h ave b een reassu rin g w ith n o evidence o f significant con tam ination. Typical H eliu m g as analysis: O2~0.4%, CO2 <0.01%, CO <0.1ppm,

Hydrocarbons ~ 40ppm.

W h e n u sin g nitrogen, th e g as so u rce u s e d to fill th e cy lin d er m u st b e clean a n d free from contam inants. N ote: T h e g as u sed in failed attem p ts h as n o t b een tested. N ote: Exit has been in contact w ith the m anufacturers o f B alloon Tim e h eliu m cylinders. W e h ave been as su re d that i f oxygen w ere to b e a d d e d to th eir h eliu m cy lin d ers it w o u ld b e noted p ro m in en tly on the cylinder.

C o n n e c tin g th e C y lin d e r to th e E xit Bag To u se th e Exit B ag w ith an inert g as like H elium , o n e needs to c o n n e c t th e cy lin d er to the E xit b ag u sin g th e Exit g a s flow fitting. Plastic tu b in g (stan d ard 2 m etre o xygen tu b in g w ith soft con nectors) is suitable fo r this p u rp o se an d c o m e s inclu ded w ith the Exit H eliu m fitting. T h e tu b in g is fitted very tightly to th e tail-end on the flow control fitting. T h e o th er e n d is then stuck to the inside o f the Exit b ag with M icro p o re tape. It is rec o m m e n d e d to te st that th e a tta c h m e n t o f th e tu be to th e flow fitting an d to th e Exit b ag is secu re an d not easily dislodged.


T h e P roced u re T h e goal for this m e th o d is to p ro d u c e a reliable, quick and p eacefu l death from hypoxia. T h e re are 3 stag es in this p ro cess and these are sh ow n in th e V id eo (B etty an d th e E xit Bag) and in fig 5.14. A d ju st th e e lastic in ne c k o f th e b ag so that it is a firm fit a ro u n d th e h u m an neck. T h e n p la c e the b ag on th e head acro ss the forehead. C ru sh the b ag d o w n onto the h ead to e x c lu d e all air then open the tap on th e H elium bottle. T h e flo w o f H eliu m at ~15 1/min fills the b ag in a b o u t a m inute. W h e n the b ag is filled w ith gas the H elium w ill begin to leak a ro u n d the elastic w h ile th e b ag re m a in s fully inflated. A q u ic k lo ok in th e m irro r w ill en ab le the b ag to be correctly p osition ed an d full o f H elium . To b rin g about a p eaceful death, a person w o u ld exhale totally (fu lly e m p ty th eir lungs) a n d h o ld their b reath w hile p u llin g the bag d o w n o v e r th eir head. W h e n the bag is o ver th e h ead an d s n u g ly a ro u n d th e neck, th e y w o u ld take the d e e p e s t breath possible. L o ss o f c o n s c io u sn e s s w ill o c c u r a lm o s t im m ed iately - w ith in o n e o r tw o breaths. Death o c c u rs few m in utes later.


W h o shou ld n o t u se th e Exit Bag F o r a p eacefu l death o n e m u st b e a b le to fu lly e x h a le an d in h ale. T h is allo w s th e rap id e x c h a n g e o f th e a ir in th e lungs w ith the g as in th e bag. S o m e respiratory d isea ses can m ake this difficult o r impossible. F o r ex am p le, p eo p le w ith e m p h y s e m a o r ch ron ic obstructive a irw a y s disease sh o u ld be a w a re o f p o ssib le p ro b le m s i f th ey a tte m p t to use this m eth o d. I f the g as ex ch ang e c an n o t take p la c e quickly, the tim e befo re c o n s c io u sn e s s is lost can be u n a c c e p ta b le lon g an d result in panic.

C le a n in g A w ay - T h e A ffect o f Inert G a s on the B ody T h e u se o f an inert g as w ith an E xit B a g p ro d u ces n o changes in the b o d y that can b e seen o r found on initial inspection. In 2 0 0 7 forensic labo rato ry tests w e re d e v e lo p e d to establish the pre sen c e o f g ases like H eliu m , A rgon a n d N eo n in th e lungs o f th e deceased . In 2009, the first report o f the use o f this technique in establishing the c a u se o f death o f an Exit m e m b e r w a s noted. S u ch testing is u n c o m m o n an d it rem ain s true that i f th ere is no e v id en ce o f an E xit b ag o r g as cy lin d er h av in g being u s e d , it is likely that the death will be certified a s natural. T h e exception is N itrogen. I f N itro g e n is u s e d fo r a h y p o x ic death, a n d i f th e Exit bag a n d tu b e is r e m o v e d , n o c o n c l u s io n s can b e d r a w n fro m d etectin g its presence. T h e Exit B ag w ith N itro g e n is th e only m eth o d o f a p eacefu l an d dignified death w h ic h p ro v id e s total undetectability.


C o n c lu d in g C o m m e n ts T h e Exit B a g w ith Inert G a s is an en d o f life m eth o d that is reliable, sim ple an d d oes n o t in vo lve illegal d ru g s o r equipm ent. N ev erth eless, th e m eth o d d e m a n d s substantial preparation. A d isp o sab le g as c y lin d e r needs to b e pu rchased , a lo n g w ith the requ isite co nn ectio ns, tubing a n d a B a g m u s t be m ade. Techn iqu e is also im p o rtan t a n d a certain d eg ree o f physical d ex terity is required. O n th e d o w n sid e , the n e e d fo r s o m u ch eq u ip m en t an d the unaesthetic nature o f placin g a bag ov er o n e's h e a d p rev en ts m an y p eo p le from even c o n sid e rin g this m ethod.

T H E R P T E S T S C O R E - Exit B a g + H elium R eliability (R = 8/10) T h e m e th o d is reliable b u t tech n iq u e is im p o rtan t a n d a d eg ree o f co o rd in atio n an d dex terity is required P eacefu ln ess

( P = 7 / 10)

C o n sid e re d “ p eacefu l” p artly b ecau se the loss o f co n scio u sn ess c o m e s quickly. T h e re is the sensation o f “ air h u n g er” an d alarm A vailability All co m p o n e n ts are re a d ily available

(A = 5/5)

Preparation ( P r = 1/5) C o n sid era b le a sse m b ly a n d “ setting u p ” o f eq u ip m en t U n d ete ctability (U = 5/5) I f all e q u ip m e n t is re m o v e d d etectio n is rare. I f N itro g e n is the g as used th e m e th o d is totally undetectable.


Speed L oss o f co n scio u sn ess c o m e s quickly

(S p = 5/5)

Safety T h e m e th o d presents n o d a n g e r to others

(S a = 5/5)

Storage (S t = 5/5) C o m p o n e n ts d o n o t deteriorate w ith tim e. G a s p ressu re test can re a d ily establish helium cy lin d er is full Total R P S c o r e

41/50

(82 % )

T H E R P T E S T S C O R E - Exit B a g + H elium C rite ria

S core

R eliability

8/10

P ea cefu ln ess

7/10

A va ila b ility

5/5

P rep a ra tio n

1/5

U n d etecta b ility

5/5

S p e ed

5/5

S a fety

5/5

S to ra g e

5/5

T o ta l

41 (82% )

The P eaceful P ill H andbook C h a p te r 5: F r eq u e n tly A sk ed Q u estio n s C an a fa c e -m a sk b e u se d in ste a d o f th e E x it B a g ? C o m m o n , in e x p e n s iv e fa ce m a s k s are o fte n u s e d to d e liv e r o x y g en to patients. T h e y a re u s u a lly h e ld in place b y clastic w h ic h c o v e r s th e n o s e a n d m o u th w i th o x y g e n d e liv e r e d th ro u g h a plastic tu be attach ed to th e b ase o f th e m ask. T h ere is no a tte m p t to seal th e m ask an d face. T h e p u rp o se is sim ply to increase th e co n cen tratio n o f o x y g en b reath ed a b o v e the u sual 21 %. In contrast, th e Exit B a g p ro d u ces r a p id loss o f co n scio u sn ess b y en su rin g th a t N O ox ygen is inhaled. T o a c h ie v e this using a m ask , flow delivery flow rates o f at least 2 0 litres/sec w o u ld be req u ired to red u ce the ch an ce o f o x y g en c o n tam in atio n during inspiration (ie. 100 tim es that necessary w ith th e E xit Bag!). W hile technically possible, a large diam eter delivery hose w ould b e n eed ed a lo n g w ith a g as source very m uch g re a te r than the 4 2 0 litre B alloon T im e cylinders. R isky an d n o t reco m m en d ed .

D o I n e e d to c o n n e c t 2 B a llo o n Time H eliu m C ylin d ers to en su re S u ffic ien t G a s is A va ila b le? N o, this is not necessary i f the flow o f g as is reg u lated using the Exit flow control fitting. W ith th e g as flo w regulated, ev en the s m a lle r (2 50 litre) Balloon T im e cy lin d er will p ro v id e sufficient g as flow, en su rin g there is n o b u ild u p o f c arb o n d iox ide in the b ag for at least 15 m in u te s (F ig 5.4). T his is m o re th an enough tim e for a p eacefu l death. I f th e tu be is to b e c o n n ected directly to the cy lin d er w ith no g as flow regulation (other than the cy lin d er o n /o ff tap), m ultiple cy lin d ers sh o u ld be em ployed.

6

Carbon M onoxide

Introd u ction C arb o n M o n o x id e (C O ) is o n e o f the m o st lethal g ases known. Its toxicity is d u e to its ability to strongly bind w ith h aem oglobin w h ic h g r e a t l y r e d u c e s th e o x y g e n - c a r r y i n g c a p a c i t y o f a p e r s o n 's blood. A re a s o f the brain sensitive to isch a em ia (low o x y g en level) are affected sev erely an d a rapid, p eaceful death is the c o m m o n result. T h e g as is p articu larly d a n g ero u s, a s it is a co lo u rle ss, o d o u rle ss a n d a n o n -irrita tin g gas. W ithout sp ecializ ed m o n ito rin g eq u ip m en t, there is no w a y o f know ing that c arb o n m o n o x id e is present. Death b y p o iso n in g fro m c arb o n m o n o x id e can b e reliable, q uick a n d peaceful, p ro v id e d the co ncentration o f th e inhaled g as is sufficiently hig h. In th e 19 9 0s, D r Jack K ev o rk ian helped m ore than 100 serio u sly ill p eo p le to en d th eir lives peacefully, n early h a l f o f w h o m used c arb o n m o n o x id e . D r K evorkian used a c y lin d e r o f co m p re ss e d carbon m o n o x id e (9 % C O in N itro g e n ). T h e person w a n tin g to d ie sw itch e d on th e g as at th e cy lin d er an d b reath ed through a loose-fitting face m ask . A f e w d eep b re a th s o f the c arb o n m o n o x id e-n itro g en m ix tu re and th e person lost co n scio u sn ess a n d d ied quickly. D r K evorkian w o u ld then sw itch o f f th e g as an d rem o v e the cy lin d er an d face m ask . T h o s e present a t these d eath s describ ed th e effectiveness an d peacefu ln ess o f th e approach.

C arbon M onoxide

PPM

T im e

S ym p to m s

[C O ] 8 hours

35

M axim u m

e x p o s u r e a l l o w e d b y O S H A in t h e w o r k p l a c e o v e r a n e ig h t h o u r period .

200

2 -3

hours

M ild h e a d a c h e , f a t i g u e , n a u s e a a n d d i z z i n e s s .

400

1-2

hours

S e r io u s h e a d a c h e -o t h e r s y m p t o m s in ten sify. Life th re ate n in g a fte r 3 hours.

800

4 5

m in u te s

160 0

20

m in u te s

320 0

6400

5 -10 m in u te s 1-2

D iz z in e ss, n a u s e a a n d c o n v u lsio n s . U n c o n s c io u s w ith in 2 D e a t h w ith in 2 - 3 h o u rs.

hours.

H e a d a c h e , d iz z in e ss a n d n a u s e a . D e a th w ith in 1 h o ur. H e a d a c h e , d iz z in e ss a n d n a u s e a . D e a th w ith in 1 h o ur.

H e a d a c h e , d iz z in e ss a n d n a u s e a . D e a th w ith in 2 5 - 3 0

m in utes.

m in u te s 12,8 0 0

1-3 m in u te s

R ap id D eath

Table 6.1 Effect of carbon monoxide exposure

It is im p o rtan t to establish that m o n o x id e co ncentration is high enough a s p e rio d s o f tim e sp en t in sub-lethal g as levels can lead to s e rio u s irreparable dam ag e. From th e acco m p an y in g table (Table 6 .1 ) it is clear that altho ug h d e a th will o c c u r at m u ch lo w e r levels, i f o n e is in the e n v iro n m e n t for so m e tim e, it is s tro n g ly re c o m m e n d e d that c o n cen tratio n s g re a te r than 1% (10,000 p p m ) are g e n e ra te d by th e m eth o d chosen. T h e re are often no specific clinical findings to identify this agent as the c a u se o f death, alth ou gh o ccasio n ally th e red colouration o f ‘v e n o u s ʼ b lo o d gives a flushed pink c o lo u r to th e skin o f the corpse. T h is co lo uration m a y indicate th e cause o f death to an ex am in in g d o cto r an d its presen ce will b e d etected at autopsy. I f it is im p o rtan t that th e death look ‘n a tu ra lʼ (a n d ‘s u ic id e ʼ not b e stated on th e death certificate), th en p o iso n in g by carbon m o n o x id e m a y n o t b e th e best c h o ic e .


T esting th e C o n cen tra tio n o f C a r b o n M o n o x id e To ensure that th e m o n o x id e co ncentratio n is sufficiently high f o r a peaceful death, it is w is e to test the g as concentration. To d o this one needs an appropriate m e te r capable o f reading carbon m o n o x id e co n cen tratio n levels. Exit h as tested sev eral m eters for this p u rp o se. T h e cheapest m o n ito rs h av e o n ly a w a rn in g light set to alarm w h e n levels o f 5 0 p p m are ex ceeded. T h e se are o f lim ited use.

Fig 6.2 a) RKI sampling multi-gas meter b) TPI 707 high level monoxide analyser c)TPI 770 monitor with sampling probe

C arbon M onoxide

G au g es w ith a digital read ou t o f u p to to 1000 p p m (0.1 % ) can b e easily ob tain ed . It is ad v isa b le to h ave a sa m p lin g facility on th e g a u g e s o that the level p ro d u c e d can b e sa m p le d before u sin g this m eth od . S a m p lin g g au g es can b e m o dified w ith a 10:1 reduction, so that levels up to a n d g re a te r th an 1% can be m easured. G a u g e s u s e d b y E x it a re s h o w n in F ig 6.2. T h e m u lti-g as s a m p l i n g m e t e r (R K I E a g le ) e n a b l e s t h e m o n i t o r i n g o f carbon m o n o x id e levels, carbon dio xid e levels a s well as the concentration o f av ailab le o x y g en . T h is g a u g e retails for ov er U S $20 0 0 an d is p rim a rily u s e d a s a research tool. A sm aller h an d -h eld d ev ice (TPI m od el 701 carbon m o n o x id e analyser) that m e a su re s asp irated g as o f u p to 10 ,0 0 0 ppm is also show n. T h is useful g a u g e co sts ~ U S $ 600. A c h e a p e r T P I g au ge used b y E xit w ith a m o d ified 10:1 sa m p lin g p ro b e (TPI m o del 770) costs ~ U S$200.

S ou rces o f C a r b o n M o n o x id e From C o m m ercial G a s Suppliers: C ylinders o f co m p re ss e d carbon m o n o x id e , either a s the pure g as o r a s a m ix tu re (eg 5 % in N itro g e n ) are av ailab le from scientific g as su p p ly com panies. T h e re are no special restrictions b u t an acco u n t w ill be n eed ed . T able 6.1 lists so m e available p a c k a g in g fo r p ure co m p re ss e d carbon m o n o x id e from HOC. http://w w w .boc.co m C ylinders o f sp ecial g as m ix tu res that contain lethal levels o f m onoxide a re also used a s source gases for so m e industrial lasers (eg 6 % C O in g as u s e d in th e Rofin C O 2 slab laser). h t t p : //w w w .lin d e - e le c t r o n i c s . e u / s g / m i x s g / l a s e r m i x __ 6 9 0 _ e n . h t m l

The P eaceful P ill H andbook C arb o n Monoxide (CO )

Table 6.3. Compressed CO cylinder sizes

Vehicle E x h au st Gas: C arb o n M o n o x id e is p ro d u c e d a s an ex h a u s t g a s from internal c o m b u s tio n eng ines. T h e c o n c e n tra tio n o f th e m o n o x id e in th e ex hau st g as varies, d ep en d in g on a n u m b e r o f factors and e stab lishin g this is critical. U sin g F o rm ic A c i d : C a rb o n M o n o x id e is p r o d u c e d b y a ch e m ic a l reactio n that o ccu rs w h e n th e form ic a c id ( H C O O H ) is b ro k en d o w n into w a te r ( H 2O ) an d c arb o n m o n o x id e (C O ). T h e catalyst for this b reak d o w n is c o n c e n tra te d su lp h u ric acid. T h e su lp h u ric acid r e m a in s c h e m ic a lly u n c h a n g e d b u t is d ilu te d b y th e w a te r released. M o n o x id e g e n eratio n ceases w h e n all o f th e fo rm ic acid is b ro k en dow n, o r w h e n th e sulphuric acid b e c o m e s to o dilu te to cataly ze the reaction. H eat is g e n e ra te d in th e reaction a n d this c an lead to traces o f fo rm ic an d su lp h u ric acid in the em erg ing carbon m onoxide. O n e m o le o f form ic acid (4 6 g m ) will produce ~ 22 litres o f carbon m onoxide. T h e chem ical eq uation is: H C O O H → H 20 + C O

C arbon M onoxide U sin g O x alic A c i d : C oncentrate sulphuric acid can be used to b reak do w n anhydrous oxalic acid to pro d u ce c arb o n m o n o x id e (an d c arb o n dioxide). A g ain th e su lp h u ric acid re m a in s c h e m ic a lly u n ch an g ed but is d ilu te d b y the w a te r p r o d u c e d in th e reactio n . L ess heat is g e n e ra te d in th e re a c tio n a n d th e r e is less lik elih o o d o f con tam ination w ith v a p o u r from th e su lp h u ric acid. O n e m ole o f oxalic acid (~ 9 0 g m ) pro du ces equal m o la r am o u n ts o f carbon dioxide a n d c arb o n dioxide. T h e chem ical eq uation is: H O 2C C O 2H 20H →

+ C O 2+ C O

U sin g C arb o n (charcoal ): T h e in c o m p le te o x id a tio n o f c a r b o n can p r o d u c e c o p io u s a m o u n ts o f c a rb o n m o n o x id e . A s th e o x y g e n a v a ila b le to a c h a rc o a l fire d e c r e a s e s th e p ro d u c tio n o f c a rb o n d io x id e d ecrease s a n d c arb o n m o n o x id e increases. The chem ical eq uation is: 2 C O 2→ + C U sin g Z in c an d C alciu m C a r b o n a te : P o w d ered zinc can b e m ix e d with calciu m carbonate an d heated to produce carbon m onoxide, along w ith calcium and zinc oxide. H eat is n eed ed fo r the p ro c e ss a n d this o ffers the o p p o rtu n ity o f con trolling th e p rocess (u sin g an electrical heater). The chem ical eq uation is: Z n + C a C O 3 → Z n O + C a O + C O

U sin g Vehicle E xh au st G a s a s a S ou rce o f C a r b o n M on oxid e Internal co m b u stio n en g in e s p r o d u c e a sm all p e rc e n ta g e o f carbon m o n o x id e in th e exh aust gas. I f this g as is inhaled, death w ill result. Piping th e g as into th e car, o r run n in g the c a r in a clo se d shed are c o m m o n ap p ro ach es. In all eases, though, the carbon m o n o x id e w ill be m ix e d w ith a large am o u n t o f other fo ul-sm elling ex h a u s t products. O n e o f th e benefits o f using this g as, p e a c e fu ln e ss, is lost.


O ld e r cars ten d to p ro d u ce the high est levels o f ex h a u s t carbon m o n o x id e. W ith the in troduction o f u n le a d e d petrol in the 80s, there h ave b een controls on th e m o n o x id e levels in exh au st gases to m eet en viron m ental standards. S ince 1997 n e w cars can em it n o m o re that 10% o f the levels o f c arb o n m o n o x id e acceptable in 1976. M andatory catalytic con verto rs o x id iz e m o s t o f the p ro d u c e d carbon m o n o x id e to form c arb o n dioxide. D e s p ite th e se s ig n ific a n t c h a n g e s in th e em issio n le v e ls o f c arb o n m o n o x id e , m o to r vehicle ex h a u s t g as su icid es co ntinu e to o c c u r at a s u rprisin g ly high rate. In d eed , in the p erio d from 1976 to 1995 th e rate o f ex h a u s t g as su icid es in so m e countries increased faster th an th e ra te o f m o to r v e h ic le reg istratio n s (R o utley & O zanne-S m ith, 1998). Possible explanations include th e fa c t th a t id lin g m o to rs d o n o t n e c e s sa rily c o m p ly w ith international standards. A dditionally, catalytic co n vertors do n o t function w h en co ld. R ather, th ey re q u ire several m in u te s to w arm from a cold start. O f significance though is the increasing n u m b e r o f failed suicide attem p ts from b re a th in g ex h au st gas rep o rted in this period. T h is is n o t to say that th e m o to r c a r c an n o t be u s e d a s a source o f c arb o n m o n o x id e to effect a reliable death, b u t th ere are p r o b le m s a s s o c ia te d w ith th e m e th o d . O n e c o n c e rn is th e m e c h a n ic a l c o n n e c tio n o f th e ex h a u s t to th e h ose carry in g g as to th e car. M a n y m o d e m v eh icles h av e elliptical exhaust outlets. C o u p lin g th e ex hau st to a round hose, often using plastic tape, can c a u se p ro b le m s b ecau se o f the heat o f ex h a u s t gas. I f th e tape o r tu b e m elts o r is d estro y ed b y th e heat, failure is likely. Fig 6.4 sh o w s a carefu lly e n g in e e re d system u sin g metal co n n ectio n s an d clam p s an d heat resistant tubing.

C arbon M onoxide

Fig 6.4. The car as a carbon monoxide source

T his approach d em an d s m eticulous attention to detail an d testing is s tro n g ly re c o m m e n d e d . A c arb o n m o n o x id e m e te r sh o u ld be u s e d for testing. T h e m e te r sh o u ld be p laced on th e front scat. T h e car sh o u ld then be run u sin g the p la n n e d setup. T h e m e te r can be w a tc h e d safely fro m outside the car. T h e m e te r reading will soo n s h o w i f th e sy stem w ill w o rk . I f th e m e te r m oves q uickly o ff-scale (> 5 0 0 p p m ), the m e th o d is u nlikely to fail. If th e m e te r strug g les to rise, ev en w h e n the m o to r is started cold and a llo w e d to idle, th e system sh o u ld be avoided. In addition, careful p lan n in g is req u ired to a v o id th e possibility o f intervention. A car ru n n in g w ith a ho se fed into th e back w in d o w w ill a lm o s t c e rta in ly attra ct a tte n tio n . A n d , even i f effective, sitting in an e n v iro n m e n t o f hot, foul sm elling, b u rn t e n g in e w a ste , j u s t to m ak e u se o f th e tiny p ercen tag e o f m o n o x id e present, is an unpleasant w a y to die. In E x it's research o f o u r eld erly m e m b e r s ' attitudes, only a small n u m b e r sh ow ed interest in u sin g ex h a u s t carbon m onoxide.


Fig 6.5 The early CoGen

C arbon M onoxide

M aking C a rb o n M onoxide (the C O G en) F o r o v e r a d e c a d e , E xit International h as in v estig ated the use o f c arb o n m o n o x id e. S ince the co m p re ss e d g as is difficult to so u rce, Exit h as d e v e lo p e d g e n erato rs that pro d u ce th e carbon m o n o x id e gas w h en an d a s required. T h e first carbon m o n o x id e g e n e r a to r (th e C O G e n ) m a d e u se o f th e c h e m ic a l reactio n (catalytic b re a k d o w n ) th a t tak es p la c e w h en fo rm ic a c id is ad ded to su lp h u ric acid. In the original m od el (F ig 6.5) the form ic a c id w a s p laced in an intraven ou s b ag an d a llo w e d to d rip into th e reaction c h a m b e r co ntainin g th e sulphuric acid. T h e g as p ro d u c e d w a s then fed to th e m an n eq u in u sin g nasal prongs. F ilm m a k e r Jan in e H osking re co rd ed this first d em o n stratio n a t E x it's labo ratory in late 20 0 2 , an d the se q u e n c e w a s s h o w n in th e film M a d em o iselle a n d th e D octor. S ince that tim e o th er m eth o d s o f carbon m o n o x id e generation have b een investigated. M eth o d s includ e the partial oxidation o f c arb o n (ch arco al), the red u ctio n an d cataly tic co n v ersio n o f oxalic acid, an d th e reaction betw een p o w d e re d zinc and calcium carbonate.

Fig 6.6. COGen 4 on fume cupboard test bench with acid bottles and CO monitor


Fig 6.7 The COGen & acids

C arbon M onoxide

How th e C O G e n W orks T h e C O G e n c o n sists o f tw o P V C c h a m b e rs ( ‘Aʼ & ʻC ʼ, Fig 6.7). T h e inner c h a m b e r ʻ A ʼ is m o u n te d to th e s c re w lid o f the larger o u ter 10cm (3 .9 inch) co n tain er an d has a drip e x it ʻF ’ in its base. T h e drip rate is co ntro lled b y a s c re w ‘E ʼ. 150 m l o f 8 5 % form ic a c id is p laced in c h a m b e r ( ‘A’) w ith the control-valve shut. 25 0m l o f c o n c e n tra te d su lp h u ric a c id (9 8 % ) is p laced in the outer c h a m b e r ʻD ʼ an d th e C O G e n assem bled. O p e n in g th e s c re w ‘E ’ a llo w s th e fo rm ic a c id to d rip into th e c o n c e n tra te d su lp h u ric acid. C o p io u s a m o u n ts o f carbon m o n o x id e are released an d exit the c h a m b e r th ro u g h v e n t holes in the lid ‘H ʼ. T h e V id eo sh o w s th e C O G e n b e in g a r m e d an d p la c e d in a small car. T h e c arb o n m o n o x id e co n cen tratio n in th e c a r w a s c o n tin u o u sly sa m p le d w ith a p ro b e p ositio ned n e a r th e head o f th e m an n eq u in . T h e g raph (F ig 6.8 ) sh o w s the m easu red concentration in p p m , p lo tted o v e r th e first 30 m inutes. Lethal concentratio ns w e r e re a c h e d a few m in u te s after s w itc h in g on th e generator. A p eak level o f ~ 3 % C O w a s recorded.

S ou rcin g th e Acids C o n c e n tr a te d su lp h u ric a c i d ( 9 8 % ) can b e p u r c h a s e d from chem ical su p pliers o r at h a rd w a re sto res w h e re it is s o ld as a drain cleaner. C o n ce n trated laboratory sulphuric acid is an oily clear liquid, w h e re a s the d rain -clean er su lp h u ric acid can b e dark b ro w n in co lo u r b e c a u s e o f ad d itiv es, but this d o e s not effect the g e n e r a to r's operation.


F o rm ic a c id is a v a ila b le fro m ch e m ic a l s u p p ly co m p an ies. H o m e h o b b y ists use form ic a c id in ta n n in g o r bee-keeping. F orm ic acid can also b e p u rc h a se d o n lin e th ro u g h chem ical s u p p ly w ebsites. O xalic acid is used a s rust an d stain cleaner and can be purchased from h ardw are stores.

S a fety N o te C o n c e n tra te d fo rm ic an d sulphuric acids a re co rro s iv e liquids. T h e y sh o u ld be kep t s e c u re d in glass o r p o ly eth y len e containers (plastic soft d rin k / sod a bottles are n o t suitable). W h e n using su lp h u ric acid, ru b b e r g lo v es s h o u ld b e w o rn along w ith eyep ro tectin g g o g g le s an d a face-splash protector. S pills o f acids on to th e skin sh o u ld be w a s h e d o f f im m ed iately w ith copious a m o u n ts o f w ater. I f either o f these acid s gets in th e eyes, w ash th e eyes con tin uo usly for several m inu tes an d th en seek m edical assistance.

Table 6.8 CO concentration with time using COGen in a vehicle

C arbon M onoxide

G enerating C a rb o n M onoxide using a C h a rc o a l B urner T h is m e th o d o f g en eration is c o m m o n ly u sed a s it is sim p le to set u p an d all n ecessary item s are re a d ily obtained. A charcoal b u rn e r can m ad e fro m a steel c o n ta in e r o r b y u sin g a b ra z ie r or u sin g a p re -p a c k a g e d ch arcoal B B Q grill. I f y o u m ak e y o u r ow n burner, o b tain go o d q u a lity charcoal to red u ce th e level o f u n w a n te d sm o ke. You w ill a lso n e e d a car, or o th er sm all ro o m th a t can b e sealed. In th e series o f ex p erim en ts ca rrie d o u t b y Exit, a sm all p rep a c k a g e d charcoal bu rn er w a s set aligh t an d p laced o n th e floor in a sm all car. T h e level o f carbon m o n o x id e in sid e th e car w a s c o n tin u o u sly m on ito red . O th e r te s ts w e r e c a r rie d o u t u s in g a s e a le d 2 0 f t s h ip p in g co n tain er as the clo se d en v iro n m en t. A brazier w a s loaded with 1.5 K g m o f g o o d q uality charcoal w h ic h w a s then set alight and p laced in the cen tre o f the floor. T h e c o n ta in e r d o o rs w ere shut (see F ig 6.10). A gain, the c arb o n m o n o x id e concentration w ith in th e co n tain er w a s c o n tin u o u sly sa m p le d fro m outside u sin g a sa m p lin g probe.

Fig 6.9 Test vehicle with BBQ charcoal burner


Fig 6.10. Charcoal burner brazier and test shipping container

N O T E : It is stressed that carbon m o n o x id e is an extrem ely lethal gas. A p erso n w is h in g to en d th eir life using this g as should n o t h a v e o thers n e a r th em . T h is is o n e d isad v a n ta g e o f using c arb o n m o n o x id e.

I f carbon m onoxide is used , place a warning sign in a prom inent position to prevent any accidental exposure to other people.

Table 6.11. CO concentration with time in test shipping container

C arbon M onoxide C o n clu sio n C arbon M o n o x id e can p ro vide a p erso n w ith a peacefu l death. The g as can be o b tain ed in a variety o f w a y s ra n g in g from sim ple b u rn e rs to m o re sop histicated g enerating devices. Tests sh o u ld b e m ad e to ensure that c o n cen tratio n s o f o v e r 1% can be established. M o st interest in this m eth o d has co m e from those w h o reject the taking o f drugs orally (eg. for fear o f v o m itin g ) an d b y others w h o reject th e u se o f h eliu m b ecau se o f th e n eed f o r a plastic b ag to be p laced o v e r o n e 's head. T h e C O G e n ad d resses these concerns.

E xit R P Test f o r C a r b o n M o n o x id e The m e th o d lo ses p oin ts in the sub catego ries o f P reparation, U n detectab ility an d Safety. Preparation is n o t sim ple ( P r = l ) , there is eq u ip m en t presen t a t th e death, an d i f u sin g a C O G en p reparation w it h c o n c e n tra te d acid s req u ires care. T h is m etho d m a y b e d etectab le o n in sp ectio n o f the b o d y (U = 2 ), an d can present so m e risk to o thers ( S a = l ).

C rite ria

S co re

R e lia b ility

8 /1 0

P ea cefu ln ess

7/10

A vailability

3/5

P reparation

1/5


1/5

Speed

5/5

S a fe ty

1/5

S to ra g e

4/5

T o ta l

3 0 (60% )

7

Cyanide T h e d e a th o f S p a n ia r d R a m o n S a m p e d r o in 1998 a n d th e s u b se q u e n t a w a rd -w in n in g film T he S ea In sid e h as fo cu sed attention on th e u se o f cy an id e a s an effectiv e m ean s b y w h ich a serio u sly ill person can p u t an en d to their suffering. S am p ed ro , a q u ad rip le g ic sin c e a d iv in g accid en t at age 26, e n d e d his life by d rin k in g a g lass o f w a te r in w h ich soluble p o tassiu m c y a n id e h ad b een dissolved. H e d ied quickly, and peacefully. M a n y p eo p le w h o h av e seen The S e a In sid e have a sk e d w h y these cy an id e salts are n o t m o re frequ en tly u s e d by th o se w h o are serio u sly ill to p ro vide a peaceful death. In this ch a p te r w e explain s o m e o f the difficulties in v o lv ed in using cy an id e a n d p ro v id e so m e an sw ers. It is n o t u n re a so n a b le to ex p ect that th e u se o f cy an id e will increase in th e future, and it m a y y et b e c o m e an acc e p ta b le form o f the ‘P eaceful P ill’.

S o m e b a ck g ro u n d to cy a n id e In 1814, th e c a r b o n - n itr o g e n (C N ) ‘r a d i c a l ʼ c o m m o n to a n u m b e r o f c h e m ic a l s u b sta n c e s w a s iso la te d a n d g iv e n the n a m e ‘c y a n o g e n ʼ b y th e French ch em ist J o sep h G a y Lussac. T h e su b seq u en t n am e ʻth e b lue g e n e ra to rʼ referred to th e p lace o f th e C N radical in a n u m b e r o f ch em icals that w e re u sed as

Cyanide

blue dyes; th e P russian Blue o f blueprints (iron ferro cy an id e) is p e rh a p s th e best know n. In m an y o f these c o m p o u n d s, the C N radical is s o tightly b o u n d that th e sub stan ces are relatively non-toxic. W ith th e d isco v e ry o f su bstances w h e re th e C N radical w a s not so tig h tly bo un d - th e g as h y dro gen cyanide, h y d ro cy an ic acid, and sim p le salts like po tassium an d sodium cyanide - it w a s soon realised that cy an id e w a s ex trem ely toxic to anim al cells. By d estro yin g th e m ito ch o n d ria, an essential e le m e n t w ith in each cell, th e C N radical cau sed rap id cellu lar death. In 1921, cy an id e g as (hyd rog en c y a n id e , H C N ) w a s p rop osed as a h u m a n e m e th o d o f ex ecu tio n a n d led to th e p a s sa g e o f the ‘H u m a n e D eath B illʼ in N e v ad a. T h e g as w a s first used to ex e cu te G e e Jon in 1924. S ince th a t tim e n early 1000 people have died in the execution gas cham bers in the US. All cham bers u sed the sam e m eth od to p ro d u ce cy an id e gas. Pellets o f sodium cy an id e w e re d ro p p e d into sulphuric a c id to release th e g as w h ic h th en e n v e lo p e d the prisoner. H y d ro g en cy an id e is a v o latile liquid an d can be stabilised and a b so rb e d onto a substrate. In this fo rm (Z y clo n B), it w a s used by th e N a z i's d u rin g the H o locaust. O riginally d e v e lo p e d as an insecticide, th e pellets w e r e k e p t in scaled co n tain ers an d released as H C N gas w h en the pellets cam e into contact w ith air. Today, c y a n id e c o m p o u n d s are w id ely u s e d in industry. Vast q uantities o f th e cy an id e salts are p ro d u c e d fo r u se in th e gold m ining, m etallurgy, electro platin g an d p h o to g ra p h ic industries. T h e ir toxicity is well kn o w n an d d espite the large quantities used, th ey rem ain heavily restricted an d difficult to obtain.


C a n C y a n id e p r o v id e a p e a cefu l a n d reliab le d eath ? T h o s e w a tc h in g th e c in em ato g rap h ic d ep ictio n o f S a m p e d ro 's d e a th w o u ld h ave cause to believ e that a death resu ltin g from th e ingestion o f cy an id e salts is p eaceful. U nfortunately, not all re p o rts o f cy an id e d eath s su p p o rt this view . Indeed, there is c o n s id e ra b le v a ria tio n in a c c o u n ts . W h ile re lia b ility is n o t an issue, th e qu estio n m o s t raised relates to th e m e th o d 's ‘p e a c e fu ln e ss.ʼ Just h o w peacefu l is it to d ie w ith c y an id e? M o s t acco u n ts o f death fro m c y a n id e p o iso n in g c o m e from w itn e ss e s to g as c h a m b e r e x e c u tio n s w h e r e the (u n w illin g ) p riso n er inh aled H C N . O n e study un d ertak en at S an Q u en tin prison sh o w e d that, on av erag e, co n scio u sn ess w a s lost w ithin o n e to three m in u tes, w ith death occu rrin g after n ine m inutes. T h e s e d e a th s w e r e o fte n p eacefu l w ith th e p r is o n e r falling q u ic k ly asleep. O n s o m e o c c a s i o n s , h o w e v e r , a v i o le n t ( a n d p r e s u m a b ly p ain fu l) death w a s ob served. T h is m eth o d o f ex ecu tio n w a s largely ab an d o n ed in th e U S in 1994 w h e n th e A m erican Civil Liberties U nio n too k a successful action a g a in st th e C alifornia D ep artm en t o f C orrectio ns. In their action, th e A C L U argued successfully that the g as ch am b er violated the U S C o n stitu tio n ’s b an a g a in st cruel an d u nu sual p u n ish m en t, b ecau se it inflicted n eedless pain an d suffering. E y e w itn e ss acco u n ts o f serio u sly ill p eo p le d rin k in g dissolved c y a n id e salt are also m ix ed . In his b o o k F in a l Exit, Derek H u m p h ry d escrib es d eath s that are q u ic k an d painless. B u t he also d o c u m e n ts o n e disturbing acco u n t that refers to a death that w a s ‘m ise ra b le an d v io lent, m a rk e d by frequent tetanic co n v u lsio n s w hile a w a k e ʼ (H u m p h ry , 1996: 30).

Cyanide

T o x ico lo g y tex ts o f death b y cy an id e c o m m o n ly refer to a rapid co llap se an d loss o f co n scio u sn ess i f a large en ough do se is absorb ed . In his b o o k S u ic id e a n d A tte m p te d S u icid e: M ethods a n d C onsequences, G e o Stone m a k e s th e observation that w hile c y a n id e m ight be c o m m o n ly u s e d by suicidal ch em ists, it is rarely by physicians. H e c o n clu d es that this m a y be d u e to their d ifferen t levels o f acce ss to p o iso n s (S to n e, 1999). In 1995 w h en the g u id elin es for th e N o rth ern Territory R ights o f th e T erm in a lly Ill A c t (R O T I) w ere b e in g d e v e lo p e d th e use o f c y a n id e w a s n o t considered; better d ru g s (the barbiturates) w ere available. N o r is cy an id e u sed in O rego n o r H o llan d w here e u th an asia legislation is n o w in place. In F in a l E x it H u m p h rey su m m a rise s his th oughts on th e u se o f cy an ide, ʻI believe that the b alance o f e v id en ce a b o u t using cy an id e indicates that it is b e s t n o t u s e d ʼ (H u m p h ry , 1996: 33).

T h e A vailability o f C y a n id e S o lub le c y a n id e salts a re g e n e ra lly hard to obtain u n less one has a contact in th e ind ustries w h e re these su b sta n c e s are used. T h e se salts are also heav ily reg u lated an d restricted. T h e y can h o w e v e r be m an u factu red (w ith c a re ) fro m read ily available in g re d ie n ts, u sin g u n s o p h is tic a te d facilities an d equip m en t. C a re m u st be em p lo y e d in th e m an ufacture, an d th e substance p ro d u c e d sh o u ld b e a s sa y e d to ensure the d e sire d result.


T h e M a n u fa c tu re o f S o d iu m C y a n id e S odiu m cyan ide can be m a n u f a c t u r e d in a n u m b e r o f ways. T w o relatively sim ple m e t h o d s ar e d e s c ri b e d in the scientific literature. T h e first involves the use o f the re adil y available dye, Prussian Blue (Iron III Ferro cyanide). A s e c o n d uses the c o m m o n s w i m m i n g pool chl orin e stabiliser, cyanur ic acid. In t h e first p r o c e s s th e P r u s s i a n B l u e is f i r s t c o n v e rte d to sodium ferrocyanide. Th is is done b y a l l o w i n g it to r e a c t with caustic sod a in water. Iron o x id e is precipitated a n d s o d iu m ferro cyan id e o b t a i n e d . T h i s s o d iu m ferro c y a n id e (Y ellow Prussate o f So da ) is then c o n v e r t e d to s o d iu m cy a n id e by a l lo w ing it to react w ith conce ntrate d sulphu ric acid. Fig7.1: Forge reduces sodium cyanate with carbon

T h e very toxic H C N pro duce d is passed into caustic soda to form the desired salt. Th ere is con sidera ble information available o n this p r o c e ss but it w a s a b a n d o n e d after initial exp er im en ts, considering it too dan ge ro us for the inexpe rienced h o m e chemist - s o m e o f w h o m m a y be readers o f this book. A m o re su itable m e th o d o f safe, s ma ll-sc ale h o m e m an ufac tu re o f s o d iu m c y a n i d e involves the t w o sta ge conve rsion o f the c o m m o n s w i m m i n g pool ch em ical cyanur ic acid.

Cyanide

T h e first step is carried out b y h e a tin g p o w d e re d cy an u ric acid w ith sodium carbonate. S od ium carb o n ate is o b ta in e d directly a s w a s h in g so da (or b y co n v e rtin g so d iu m bicarbo nate, baking soda). In th e s eco n d stage, th e so d iu m cy an ate p ro d u c e d is reduced to sodium cyanide by heating it with p o w d ered charcoal in a c o v e re d c ru cib le (F ig 7.1). It is im p o rtan t that this sta g e is un d ertak en outside.

In this

p ro cess, c arb o n m o n o x id e is given off. T h e resu ltan t glassy m ass is co o led , cru sh ed an d filtered w ith w a te r to rem o v e the so lub le sodium c y a n id e from the rem ain in g insoluble carbon (F ig 7.2). C areful drying pro du ces solid sodium cyanide powder. A s w ith all h o m e m a n u factu re there is a n e e d for g reat care in carry in g o u t this pro cess. C o n ta m in a te d item s n e e d to be d isp o sed o f carefu lly after traces o f cy an id e a re rem oved. T h is is best a c h iev ed u sin g ch lo rin e bleach to oxid ise an y u n w an ted c y a n id e an d to p re v e n t it c o n tam in atin g th e eq u ip m en t. The p ro du ct also n e e d s to b e tested b y analytic m e a n s to d eterm ine its concentration an d purity. Q u an titativ e tests are available and E xit offers su ch a service for supporters. F u rth er inform ation that d etails the m an u factu rin g p ro cess can b e fo u n d in m ost u n iv ersity a n d p u b lic libraries.

Fig 7.2: Filtering and weighing the sodium cyanide


C y a n id e - R P Test F o r a s u b sta n c e o r dru g to be useful a s a P eacefu l Pill tw o m ain criteria m u s t b e m et. It m u st b e , R eliable, a n d it m u s t be Peaceful. A pp lyin g the Exit R P test to a salt like sodium cyanide g iv es so m e encou rag em en t. R eliability is high, few p eo p le will e v e r surviv e the ingestion o f a sufficiently high d o s e o f sodium c y a n id e . F o r a do se o f 1gm o f sodium cy anid e, R =10. T h e re is a lso a co rrelation betw een th e size o f th e d ose an d the s p e e d o f death an d this m in im ise s th e ch an ce o f an y adverse s y m p to m s developing. In te r m s o f P e a c e fu ln e ss , th e m ix e d a c c o u n ts m a k e th is a difficult characteristic to assess. C le a rly th e size o f the dose m atters, i f o n e is to m in im ise s y m p to m s. Preparation is also im portant. T h e toxic effect is p ro d u c e d w h en sto m ach acid acts on th e salt p ro d u cin g H C N w h ic h is th en a b so rb e d by the gut into the b lo o d stream . T h is pro cess is facilitated b y dissolving th e salt in c o ld w a te r a n d drin king on an e m p ty sto m ach w here th e gastric acid co n te n t is high. A n alternative is to p la c e the cy an id e salt into a treated gelatin c a p s u le . T aking a 5 0 0 m g cap sule w ith an acid ic drink (lem on ju ic e , v in eg ar) cre a te s th e o p tim u m co n d itio n s in the stom ach. T h e delay can also u sefu lly b e em p lo y e d to induce sleep w ith th e addition o f a stro n g soporific (sleep in g tablet). Taken in this m a n n e r th e likeliho od o f a peacefu l cy an id e death is increased significantly. (P = 5)

Cyanide

L o o k in g a t th e M in o r Criteria: A vailability (2 /5 ) - S o lub le c y a n id e salts are g en erally h ard to o b tain u n less o n e h as a c o n ta c t in the industries w h e re these s u b s ta n c e s are u sed . T h e s e salts are h e a v ily re g u la te d and restricted. T h e y can h o w ev er be m an u factu red (w ith care) from read ily av ailab le ingredients, u sin g u n so p h isticated facilities a n d eq u ip m en t. C a re m u st b e e m p lo y e d in th e m an u factu re, a n d the su b stan ce p ro d u c e d sh o u ld be a s sa y e d to ensure the d e sire d result. P rep aratio n (5/5) - C y a n id e salts are c o n s u m e d a s a drink o r in a gelatin ca p s u le . S o m e clinicians will note th e pin k c o lo u r and a possible sm ell o f bitter alm o n d s b u t this can often b e m issed, esp ecially in c ases w h e re th ere is u n d e rly in g seriou s illness. U ndetectability (3/5) - at auto p sy the substance will be detected. S p e e d (5/5) - o ptim al adm in istratio n will c a u se a v e ry quick death. S afety (3 /5 ) - there is little risk to others, altho u gh the glass sh o u ld be w ashed. N o te - i f vom itin g occurs, the gastric contents m a y giv e o f f d a n g e ro u s H C N . S torage (5/5). W ith p ro p e r storage, th e so d iu m an d p otassium s o lu b le cy an id e salts h av e an a lm o s t indefinite s h e lf life. E xit R P S core fo r S o d iu m C y an id e

38 (76 % )


E xit R P Test C rite ria

S core

R eliability

10/10

P ea cefu ln ess

5 /1 0

A va ila b ility

2/5

P rep a ra tio n

5/5

U n d ete cta b ility

3/5

Speed

5/5

S a fe ty

3/5

S to ra g e

5/5

T o ta l

3 8 (76% )

Cyanide

C h a p ter 7: F r eq u e n tly A sk ed Q u estion s •

C a n o n e in h a le th e h y d r o g e n c y a n id e g a s r a th e r th a n d r in k in g th e d isso lv e d c y a n id e s a l t ?

Yes, this can b e v e ry effective. The p rocess m im ic s th a t used in th e U S g as c h a m b e r w h e re the solid cy an id e salt (so d iu m , p otassium o r calciu m cy an id e) is ad ded to concentrate acid. If 500m l o f concentrated hydrochloric acid is placed in a plastic bucket an d a few g ra m s o f the solid salt a d d e d there is a rapid p ro d u ctio n o f h y d ro g e n c y a n id e . I f this is d o n e in a co nfin ed sp a c e (a v e h ic le ,o r small ro o m with w indow s sh u t) in h alin g th is g as lead s to r a p id an d in ev itab le death. C oncentrated hydrochloric a c id (> 25% ) is read ily available from h ard w are sto res w h e re it is m a rk e te d a s a toilet cleanin g agent, brick o r p av in g cleaner, so ld erin g flux o r a n a g e n t f o r reducing the pH o f a s w im m in g pool. T h e sm ell is s o m e tim e s re p o rte d a s s im ila r to th a t o f bitter a lm o n d s , a lth o u g h s o m e p e o p le , b e c a u s e o f th e ir g e n e tic m akeu p, are unable to sm ell the gas. Be aw are that the production o f th e g as m a y co n tin u e fo r so m e tim e an d an y o n e en terin g the area m a y be un aw are o f th e p resen ce o f th e lethal gas. W arning signs m u st b e p o sted to p ro te c t those w h o m a y c o m e acro ss the site. Safety on th e Exit R P Te st, is th erefo re lo w f o r this m eth od 1/5 (see C arb o n M o n o x id e, C h 6 an d H y d ro g en Sulfide, Ch8.).

8

Detergent Death S in c e 2 0 0 9 , E x i t h a s r e c e i v e d re q u e ste d for in fo rm atio n on the so -c a lle d ʻ D e te rg e n t S u ic id e ʼ m eth o d o f e n d in g o n e 's life. W h ile a n s w e rs w e r e p r o v id e d to th o se a s k in g th e q u e s tio n s , it w a s not thought necessary to include details o f the m e th o d in T h e P e a cefu l P ill H and book. T h is d e c is io n h as b e e n r e v ie w e d in 2011 an d th is ch a p te r included. W e stress h o w e v e r that th e m eth o d scores p o o rly on the Exit RP test, an d h as little to re c o m m e n d it. It is in effect a c h e a p a n d n a sty suicide strategy, an d re a d e rs are a d v ise d to c o n s id e r o th er b e tte r altern ativ es o u tlin ed in this book.

T h e M eth o d T h e m e th o d m a k e s u se o f the toxic n atu re o f th e g as hydrogen sulfide (H 2S) a n d it’s e a s e o f g e n eratio n fro m re a d ily available (u n re s tric te d ) h o u s e h o ld c h e m ic a ls. H y d ro g e n S u lfid e (c o m m o n ly k n o w n a s ' rotten eg g g a s ') is ex trem ely toxic w hen inhaled. T h e m e c h a n is m o f actio n is sim ilar to that o f hydrogen c y a n id e (C h a p te r 7) w h e re the g as b in d s w ith an d d estro y s the function o f m ito c h o n d ria w ith in living cells. T h e g as is a s toxic as h y dro gen cyanide, b u t accidental e x p o su re is u n c o m m o n b e c a u s e o f th e stro n g a n d u n p le a sa n t smell n o te d w ith even the sm allest c o n cen tratio n s o f th e gas.

D etergent Death

C o ncentration s o f o v e r 0 . 1% ( 1000p p m ) will lead to im m ediate loss o f co n scio u sn ess an d rap id death. P roduction o f th e gas in a confined sp a c e (w ith levels in ex cess o f 1%) w ill cause certain death. P rod u ctio n o f the G as T h e g as is easily p ro d u c e d using re a d ily av ailab le ingredients. The usual m eth o d e m p lo y e d is to a d d a con cen trated a c id to an inorganic sulfide. F o r exam ple adding concentrated hydrochloric acid to calciu m sulfide leads to th e rap id pro d u ctio n o f the gas. 2H C l + CaS

→ H 2S + CaCI

T h e sulfide u s e d in th e early spate o f J a p an ese suicides w a s r e p o rte d a s ' b a th s u lp h u r ' a p r o d u c t u s e d as a s u p p le m e n t ad ded to b ath w a te r for th erapeutic use. In w estern countries w h e re there is little interest in su lp h u r baths, th e c o m m o n e st source o f sulfides is the readily available ‘ Lim e S u lp h u r ʼ used as a c o m m o n fu n g ic id e a n d in sec ticid e b y h o m e gardeners. T h e m a jo r ing redient is c a lc iu m polysulfide (C aS X) in aqueous solution.

Fig 8.1 Simple ingredients used in Detergent Suicide


T h e addition o f a stro n g a c id to Lim e S u lp h u r liqu id in a plastic bucket results in th e co pio us production o f hydrogen sulfide gas. C o m m o n acid s th a t release th e g as include hyd rochloric acid (H C I) av ailab le fro m h a rd w a re stores, an d u s e d a s a paving, brick o r toilet b o w l cleaner, o r as a s w im m in g po ol chem ical, w h e re it is u sed to lo w e r the pH o f th e pool. A n alternative acid that can be u sed in sulphuric acid (H 2S 0 4) (S ee C h ap ter 6) which is u s e d in veh icle lead a c id batteries.

P r o b le m s w ith th e m eth od W h ile th e in g re d ie n ts re q u ire d to m ak e th e g as are read ily o btain ed, an d u nrestricted , th e u se o f th e g as to en d o n e 's life p resents a n u m b e r o f significant problem s. O f m a jo r co n cern is the risk to o th ers w h e n large a m o u n ts o f h y d ro g e n sulfide gas are p ro du ced. A p a rt fro m th e lik eliho od o f a n n o y in g everyo n e in th e area w ith th e stink, th ere are real d ang ers to those w h o m ig h t try to en ter the a re a o r a tte m p t re su s c ita tio n . Indeed e m erg en cy p ersonnel are tra in e d to be careful en terin g an area w h e re this g as is su sp ected , an d n o t to attem pt m o uth to m outh resuscitation. C learly i f o n e is p lan n in g to use this m eth o d it is essential that a site is chosen w h ere leakage o f the g as can not end an ger innocent p eo p le an d p ro m in en t w a rn in g sig n s sh o u ld be displayed. The u se o f a car p a rk e d in an o u td o o r location w ith w a rn in g signs d isp lay ed p ro m in en tly on the w in d o w s w o u ld seem to be the m o st respo nsib le choice. W h ile it h as been rep o rted that a s the co ncentration o f th e gas rise s,th ere is a rap id inhibition o f th e sense o f sm ell, s o that one d oes n o t n ecessarily ex p erien ce the sick e n in g stench rig h t to the point o f death, it c o u ld n o t be co n sid ered a particularly peaceful.

D etergent Death

T h e E xit R P Test T h e m e th o d sco res p o o rly for P eacefulness (P =2), but high on R eliability (R=10). C o n sid erin g th e m in o r criteria: A vailability & S p eed score well at 5/5, Preparation & S to rage a t 4/5. H o w e v e r on Safety and Detectability, o n ly the low est score w o u ld be appropriate, giving a total sc o re o f only 3 0 (60% ). T h e m eth o d therefore scores on ly slig h tly better th an h a n g in g (2 8 , 5 6 % ), an d less th an the inhalation o f carbon m o n o x id e (3 1 , 6 2 % ) (C h a p te r 4).

E xit R P Test C rite ria

S core

Reliability'

10/10

P e a ce fu ln e ss

2 /1 0

A va ila b ility

5 /5

P rep a ra tio n

4 /5

U ndetectability

0 /5

Speed

5 /5

S a fe ty

0 /5

S to ra g e

4 /5

T o ta l

3 0 (60% )

9

Introduction to Drugs

Introd u ction F o r m a n y s e rio u s ly ill p e o p le , ta k in g d r u g s o r s u b sta n c e s o rally (b y m o u th ) is the p re fe rre d w a y to en d life. Substances taken in this w a y (eg. veterinary liqu id N e m b u ta l) req u ire no special equip m en t. It is this sim p licity that ex p lain s th e appeal o f this v e rsio n o f the P eaceful Pill. T h e lack o f an y necessary b ed side e q u ip m e n t also m eans th a t th e death is m o re likely to b e u n d e rsto o d a s o n e from 'n atu ral c a u s e s'. F o r e x a m p le , i f a person d y in g o f c a n c e r takes the final step by d rin k in g veterinary liq uid N em b u tal th ey w ill look as i f they h av e d ied in th eir sleep. M o s t e x a m in in g d o c to rs w o u ld sign the death certificate indicating that this w a s the natural, ex p ecte d death from th eir cancer. O f course, i f an a u to p sy is u n d ertak en , the c a u s a tiv e d ru g will b e discovered, b u t au to p sies are increasingly rare in situations w h e re th e atten d in g d o c to r b eliev es the c a u se o f death is clear (see C h a p te r 18). H ow ev er, w h ile taking oral d ru g s m ig h t seem to be th e sim plest w a y o f o b tain in g a peaceful an d dignified death, th e m eth od d o e s requ ire planning. K n o w le d g e o f th e su b stan ce to be used, its acq uisition, prep aration an d adm inistratio n arc im portant.

Introduction to D rugs

T h e R o le o f the D ru g O v erd o se G en erally sp eakin g, d ru g s are d e v e lo p e d to p rov ide a cu re to an illness o r to giv e r e lie f from sy m p to m s. D ru g s a re n e v e r d e v e lo p e d to e n d life, a t le a st n o t in h um ans. Yet s o m e drugs do c a u se death, esp ecially i f they are a d m in iste re d in w ay s th a t w e re n e v e r intended. T h e usual w a y to m isu se a d ru g is to ex c eed the s u g g e ste d dose: ' th e o v e rd o se '. W h ile m o s t d r u g s h ave s id e - e f fe c ts (e ffe c ts o th e r th a n the p u rp o se for w h ic h th ey a re desig n e d ), an d m o st sid e- effe cts a re m o re p ro n o u n c e d w h en a d rug is m isu s e d o r taken in overdose, a side-effect like death is a lw a y s g o in g to be a serio us problem for a d ru g m anufacturer. The c o m p a n y resp on sib le for m an u factu rin g a d ru g th a t w ill cause death in o v e rd o se will a lw a y s be n e rv o u s a b o u t such a p ro d u c t an d there will be a search to dev elo p safer alternatives. So, w h ile there a re so m e d ru g s that do relia b ly c a u se death if taken in this way, this n u m b e r is sm all an d d ecreasing . I f a d ru g that cau ses d e a th in o v e rd o se re m a in s on th e m arket, it is likely that it is an im p o rtan t d ru g f o r w h ic h there are few current alternatives. T h e p ro c e ss o f rep lacin g p o ten tially lethal d ru g s w ith safer m o d e m altern ativ es g oes on all the tim e. T h e o ld-fashioned, lethal b arbiturates h av e a lm o s t all been rep laced b y m o d e m , safer sleeping tablets. The lethal tri-cyclic an tid ep ressan ts h av e a lm o st disappeared, rep laced b y m u ch safer se ratonin u p tak e inhibitors like Prozac. P a in -re lie v in g d ru g s like p ro p o x y p h e n e are cu rre n tly u n d e r rev iew an d have alre a d y b een rep laced in co u n trie s su ch as the U K , U S an d N e w Z ealan d . T h e n u m b e r o f d ru g s that are o f practical assistan ce to a serio u sly ill person seek ing a peaceful death d ecrease s each year.


D ru g s, S w a llo w in g and Taste A serio u sly ill person se e k in g a p eacefu l death will n eed to c o n s u m e a lethal q u an tity o f th eir c h o sen d rug . O ften these d ru g s are ex trem ely b itter a n d th is b ittern ess can so m etim es p recip ita te v o m itin g (see D rug s a n d Vomiting). C o n s u m in g a large n u m b e r o f tablets can also be difficult if th e p erso n is su fferin g from a disease that effects sw allow ing. Exam ples include som e diseases o f th e throat an d oesophagus, or a disease like M oto r N eu ro n e D isease that can effect the m uscles o f th e throat. In s o m e cases, p ro b le m s w ith sw a llo w in g can be s o severe that oral ingestion o f d ru g s is sim p ly n o t an option. To a v o id the bitter taste o f the lethal d ose, d ru g s are so m etim es m ix e d w ith other s tro n g er tasting substances. A n o th er approach is to sp ra y the to n g u e an d throat w ith a topical an aesthetic like L ignocaine. In E x it’s ex p erien ce n e ith e r o f these strategies is p articu larly rew ard in g. T h is is b ecau se th e d ru g s are often s o b itte r th a t m ix in g the d ru g w ith a n o th e r s u b s ta n c e , like y o g u rt o r ja m , s im p ly cre a te s a m u c h larg er q u a n tity o f an e q u ally -u n p le asan t su b stan ce that th en needs to b e consum ed. A naesthetic s p ra y s can w o rk , b u t they are prescription items a n d requ ire s o m e expertise in adm inistration. T h e m o s t effective m e th o d o f c o n s u m in g q uantities o f bittertasting d ru g s is to turn th em into a liquid w h ic h can then be q u ic k ly drunk. T his can be d o n e b y red u cin g tablets to p o w d er w ith a m o rta r an d pestle. A n o th e r w a y is to rem o v e the gelatin co vering o f the capsules an d dissolving the p o w d er in a com m on s o lv e n t su ch as w ater. Even i f a d ru g d o e s not fully dissolve, a fine p o w d e r can still be m a d e d rin k a b le b y r a p id stirring w ith a teaspo on . A susp en sio n o f fine particles can u s u a lly be s w a llo w e d w ith o u t m u ch difficulty.


B y keep in g th e v o lu m e o f the liquid to be d ru n k to 100 m l (approx. 1/3 cup ), on ly a few m o u th fu ls are needed. T h e bitter after-taste is effectively dealt w ith b y follow ing this drink with ano ther s tro n g er tasting d rin k - u s u a lly alco ho l (see D ru gs & Alcohol).

D r u g s a n d V om itin g A n y su b stan ce taken o rally can b e v o m ite d up, an d concern about this can c a u se co n sid e rab le anxiety. A person intending to die m u st take th e full (lethal) am o u n t, s o it is im p o rtan t to ensure that v o m itin g d o e s n o t occur. S o m e p eo p le a re prone to v om itin g, an d so m e d isea ses can c a u se vom itin g. In a m in ority o f c ases v o m itin g , o r fe a r o f vo m iting , can be such a problem that it is n o t possible to u se oral drugs. To m in im iz e th e ris k o f v o m itin g , a n a n ti-v o m itin g ( ' a n tie m e tic ') d rug is usu ally taken for a p erio d o f tim e befo re the co n su m p tio n o f the lethal dru g. T h e re are a n u m b e r o f drugs u s e d for th is purpose. T hese an ti-vo m itin g drugs are re a d ily o btained, altho ug h the m o s t e ffe c tiv e a re p re sc rip tio n item s. T h e m o s t c o m m o n are m e to c lo p ra m id e (M a x o lo n , P ra m in , P a sp e rtin ) a n d p ro c h lo rp e ra z in e (S te m e til, S te m a z in e ). O n e co m m o n procedu re is to take six tablets (ie 6 0 m g m eto c lo p ra m id e as a ' s ta t' d o se) a b o u t 4 0 m in u te s befo re tak in g th e lethal drug. A n o th e r p ro ced u re is to take the an ti-em etic for a full tw o days b efo re the lethal d rug is to b e c o n s u m e d (here th e usual do se is tw o tablets every 8 hours). W ith this m e th o d there is then no n eed to sy nchron ise th e tim e at w h ich th e an ti-v o m itin g drugs are taken w ith th e tak in g o f th e lethal drugs.


I f an ti-v o m itin g d ru g s are taken a s a stat d ose o r for tw o days p rio r to tak in g the lethal drug, the risk o f v o m itin g is v ery low an d p ro b le m s a re rare, ex cep t in e ases w h e re it w a s k n o w n to b e an issue w ell in ad v an ce. In these c ases alternative m eth o d s sh o u ld b e explored.

Fig 9.1: The common antiemetic metoclopramide

I f v o m itin g d oes occur, th e individual sh o u ld bring up (vom it u p ) a s m u ch o f th e d ru g from th eir sto m ach a s th ey can an d the attem pt to en d th eir life sh o u ld be ab an do ned . Ip acec S yrup can b e u sed to e n co u rag e vom itin g. It is ad v isa b le to h a v e so m e on h a n d a n d can can be o b tain ed fro m th e local pharm acy. U nless there are specific q u estio n s o f h y p e rsen sitiv ity o r aller g y (w hich are v e ry un usu al), the a n ti-e m e tic ʻM a x o lo n ʼ is rec o m m e n d e d . T h e d ose ( 6 0 m g stat o r 2 0 m g Зх/d a y for 2 days) is in dep en dent o f the q u an tity o f the lethal drug. In reg ard to the u se o f an antie m e tic w ith d o p a m in e antagonist p ro perties, th e benefit is insignificant.

Introduction to D rugs D r u g s & A lcoh ol A lcohol is often u sed a s a su p p le m e n t w h en d ru g s a re u s e d to en d life. It serv es several functions. Firstly, lethal d ru g s taken orally are often b itter an d leave a p ro lo n g e d u n pleasan t after taste. Even w hen the d ru g is co n su m ed in a f e w quick m outhfuls, a serio u sly ill person can find this taste quite distressing. Strong alcohol is effective in re m o v in g this after-taste. A s this is to b e th e p e r s o n 's last d rin k a fa v o u red spirit o r liqu eur is often chosen. P eople sip at th eir favourite S cotch o r B aileys Irish C ream an d th e b itter taste q uickly disappears. Secondly, alcohol p lay s a useful role in ' p o ten tiatin g ' the lethal drug. To fo llo w th e dru g w ith an alcoholic drink w ill usually enh an ce its s p e e d o f action an d potency. T h is is true o f m o s t o f the c o m m o n ly -u s e d lethal, oral drugs. Thirdly, alcoh ol is a useful c a lm in g a g e n t (an x iolytic) in w hat is inevitably a stressful tim e. It is im p o rtan t that an y alcoh ol is taken a fte r th e c o n su m p tio n o f th e lethal d ru g s so th a t th ere is n o clo u d in g o f a p e r s o n 's mind. F o r ex am p le, i f a person in ten d ed to en d th eir life by drinking v eterinary, liqu id N em b u tal th ey w o u ld p o u r the N em b u tal into a sm all glass, qu ickly d o w n the d rin k in a few m o u th fu ls then im m ed iately fo llo w the N e m b u ta l d rin k w ith a shot o f alcohol. The b itter taste o f the N em b u tal w o u ld soon b e forgotten am idst the p leasin g flavo ur o f th eir favourite c o ck tail b efo re sleep ov ertoo k th em . W h a t c o u ld be m o re peaceful. People should not force th em selv es to drink, how ever, especially i f th e y f in d th e th o u g h t o f a lc o h o l d is ta s te fu l. T h e d ru g s described in this bo o k cause death, w ith o r w ith ou t alcohol. The m o st lik ely effect o f e x clu d in g th e alcohol is th a t th e process will take longer. L iq u id m o rp h in e (O rd in e ) can b e u s e d as a su p p lem en t/p o ten tiato r b y p eo p le w ith an av ersio n to alcohol.


D ru g T o leran ce E xp osu re to a p articular d ru g o v e r a p ro lo n g e d p erio d o f tim e can often lead to the d e v e lo p m e n t o f an insensitivity to that drug. If a d ru g is b e in g taken for a p artic u la r m edical p u rp o se (eg. th e re lie f o f pain), o n e m ig h t find that after a w h ile th e sam e pain r e lie f can o n ly b e o b tain ed b y increasing th e dose. T his is k n o w n as ʻto le ra n c e .ʼ S o m e d ru g s are particularly p rone to this effect. T h e b o d y 's resp o n se to o p ia te s like m o rp h in e o r p eth id in e is an exam ple. A fter tak in g m o rp h in e fo r even a sh o rt tim e, th e effect o f a p artic u la r d ose will lessen an d g re a te r a m o u n ts will b e needed to a c h ie v e the sam e p ain -reliev in g effect. A fter a p erio d o f f th e drugs, o n e 's sensitivity usu ally returns. T h is explains w h y p eo p le often accid en tally d ie w h en taking illegal narcotics like heroin. A person w h o regularly u s e s heroin so o n d ev elo p s a tolerance for it. I f they are unable to co n tinu e ta k in g th e d ru g - p e rh a p s b e c a u s e th e ir s u p p ly h as b ro k en d o w n o r p erhaps th ey h av e spent tim e in an institution, they will red ev elo p their sensitivity. W h e n a n e w su p p ly b eco m es av ailab le, th eir g re a te r sensitivity increases the lik elih oo d o f accidental death (se e C h a p te r 10 fo r m o re in fo rm atio n on the opiates). T oleran ce to a p artic u la r d ru g can be an im p o rta n t factor w hen c h o o sin g a d ru g to en d o n e ’s life. I f a serio u sly ill person has b een tak in g a dru g fo r so m e tim e an d h as d e v elo p ed a tolerance for this p artic u la r drug, the n e c e s sa ry ‘lethal d o s e ʼ for th e drug c an be h ig h er than that usu ally quoted.


S lo w R elea se D rugs M a n y d ru g s are m a n u fa c tu re d in a w a y that a llo w s a slow, steady absorption from th e gut into the b lo o d stream . T h e ‘slow r e le a s e ’ form s o f a d ru g are often g iv e n th e initials ‘S R ’. S om e drugs that are used to p rov ide a p eaceful d e a th are av ailab le in SR form s, b u t o n e s h o u ld be a w a re that these form s o f th e drug are usually le ss e ffe c tiv e th a n s ta n d a r d p re p a ra tio n s. This is because the d ru g 's lethal effect usually depends on a rapid rise in the level o f th e d rug in a p e rs o n ’s b lo o d (ie. at a rate that is to o fast for th e b o d y 's norm al excretion m ech an ism s). S lo w R elease fo rm s d o n o t c a u se a stee p rise in the b lo o d level o f the drug. C ru sh in g o r d iss o lv in g th e d ru g s before co n su m p tio n is u n lik ely to alter this. P o w d e re d , s lo w re le a se d ru g s a re s till slo w release. O p iates like m o rp h in e a re often p rep ared in a S R fo rm s o that a stable level o f th e d rug form s in the b lo o d stream to give c o n tin u o u s pain relief. T a b le t S R f o rm s o f m o rp h in e (M S C ontin, K ap ano l) a re o f little u se f o r sudden increases in pain. In these instances, an im m ed iate-release form o f m o rp h in e is u s u a lly u s e d to p ro v id e rapid r e lie f (eg. O rd in e liquid). If a serio u sly ill p erso n w ere to use m o rp hine to en d th eir life, th e liquid fo rm w o u ld be m u ch m o re effective th an the sam e am ou nt o f crushed, slow release tablets. A s described in C h ap ter 10, how ever, there are b e tte r d ru g s (than the o p iates) to use to end life relia b ly an d peacefully.


A ltern a tiv e R o u tes o f A d m in istr a tio n o f D rugs S to m a ch P egs & N a so g a stric Tubes P eople w h o h av e difficulty sw a llo w in g often h a v e a surgical p ro ced u re th a t allo w s th e introduction o f liquid fo od directly into th e stom ach. T h is fe e d in g tube is inserted thro u g h th e wall o f the a b d o m e n an d is c a lle d a ‘sto m ach p e g ’. T h e adm inistration o f drugs is o fte n e a s ie r for a p erso n w h o h as a p eg . T h e re are n o c o n cern s o v e r b itter taste, v o m i t i n g , o r th e p e r s o n ’s ability to sw allow the required q u an tity o f th e d rug . F o r a p erso n w ith a peg, a dru g can b e injected d ire c tly into the stom ach. N a s o g a s t r i c tu b e s a r e a lso o ccasio n ally u sed to provide f l u i d s to s o m e o n e w h o is h av in g difficulty sw allow ing. T h is te m p o ra ry p ro c e d u re s e e s a sm a ll d i a m e te r tub e p o sitio n ed th ro u g h the nose a n d d o w n the throat into the s to m a c h . It is p o s s ib le to d e liv e r fluids directly into the sto m ach th ro u g h such a tube.

Fig 9.2: Intravenous drug administration

Lethal d ru g s given in this w a y w o u ld n e e d to b e in liquid form. Veterinary liquid N e m b u ta l can b e d eliv ered in this way.

Introduction to D rugs In tra v en o u s D ru g s M an y drugs are delivered directly into th e bo d y through a needle or can n u la that is p laced into a vein. D rug s d eliv ered by this route m u st b e liquids. T h e p ro ced u re o f inserting a n eed le into a vein req u ires a d eg ree o f ex p ertise a n d this can be difficult for p eo p le w h o h ave n o t h ad so m e m edical o r n u rsin g training. The s p e e d o f action o f an y d ru g a d m in iste re d in this w a y is m uch g reater th an for those ad m in istered orally. T h e rapid effect o f su ch adm inistration can o ccasio n ally c a u se difficulty. I f the p erso n d e c id e s to inject the d ru g th em selv es they m a y loose co n scio u sn ess befo re th ey h av e finished pu sh in g th e syringe plunger, an d o n ly part o f th e req u ired d ose w o u ld be delivered. To en su re that th e full lethal d o s e is ad m in istered intravenously, a b ag o f salin e can be u sed. T h e saline b ag is a tta c h e d to a c a n n u la th ro u g h a s ta n d a rd in tra v e n o u s ' g iv in g s e t ' (F ig 9.2). T h e d ru g s are a d d e d to th e saline an d co n tin u e to flow, even i f co n scio u sn ess is lost. O n e a d v an tag e o f intrav eno us adm in istration is that it ex tend s the range o f d ru g s that can be u sed . S o m e drugs that are n o t w ell a b so rb e d th ro u g h the gut w h en taken orally, d ru g s like p otassium , can cause death w h en ad m in istered intravenously.

R ecta l A d m in istr a tio n Drugs are occasionally adm inistered rectally using suppositories, or by direct infusion (enem a). T h is is u s u a lly d o n e i f there is difficulty sw a llo w in g o r i f v o m itin g is a problem . S o m e lethal drugs can be q uick ly a b so rb e d in this w ay, an d o ccasio n ally this p ro v id e s a w a y o f p ro ceed in g i f there are intractable difficulties associated w ith oral adm inistration.


R esu scita tio n T h e act o f tak in g a lethal dru g do es n o t result in an im m ed iate death. Rather, th e tim e that e la p se s from co n su m in g the drugs until death, d ep en d s on a n u m b e r o f factors. T h e m o st im portant d eterm in a n t o f h o w lo ng a d rug w ill take is th e d rug itself. S o m e d ru g s o r su bstances taken o rally act v ery quickly. In som e cases, s p e e d o f death is an im p o rtan t factor, such as the case o f a sp y tak in g a su icid e pill to p re v e n t interrogation o r torture. F o r ex am p le, H erm an n G o e rin g u s e d c y a n id e in his cell the n ig h t b efo re he w a s d u e to be executed. A lth o u g h G o erin g w a s b e in g w a tc h e d v e ry closely, his death w a s s o q u ic k that resuscitatio n w a s im possible. H ow ever, su ch a rap id death is rarely a consideration fo r a serio u sly ill p erso n w a n tin g to put an en d to th eir suffering. P eople often think o f a ' peaceful d e a th ' a s d ying in o n e 's sleep, a n d drugs that c a u se this a re so u g h t out. T h e tim e sp en t asleep b efo re death can v a ry considerably. T h e lo n g er this tim e, the g re a te r th e lik elih oo d o f so m e u n e x p e c te d intervention. To red u ce a n y ch an ce o f this, it is in the p e rso n 's interest to obtain those drugs w hich bring about sleep, loss o f consciousness, then death, relativ ely quickly. T h is is one c le a r a d v an tag e o f the barb itu rate, N e m b u ta l. A death th a t results from d rin k in g 100 m l (6 g m ) o f veterinary, liquid N e m b u ta l is u s u a lly v e ry quick. S leep o ccu rs w ith in m inu tes o f con su m p tio n o f th e N em b u tal an d alcoh ol, w ith death follow ing w ith in th e hour.


O th e r c o m m o n ly -u s e d d r u g s h ave a m u c h lo n g e r ʼw in d o w p e r i o d ʼ w h e n i n t e r v e n t i o n c a n o c c u r . F o r th e c o m m o n p ro p o x y p h e n e /o x a z e p a m co m b in atio n (see C h a p te r 11), this w in d o w p e rio d m a y b e a m a tte r o f h o u rs. T h i s m e a n s that con siderable p lan n in g m a y be n eed ed to reduce th e ch an ce o f d iscovery d u rin g this time. T h e p o ssib ility o f u n w a n te d intervention is w h y m a n y people p re fe r to take lethal d ru g s in the ev en in g w h en there is less ch an ce o f d iscovery. A p e rs o n w h o tak es N e m b u ta l in the ev en in g will h av e d ied b y the early h o u rs o f th e follow ing day. The risk o f d isco v e ry is g re a te r for a p erso n e n d in g th eir life w ith the p ro po xy ph ene/ox azepam com bination. T his is because these d ru g s take co n sid e rab ly lo n g er to w o rk . If th e d ru g s are taken in th e ev en in g , there is a greater ch an ce the person m ay still b e aliv e in th e early h o u rs o f th e fo llo w in g m o rn in g an d that d isco v e ry m a y occur. I f th e d eep ly u n co n scio u s person is fo u n d b efo re death, this can presen t a significant pro b le m to th e person task e d w ith, or w h o accidentally, finds them . E v e n i f th e y are a w a re o f the u n c o n s c io u s p e r s o n 's plan, th e d isco v e rer m u st d o som eth ing to pro tect them selves. It w o u ld not be acceptab le, fo r ex am p le, to claim in the m orning that y o u n o tic e d that y o u r friend o r p a rtn e r w a s un con scio us but y o u chose to do n o th ing a b o u t it. D uring th e n ig h t a person m ight argue that they h ad b een asleep a n d h a d n 't n o tic e d , but in th e m o rn in g , the situation changes. A person in this position needs to c o n s id e r th eir o p tio n s carefully.


I f an a m b u la n c e is c a lle d , th e d isc o v e re r w ill b e protected, b u t the a tte n d in g p a ra m e d ic s will a tte m p t to resu scitate the u n co n scio u s person a n d this m a y well th w art th eir w ish to die. R em em ber, a m b u lan ce p aram ed ics arc generally u n d e r no legal oblig atio n to a b id e b y a p e r s o n 's A d v an ce M edical D irective (A M D ) (L iv in g W ill/ Do N o t R esu scitate (D N R ) notice). The O fficers a tte n d in g w ill u s u a lly s a y that these issues ' can be so rted o u t a t th e h o sp ital.' (F o r m o re discussio n about the pros an d co ns o f A M D s an d role o f e m e rg e n c y w o r k e rs see m y first bo o k - K illin g M e So ftly: V oluntary E u th a n a sia a n d th e R o a d to th e P e a c efu l P ill.) Alternatively, so m eo n e discov erin g an un con scio us person m ay p rotect th e m se lv e s by ca llin g the fam ily physician. T h e p h y sician s h o u ld b e aw are i f a A M D ex ists a n d can avoid initiating resuscitation w ith o u t risk ing legal repercu ssion s. A d o c to r w h o k n o w s th e b ac k g ro u n d m a y w e ll begin a m o rp h in e infusion (“ to m a k e th e p atient co m fo rtab le” ), an d a llo w their p atient to peacefully die.

T h e S h e lf L ife o f D ru g s M o st d ru g s are su bject to so m e fo rm o f degradation o v e r time. T h is m a y b e b ro ug ht a b o u t by chem ical, physical o r m icrobial b reak d o w n . T h e m ain im pact o f deg rad ation on a d ru g is the loss o f potency. To ensure that d ru g s a re a s effective a s possible, m anufacturers include storage instructions an d an ' ex p iry d a te ' w ith each item. T h e tim e ta k e n from m an u factu re to ex p iry date is referred to a s the d r u g 's ' s h e lf life'.


It is in th e m a n u f a c tu re r s ' in terest to m a k e th is a s lo n g as p ossible. T h is is n o t to say that a d rug w ill not b e effectiv e after th e stated expiry date. Rather, this date m erely indicates that if sto red correctly, no significant c h em ical, physical o r m icrobial deg rad atio n o f the d ru g w ill h av e o c cu rred before this date. R esearch sh o w s that m a n y drugs rem ain h ig h ly e ffective long after th eir expiry date a n d effectiv en ess is usually defined as > 9 0 % potency. F o r m o d e m m ed icin es, exp iratio n d ates are usually set fo r tw o to three years after the date o f the m anufacture o f the drug. F o r ex am p le, veterinary liquid N e m b u ta l w ill have a s h e lf life o f tw o y ears in adv an ce o f th e tim e o f pu rch ase sta m p e d on th e side o f th e bottle. A lso, th e fo rm o f th e d ru g w ill often effect its s h e lf life. F o r ex am p le, pills a n d cap su les sto red in th eir original, air-tight containers at cool ro o m tem peratures an d free from hum idity are often v iab le fo r a ro u n d 10 years. T h is is m u ch lo n g er than the stated ex p iry date. T h e p o w d e re d fo rm o f a dru g (eg. C h in ese p o w d e r N e m b u ta l) h as s im ila r longevity, e s p e c ia lly i f it is v a c u u m -p a c k e d (u sin g a stan d a rd kitch en fo od v a c u u m -se ale r) a n d kep t cool a n d a w a y from light. F o r d ru g s in liqu id form , th e s h e lf life is c o m m o n ly shorter. To tell i f a d ru g h as deteriorated, there are so m e c o m m o n sense guidelines. In the c a s e o f a liquid, th e d r u g 's ap p e a ra n c e is im portant. O n e s h o u l d c h e c k its c o l o u r a n d c l a r i t y ( h a s it b e c o m e cloudy); particulate m atter (eg. a re there tiny v isib le particles); preserv ativ e co n te n t ( i f stated); sterility (has the bottle been ta m p e re d w ith o r op en ed ) an d w h e th e r th e dru g h as interacted w ith its en clo su re (b o ttle o r lid). I f n o n e o f these sig n s a re presen t, then the liquid in qu estio n is m o re likely to be viable, th an i f there w e re a n y sig n s o f degradation.


I f the dru g is in tablet form , sig n s o f degrad atio n in clu de the t a b l e t ’s a p p e a r a n c e , m o is tu r e c o n te n t, h a r d n e s s (h a v e the tablets b e c o m e a s h a rd as rocks), friability (u n c o a te d tablets), d isin te g ra tio n tim e (w h e n p la c e d in w a te r) a n d u n ifo rm ity o f co n te n t. A gain , an y o f th e se tell-tale sig n s m a y indicate chem ical degradation. O f c o u r s e , th e o n l y c e r ta in w a y o f e s t a b l i s h i n g w h e t h e r significant d eg rad atio n h as taken p lace is b y c a rry in g o u t a chem ical assay on th e p rod uct. F o r d ru g s that are hard to obtain an d difficult to replace w ith fresh sam p les, an a ssa y m a k e s a lot o f sense. F o r ex am p le, ev en th o u g h N e m b u ta l is ex trem ely stable and k n o w n to b e effective well p a s t its ex p iry date, an a ssa y should be ca rrie d o u t to g iv e c o n fid e n c e an d a v o id risk. T h e E xit B arb itu ra te T est K it d e s c rib e d in C h a p te r 15 a llo w s o n e to p erfo rm this test at hom e. T h e Kit is av ailab le from E xit at:

http://bit.ly/9swOxk

C o n clu sio n T his C h a p te r details so m e o f the m o st im p o rtan t issues that sh o u ld be co n sid ered i f a serio u sly ill p erso n is p lan n in g to use drugs to a c h ie v e a peacefu l, dignified death. Specific issues such a s preparation , adm in istration , vo m itin g, an d th e shelf-life o f a d rug are c o m m o n to all drugs, an d an u nd erstanding o f these issu es red uces the chance o f failure. This C h a p te r s h o u ld be read in co n ju n ctio n w ith th e ch ap ters that detail th e u se o f p artic u la r d ru g s (C h ap ters 1 0 - 1 5 ) .

10 Drug Options - Morphine & Slow Euthanasia

In tro d u ctio n - T h e D o c to r 's L o o p h o le S lo w e u th an asia o r th e ʻD octrine o f D o u b le E ffectʼ a s it is often called , is the o n ly w a y a carin g d o c to r can h aste n the death o f a p atient a n d escap e an y legal consequence. K n o w n c o m m o n ly as th e ' d o c to r 's lo o p h o le ' s lo w euthanasia a llo w s a d o c to r to en d a p a tie n t’s life b y slo w ly in creasin g the a m o u n t o f a p ain-k illing drug. In th e e y e s o f th e law it d o e s n 't m a tte r if, in th e co u rse o f treating a p e r s o n 's pain , the person dies. It is th e adm in istratio n o f the pain -relievin g drug that cau ses the d o u b le effect; it relie v es pain but it also cau ses death. A s long a s th e stated p rim a ry intention is th e treatm en t o f the p erso n 's pain , th e d o cto r is legally safeguarded. W h ile s lo w eu thanasia is relativ ely co m m o n , few d o c to rs will e v e r a d m it their in vo lvem ent. Even w h ile ad m in isterin g slow eu thanasia, s o m e doctors w ill argue th a t th e y are o n ly treating

M orphine & Slow Euthanasia

th e p a tie n t's pain . O th e r s k n o w e x a c tly w h a t th e ir ‘p rim e in ten tion ʼ is, but w is e ly d ecid e to k eep q u iet a b o u t it. O thers j u s t p refer not to th in k a b o u t it too clo sely . It is a pity that this p ractice is so clo ak ed in secrecy. Clearly, it w o u ld b e better i f there w e r e op en an d h o n est co m m u nication b e tw e e n th e m ed ical s y s te m (re p re se n te d in the d o c to r an d health care team ), the patient and the p atien t's family. However, w ith law s in p la c e th a t m ak e it a seriou s c rim e to h aste n a p a tie n t’s death, b u t m a k e it no crim e at all to a g g re ssiv e ly treat p ain, th ere is little p ro sp ect o f change.

H o w S lo w E u th a n a sia W ork s in P ractice A d o cto r p ractisin g s lo w euth an asia usu ally g iv es a narcotic analgesic (m orphine), w hile periodically review ing the patient's p ain. T h e claim is then m a d e that treatm en t is in ad eq u ate, and th e m o rp h in e do se increased. I f this r e v ie w takes p lace every 4 - 6 hours, m o rp h in e levels will rise. Eventually lethal levels w ill be reach ed an d th e patient will die. T h e d o cto r d efend s h is o r h e r actio ns b y sim p ly saying that they w ere try in g to con trol th e p a tie n t's pain. D eath, they argue, w a s an u n p lan n ed co n se q u e n c e o f e ith e r th e patien t's d ise a se o r th e n ecessary treatm en t fo r th e pain. It can take d ays fo r the levels o f m o rp h in e to b e c o m e high en o u g h to cause death. It is im p o rtan t fo r th e d o c to r 's safety that th e p rocess is slow . Indeed, it is the length o f tim e taken th a t gives credibility to th e a rg u m e n t that there w a s effort put into esta b lish in g ju s t th e right d o s e o f m orphine.


A n o th e r w a y o f u nd erstan d in g the p rocess o f slo w euthanasia is to co n sid e r the link b etw een cause an d effect. T h e tim e taken for th e m o rp h in e to e n d life m u d d ie s th e w a te r an d b lu rs the connection betw een the cause (the c o m m e n c e m e n t o f m orphine) a n d th e effect (the patien t's death). B y blurring this link, a d o c to r can help a p a tie n t d ie an d escap e th e legal consequences.

P ro b lem s w ith S lo w E u th a n a sia S lo w e u th an asia h as a n u m b e r o f features that lim it its appeal to a patient. Firstly, it is th e d o c to r w h o is in control. W h ile a patient m ig h t ask for this fo rm o f help, it w ill be th e d o c to r w h o d e c id e s i f an d w h e n it will be prov id ed. J u st b ecau se y o u - the patient - feel that n o w is th e rig h t tim e to begin the process, there is no gu aran tee th a t th e d o c to r w ill agree. T h e y m a y feel y o u sh o u ld w ait; w a it until y o u b e c o m e sicker, p e rh a p s until y o u r haem o g lo b in d ro p s a few points, o r y o u r resp irato ry fu nction tests d eteriorate further. T h e s ic k e r y o u are, th e safer it is fo r the d o c to r to go d o w n this path. I f the d o c to r d isag rees w ith y o u an d th ink s th e ' b est tim e ' to help s h o u ld b e several w e e k s away, there is ab so lu tely n o th in g you c an d o about it. A n o th er d ra w b a c k o f slo w euth an asia is the restriction on the ra n g e o f d ru g s that a d o cto r m ig h t u se to h elp a p erso n die. If th e d o c to r 's d e fe n c e is to b e that it w a s th e treatm en t o f the p a tie n t’s pain that cau sed th e death, then a p ain -reliev in g drug like m o rp h in e m u s t be used.


A d o cto r could not, fo r ex am p le, a d m in ister a large d ose o f a barbiturate. W hile a barbiturate m ight p rov id e the m o s t peaceful an d quickest death, barbiturates are n o t p ain relieving drugs, and th e claim that su ch a dru g w a s being u s e d to treat pain m ak es n o sense. T h is u se o f m o rp h in e b y d o c to rs to e n d life h a s led to the c o m m o n c o m m u n ity m isc o n c e p tio n that th e best d ru g to u se to en d o n e 's life is m o rp h in e - it m u s t be, b ecau se th a t's th e dru g d o c to rs use! T h is u n fo rtu n ate m isu n d erstan d in g leads to m an y failed suicide attem pts. A nd the process m ust b e slow. Indeed, s lo w euthanasia can often take days o r even w eek s. O ften the patient is given a sedative th a t k e e p s th em asleep thro u g h th e w h o le process; m id azo lam is the d ru g o f c h o ic e . C o u p led w ith m orphine, this m orphine - m id azolam m ix (know n a s ‘ D o uble M T h e ra p y ʼ) p laces the patient in an in d u ced co m a for the tim e n eed ed to raise the m orphine level sufficiently. D o u b le M th e ra p y a llo w s th e p a tie n t to sleep th ro u g h their o w n death a n d g iv es rise to an o th e r n a m e fo r th e p ro c e ss ‘ph arm acolog ical o b liv io n .’ T h e d o cto r still m a k e s th e a sse ssm e n t about the n e e d for larger a n d larger m o rp h in e doses. H ere th e decision is b a se d n o t on th e p atien t's co m p lain ts, b u t upon a clinical a sse ssm e n t o f the u n co n scio u s person. T h e d o cto r w ill also c h o o se th e p lace o f death. It is u nu sual for s lo w eu than asia to take p la c e in a p a tie n t's h o m e. U su ally it o ccu rs in an institution, c o m m o n ly a hospital o r hospice.


In an institution, a team is often inv olv ed in p ro v id in g c a re and several doctors m ight p articipate in th e relentless increase o f th e m o rp h in e . T h is further b lu rs th e link betw een c a u se and effect an d m a k e s it ev en safer fo r th e m edical s ta f f involved. W h ile s lo w e u th an asia c o u ld take place at th e p atien t's hom e, in p ractice this p resen ts m a n y logistical difficulties. T h e d o cto r w o u ld n e e d to m ak e m a n y visits, p e rh a p s sev eral a day, to facilitate the relentless increase in drugs. A ls o full n ursing care is required; an u n c o n s c io u s p a tie n t needs to be m o v e d regularly an d w atch ed constantly to ensure the flow o f d r u g s is n o t interrupted. T h is is often a n ex trem ely difficult tim e f o r th o se clo se to th e p a tie n t a s th e y find th e m se lv e s p articip ating in this deliberate, s lo w death w atch. F o r th e s e r e a s o n s , f e w p e o p le o p t f o r s lo w e u th a n a s ia as th eir preferred ch o ice for a peaceful, dignified death. M ore co m m only, it is an option o f d esp eration , w h en few alternatives exist. In such d ire c ircu m stan ces, i f a d o c to r d o es offer help (u su ally through a nod, a w in k a n d an u n d erstan d in g ), patients will g rab the ch an ce, reaso n in g correctly, that this is better than nothing. T h o s e w h o are left often see th is a s an ex am p le o f a d o cto r h e lp in g s o m e o n e to d ie , a n d th is le a d s to th e c o m m o n l y e x p re ss e d v iew that there is n o n eed for euth anasia legislation. P eople say T c a n 't see w h a t all th e fuss is a b o u t w ith voluntary e u th an asia - it g o e s on all th e tim e p eo p le to die.'

doctors a re alw ay s helping

It is a s w ell to re m e m b e r that ' w h a t g o e s on all the tim e ' is the g rim pro cess o f su sp en d in g a sick p erso n by a th read betw een life an d death fo r an arbitrary tim e, until the th read breaks. T hat is slo w euthanasia!


A s k in g f o r S lo w E u th a n a sia The p ro c e ss o f s lo w e u th a n a s ia is a lw a y s co n tro lled b y the doctor. B ec au se o f this, there is u s u a lly little a patient can d o to ensure that th e option is available. O ften w h en p atien ts realize that th ey h ave a d eterio ratin g m ed ical co n d itio n , they ask their d o cto r w h e th e r o r n o t th e y will be able to help th em ' a t th e end.' T h e d o cto r m a y ev en v o lu n te e r to h av e this d iscussio n an d this is en co u rag in g - but be careful. W h e n d o c to r an d p atient begin sp eak in g in this tan g ential way, there is a very real ch an ce that significant m isu n d erstan d in g s can occur. It is n o t u n c o m m o n for a d o c to r to p ro m is e ' e v e ry assistance w h en th e tim e c o m e s ' a n d fo r th e p atient to draw im m en se c o m fo rt from this. A patient m ight even im agine that the doctor is saying that ‘w hen things deteriorate I w ill g ive y o u access to lethal d r u g s .’ In reality, this is h ig h ly unlikely. F e w m edical do ctors w o u ld risk de-registration an d a significant ja il term . T h e only assistance likely fro m the doctor, is fo r th em to initiate s lo w euthanasia, w ith th e p a tie n t b e in g a d m itte d to an in stitutio n , a hospital o r h osp ice. A n d th ere m a y w ell b e a rg u m e n t a b o u t w h en the p ro c e ss sh o u ld co m m ence. E xit s u g g e s ts that in s itu a tio n s w h e r e s lo w e u th a n a s ia has appeal, th a t early d iscu ssio n s b etw een p atient an d d o cto r take p la c e . B e blunt. I f th e d o c to r p ro m ises h e lp ‘w h en th e tim e c o m e s ’, insist on k n o w in g w h o w ill d ecid e w h en that time is, and e x a c tly w h a t sort o f help is b e in g pro m ised ? I f there is an y attem p t to skirt o r d ism iss y o u r questions, be very w ary. Try discussin g th e issue w ith an o th e r doctor, o r look into an alternative e n d o f life strategy.


T h e R o le o f O p ia te s and O p ioid s O p ia te s a re naturally occu rrin g c o m p o u n d s that o rig in ate from th e sap o f th e poppy, p a p a v e r so m n ife ru m . S u b stan ces derived fro m th e se c o m p o u n d s are opioids. T h e se c o m p o u n d s all effect th e sam e recep to rs in the brain an d are g en erally used for the con trol o f stro n g pain. W h ile m o rp h in e is the c o m m o n e st ex am p le, o th er ex am ples include, pethidine, codeine, m eth ad on e an d fentanyl. The illegal d rug heroin is also an opiate. All o p iates h a v e p ro p erties that m a k e th em difficult d ru g s for a person to u se to relia b ly end th eir life. T h e bigg est p ro b le m associated w ith taking opiates is predicting the effect. There is rem arkable individual variability in sensitivity to th e se drugs w ithin th e norm al population. P eople w h o a re sim ila r p h y sica lly (sam e height, w eig h t, sex etc) can h ave a v astly different resp o n se to th e a d m in istratio n o f a n opiate. A sm all d ose o f m o rp h in e m a y h ave a lm o st no effect on one p erso n , w h ile th a t sam e do se could kill another. P redicting th e effect o f th e d rug on an individual is difficult. W h e n these d ru g s are u s e d clinically the rule o f th u m b h as b een to ' start lo w an d go s lo w ' until th e in d iv id u a l's sensitivity to th e drug is established. A n o th e r d ifficulty w ith o p ia te s is th e rap id d e v e lo p m e n t o f to le ra n c e w h e n th e d ru g s are taken for an y p e rio d o f tim e. W ithin d ays, the m o rp h in e that initially h ad a p ow erful effect on th e pain can b e c o m e a lm o st ineffective.


T o obtain th e sam e pain r e lie f th e d ose m u st be increased. If these d ru g s a re taken for lo ng periods, v e ry large doses m ight b e n eed ed to p rov ide adeq uate p ain con trol. T h e se req u ired d o se s can b e c o m e so large that i f they w ere taken befo re the to leran ce h ad dev elo ped, death c o u ld w ell h av e b een th e result. It is this d e v e lo p m e n t o f tolerance, an d its rap id loss o n ce the d ru g s stop, that often leads to the accidental death o f people w ho self-ad m in ister op iates, especially heroin. I f there is a b re a k in s u p p ly an d th e acq uired to leran ce is lost, a sudden resum ption m a y result in an u n e x p e c te d fatal overdose.

Fig 10.1: Liquid morphine


M o rp h in e is c o m m o n ly p rescribed a s a s lo w release (S R ) tablet. M S C o n tin an d K apanol are m a rk e te d form s. T h e se m a y be ta k e n o n c e o r tw ic e a d a y an d s lo w ly release th e m o rp h in e to g iv e ‘b a c k g ro u n d ʼ p ain control. F o r the o n set o f sudden (b reak th ro u g h ) pain , a fast release form o f the drug, liquid m o rp h in e is o fte n p rescribed (O rdine). M an y v ery sick people receive these drugs for the pain o f serious illness an d so m etim es g o to g reat leng th s to sto ck p ile tablets believing that they will soo n acqu ire a lethal dose. But know ing h o w m a n y m o rp h in e tablets to ac c u m u la te is like a sk in g the length o f a p ie c e o f string? A single d ose o f S R tablet m o rp h in e m a y c a u se death, b u t the resu lt is often u n p red ictab le. T h e fast-acting liq uid m o rp h in e m a y b e a m o re effective fo rm o f th e drug, b u t the p ro b le m s o f s en sitivity a n d tolerance rem ain. F o r these reason s it is difficult to a d v o cate th e o piates a s sta n d alone, sin gle-do se, oral ag en ts to p ro vid e a reliable death. O ne exception to this general rule is p ro p o x y p h en e (see C h ap ter 11). W h e n this dru g is taken w ith a (n on -leth al) b en zo d iazep in e, a reliable d e a th w ill occur. T h e o p ia te s do, ho w ev er, h a v e a role a s s u p p le m e n ta r y o r potentiating agents, (ie. a d rug taken to enhance th e effectiveness o f a n o th e r drug). T h is role is u s u a lly filled b y a lc o h o l, but for p eo p le w h o do n o t drink, m o r p hine liquid can be a good alternative.


T h e U se o f H eroin E xit is o c c a s io n a lly a s k e d a b o u t w h e th e r h ero in s h o u ld be o btained from ‘th e s tre e t’ a n d u s e d to en d life. T h e se questions are o fte n p ro m p te d by n ew s rep orts o f p eo p le d y in g from a heroin ov erdo se. In reality, there is little to b e g ain ed b y using heroin. A s an o p iate heroin suffers from th e p ro b le m s o f to leran ce an d sensitivity m e n tio n e d ab ov e. In addition there is the question o f th e u n certain ty o f th e do se w ith heroin. B ec au se it h as been acq u ired on th e streets, o n e can n e v e r b e e x a c tly sure w hat o r h o w m u ch o n e h as a ctu ally p u rch ased . It also n e e d s to be injected intravenously. In E x it's ex p e rie nce , f e w eld erly and seriously ill p eo p le h ave th e se skills. N o te: I f h ero in is ta ken orally, it tu rn s b a c k in to m o rp h in e in th e g u t a n d o ffe rs n o a d v a n ta g e o v e r p rescrip tio n ta b le t m orphine, w h ere a t le a st th e e x a c t d o se is know n. O ne final point o n th e opiates. I f o n e d oes d ie tak in g these drugs, th e d e a th is likely to be v e ry p eacefu l. M o rp h ia is, after all, th e g o d d e s s o f dream s.


C o n clu sio n In E x it's internal p ollin g o f o v e r 1000 o f o u r su pp orters, less th an o n e percen t (0.3 % ) o f E xit m e m b e rs say that th ey w o uld p refer slow euthanasia co m p a re d to a Peaceful Pill (89% ). Slow e u th a n a s ia is, th erefo re, o n e o f th e least-p referred m eth o d s o f d ying, a n d o n e that is usually a v o id e d w h en o th er options exist. G iven a ch o ice, p eo p le p refer to h a v e co ntro l o f the d ying process. T h is is n o t the case w ith s lo w euth anasia. It is relatively rare to find so m eo n e w h o w a n ts to sp e n d th eir last d a y s in a drugin d u ced com a. W h e n p eo p le d ecid e that th eir su fferin g is so great that death is preferable, th ey w an t their passing to b e quick. T h is is w h y slow eu thanasia is a lm o s t a lw a y s an option o f last resort. It is the m eth o d a c cep ted w h en n o thin g e lse is on offer, a n d th e only altern ativ e is relentless an d on g o in g suffering. Finally, th ere rem ains a c o m m o n b e lie f th a t th e ‘o p ia te s’ are the b est d ru g s to en d life. T h is u n d eserv ed rep utatio n c o m e s from th eir alm o st-un iversal use in s lo w eu thanasia, w h e r e doctors h av e little choice. W h i l e a s in g l e o v e r d o s e o f m o r p h i n e m a y c a u s e d e a th , individual sensitivity a n d to leran ce to these d ru g s m ak e this an u n certain a n d u n p redictab le p ro cess. T h e o p iates are best used to do th e j o b they are d esig n e d to do, co ntrol stro n g pain. T h ere are b e tte r eu thanasia optio ns available.


T h e E x it R P T est fo r M o rp h in e M o rp h in e (o r a n y o f the o th e r opiates) d o n o t score particularly w ell on the RP Test. W h e n u s e d a s a dru g an d taken as a single dose by a person w an tin g to die, the difficulty o f establishing the lethal d ose significantly reduces R eliability (4/10). Peacefulness though is g o o d (10/10). M in o r criteria scores are patchy. A vailability (3/5), som etim es m o rp h in e is available - i f a person is suffering from a recognised p ainfu l disease. But th e u se o f th e o p ia te s as drugs o f addiction an d th e ir p la c e in th e illegal n a rc o tic tra d e can a lso m ak e th e m o c c a s i o n a l l y v e r y d if f ic u lt to o b ta in . P re p a ra tio n is easy (5 /5 ), a lth o u g h c o n s tric te d ' p in p o in t' p u p ils can often alert a m edical o fficer to th e p rese n c e o f th e se d ru g s in the sy stem (U n d e te c ta b ility = 2 /5). D eath can a lso take so m e tim e, d ep en d in g on o n e ’s tolerance an d resu scitation is often straig h tfo rw ard u sin g th e o p iate an tag o n ist N alo x o n e (S p eed = 2/5). T h e re are n o safety issu es (S afety = 5 /5), an d th e drug has a m od erate s h e lf life (S torage = 3/5). E x it R P T e s t - M orp h in e C rite ria

S core

R eliability

4 /1 0

P e a ce fu ln e ss

10/10

A va ila b ility

3 /5

P rep a ra tio n

5 /5


2 /5

S p ee d

2 /5

S a fe ty

5 /5

S to ra g e

3 /5

T o ta l

3 4 (68% )

11 Drug Options - Propoxyphene In tro d u ctio n A useful, lethal d rug , still p rescrib ed in a handful o f countries, is p ro p o x y p h en e. T h e dru g is m a rk e te d u n d e r v a rio u s nam es an d used as an oral analgesic (pain reliever). I f p rep ared in a certain w ay, a n d taken in co m b in atio n with a c o m m o n b e n z o diazep in e slee p in g pill su ch a s o x a z e p a m (S erep ax ), p ro p o x y p h e n e w ill p ro v id e a reliable, peaceful an d dignified death.

Fig 11.1 Propoxyphene capsules (Doloxene)

D rug O ptions - Propoxyphene

T he V ariou s F o r m s o f P ro p o x y p h en e P ro p o x y p h en e is m a rk e te d u n d e r a n u m b e r o f nam es, e x a m p les include D arvo n, D o lo x en e, a n d D epronal. R eg ard less o f its nam e, th e key n ecessary ingredient is p ro p o x y p h e n e - e ith e r a s th e hy d ro ch lo rid e o r napsylate, an d it is im p o rtan t that the d ru g labels are re a d very carefully. In so m e v id e o se g m e n ts in clu d ed in this ch a p te r th e n am e D o lo x e n e is u s e d to refer to p ropoxyphene. P ro p o x y p h en e cap su les h ave o n ly o n e active ing red ient (dextro p ro p o x y p h e ne napsylate). H ow ever, th e d ru g p ro p o x y p h e n e is often m a rk e te d in co m b inatio n w ith o th er co m m o n an algesics such a s paracetam ol (a c e ta m in o p h e n ) an d m ark eted as D i-G e sic (D a rv o c et). T h e se co m b in atio n p ro d u cts are o f lim ited use. T aking a large am o u n t o f the a sso ciated d rug can co m p licate th e p ro c e ss . The ingestion o f a su b stan tial q u an tity o f p aracetam o l (aceta m in o p h e n ) f o r e x a m p le m a y well lead to death, b u t it w o u ld not b e re g ard ed a s particularly peaceful.

Note: W ith th e w ith d ra w a l o f th e b a rb itu ra te s le e p in g tablets fr o m th e m e d ic a l p re sc rib in g list, D o lo x e n e h a s b e c o m e th e m o st c o m m o n d o c to r-p re sc rib ed m ed ica tio n u s e d b y s e rio u sly ill p e o p le to e n d th e ir lives. R ecen tly, th e u n iq u e p ro p e rtie s o f D o lo x e n e h a v e b e g u n to a ttra c t a tten tio n : f i r s t in th e U K a n d th e EU , th en N e w Z e a la n d a n d m o re re c e n tly in th e U S a n d C a n a d a w h ere it h a s n o w b een re m o v e d fro m th e p re sc rib in g schedule.

Note: P re sc rib e d d r u g s c o n ta in in g p ro p o xyp h en e w ill b e re m o v e d in A u stra lia fro m 1 M a rch 2 0 12. O n -lin e so u rc e s o f th e d ru g a re c u rre n tly b e in g in v e stig a te d b y Exit.


W h en is P r o p o x y p h en e P rescrib ed ? P ro p o x y p h en e (d ex tro p ro p o x y p h en e nap sy late) is a lm o st a l w a y s av ailab le fro m a d o c to r on p rescription, w h e re it is used for p ain m an ag em en t. P ro p o x y p h en e is usu ally prescribed w h e n o v er-th e-co u n ter pain reliev ers prove in ad eq u ate and w h en other, m o re c o m m o n prescription p ain -re liev e rs (eg. P anadein e F orte o r T y leno l-C od ein e - a m ix tu re o f paraceta m ol an d cod eine) p ro v e unsatisfactory. P ro p o x y p h en e can be u s e d w h e n e v e r there is a n e e d for g en eral pain relief. B efore th eir rem o v al in late 2 0 1 0 in th e US (a n d C an a d a), p ro p o x y p h e n e an d co m b in a tio n s w e re the 12th m o s t p rescribed gen eric d rug (P u b lic C itizen, 2006)

H o w L eth a l is P ro p o x y p h en e? P ro p o x y p h en e h as a v ery n a rro w th erapeutic m argin. T h e dif feren ce in d ose betw een th a t p ro v id in g analgesia a n d th a t c a u s ing death is small. L ike th e o p ioid s, th e o u tco m e fro m a partic u la r do se can b e difficult to pred ict (S ee C h a p te r 10), b u t this dru g p ro d u ces a cardio-toxic m etab olite w h e n it break s d o w n w h ich in creases its u sefu ln ess as a s e l f d eliv eran ce agent. W h e n an o th e r drug, the read ily-av ailab le, non-lethal sleeping tablet, o x azep am , is add ed , a lo n g w ith alcoh ol, th e result is certain. E xit has n o rep o rted failures from this com bination. A s the repu tatio n o f p ro p o x y p h en e has g ro w n , so scrip t sizes have been red u ced . T h e stan d a rd p a ck ag in g n u m b e r fo r p ro p o x y p h e n e is n o w 50 cap sules. All cap su les co ntain the sam e 100m g o f d e x tro p ro p o x y p h e n e napsylate.

D rug O ptions - Propoxyphene If 10gm o f d e x tro p ro p o x y p h e n e n a p s y la te p o w d e r is o btained from 100 capsules an d ta k e n w ith 10 o r m o re m oderately, long -actin g slee p in g tablets like o x azep am , death will follow. P ro p o x y p h en e is usually p rescrib ed a t th e rate o f 4 -6 capsules p er d a y (40 0 - 6 0 0 m g ) to deal w ith pain. Ten g ra m s o f th e drug w o u ld p ro v id e a ro u n d 2 to 3 w e e k s o f p ain control.

T h e R o le o f O x a zep a m O x azep am (S erep ax ) is a m o d erately lon g-actin g, non-lethal sleeping tablet. A n o th e r m o d e ra te ly long -acting slee p in g tab let often u s e d in co m bin ation w ith p ro p o x y p h e n e is nitrazepam (M og ad on ). T h e se m o d e m slee p in g tablets are m e m b e rs o f a d ru g class kn o w n a s b en zo d iazep in es an d w h en taken b y th em selves a re n o t u s u a lly lethal, ev en i f taken in large am ounts. W h e n taken in co m b inatio n w ith p ro p o x y p h en e, o x a z e p a m or n itra z e p a m reinforce the effect o f a p ro p o x y p h e n e an d a lethal co m b ination is th e result. N o te : D u ra tio n o f a ctio n o f th e b e n zo d ia zep in e is im p o rta n t - s h o r te r a c tin g d ru g s lik e tem a zep a m a re n o t recom m ended.

Fig 11.2: The common sleeping tablet - oxazepam (Serapax)


W h en is O x a z e p a m P rescrib ed ? Well k n o w n a s slee p in g drugs, o x a z e p a m an d n itra z e p a m are av ailab le on p rescriptio n from a doctor. T h e y are prescribed f o r in so m n ia (w h e n a p erso n is u n ab le to sleep). O x a z e p a m is u su ally p rescrib ed in pack ets c o n tain in g 25 slee p in g tablets, w h ic h co m e in tw o sizes, 15mg an d 30m g. P eople u sin g p ro p o x y p h en e, often take a full p ack et o f 3 0 m g o x a z e p a m tablets a s the supplem ent.

T ak in g P r o p o x y p h en e T he drugs are taken sequentially. P rep are th e p ro p o x y p h en e b y p ullin g apart 100 x 100m g cap su les (or cu t th em o p en w ith scisso rs) a n d e m p ty th e 10gm w h ite dex tro p ro p o x y p h ene nap sy late p o w d e r into a glass. In an o th e r g lass p la c e 10 o r m o re 3 0 m g o x a z e p a m tablets an d c o v e r th em w ith water. It is w ise to take an a n ti-e m e tic (eg m e to c lo p r a m id e ) e ith e r as a sin g le stat do se o r f o r 4 8 h o u rs befo re th e p la n n e d death (see C h a p te r 9). A fter h av in g s o m e th in g light to eat, ad d enough w a te r to the 10g m o f p ro p o x y p h ene p o w d e r s o that stirring a l low s th e d rug to be drunk. N o te : th e n ap sy la te d o e s not dis so lv e in the w ater, stir with a spo on an d then drink th e s u sp en sion o f particles. S tir the s eco n d g lass w ith th e o x a z e p a m and w a t e r till this a lso can b e taken as a drink. A lco h o l is useful to take a w a y th e b itter dru g after-taste and will s p e e d the p ro c ess. S it com fortably. In 1 0 - 2 0 m inutes s lee p w ill o c c u r a n d death will follow usually in 4 - 6 hours.


Fig 11.3 100mg pink Doloxene Capsules


S h e lf L ife o f D o lo x en e P ro p o x y p h en e h as a relativ ely lon g s h e lf life. P rescribed cap su les h av e an e x p iry d ate sta m p e d on each c a rd a n d this is u su ally 2 o r 3 y e a r s into th e future. A lth ou gh this p rovides o n ly a rough guide, in th e ab sen ce o f an y av ailab le testing o f th e dru g, it is th e on ly indication o n e has. C ap su les that have re a c h e d th eir ex p iry d ate sh o u ld be treated w ith cau tion (See C h a p te r 8 for a discussion on s h e l f life).

T h e F u tu re o f P r o p o x y p h en e P ro p o x y p h en e faces an uncertain future. T h e w ith d raw al o f the d rug fro m th e prescription sch ed ule in th e U K in early 2005 h as led to the c o m m issio n in g o f a rep o rt on possible sim ilar restrictio ns in A ustralia. T h e d rug has n o w b een w ith d ra w n in the E u ro p e a n U n ion , the US, C an a d a an d in N e w Z ealan d . In N o v e m b e r 2 0 1 0 the F D A a n n o u n c e d that th e dru g w o u ld be also re m o v e d from the U S m arket. http://nyti.ms/9iPzgD

A t the tim e o f press, p ro p o x y p h e n e is still av ailab le o n p re scription in A ustralia, M e x ic o an d a range o f S outh A m erican a n d A sian countries.


Fig 11.4: Propoxyphene powder ready for mixing with water

Fig 11.5: 10gm propoxyphene ready to drink


R P T est for P ro p o x y p h en e P ro p o x y p h en e sco res w ell on th e R P Test. E xit h as no co n firm ed rep orts o f failure an d it rates 9 /1 0 fo r Reliability. The tim e before sleep o ccu rs is lo n g er than o th er d ru g s like N e m b utal a n d this can c a u se anxiety. P eacefu ln ess (7/10). In th e m in o r categories: A vailability is listed a t 4 /5 . M ost p eo p le w h o set o u t to g et this d ru g w ill acq u ire it. R e m e m b e r th o u g h that i f the d ru g is w ith d ra w n , availab ility will drop to zero. P rep aratio n is m o re co m p licated than w ith o th er ingestib les (P r= 3/5). T h e d ru g is u n d etectab le - u n less there is an autopsy, alth ou gh co n stricted p up ils m a y c a u se suspicion (D =3/5). T h e p rocess is s lo w (S p = 2 /5 ) th e d ru g p resen ts no risk to o th ers (S a= 5/5).

T h e d ru g h as a m o derate s h e lf life

(St=3/5). Total 36 o r 72%

R P Test fo r P ro p o x y p h en e C rite ria

S core

R e lia b ility

9/10

P e a ce fu ln e ss

7/10

A vailability

4 /5

P rep a ra tio n

3 /5


3 /5

S p ee d

2 /5

S a fe ty

5 /5

S to ra g e

3 /5

T o ta l

3 6 (72% )

12

Other Drugs and Com m on M yths

In this ch a p te r a n u m b e r o f o th er d rug o p tio n s for a p e a c e ful death are co n sid ered . A lth ou gh so m e tim e s th ou gh t o f as relia b ly lethal, each o f these p o ssib le p h arm aceu tical options suffers from s o m e facto r o r issue that m a k e s th e ch o ice less d esirab le th an th e g o ld stan d a rd , N em b u tal. T h e d ru g s to b e c o n sid e re d in this ch a p te r include: T h e tricy clic an tid ep ressan t - A m itriptyline •

T h e h o rm o n e - Insulin T h e anti-m alarial - C h lo ro q u in (S ep t 2 0 1 2 update)

A m itrip ty lin e A m itrip ty lin e is the m o st useful in a c lass o f d ru g s k n o w n as tricyclic an tid ep ressan ts (T C A s). T h e se d ru g s can b e lethal if taken in a certain way. T h e T C A s d ate b ack to th e early 1960s w h e re they established th e m se lv e s as useful an tid ep ressan ts. H ow ever, their n arrow th erap eu tic m arg in (the do se n eed ed for therap y a s an antidep ressan t a n d that w h ic h is toxic is clo se ) m e a n t that there w ere d a n g e rs in prescribing th e se d ru g s, especially to depressed p eople, fro m e ith e r accidental o r intentional overdose.

O ther D rugs & C om m on M yths

T h e ir im p licatio n in a large n u m b e r o f d eath s from o verdo se m e a n t that o th e r classes o f safer an tid ep ressan ts su ch as the serotonin r e-u p ta k e inh ibitors (S S R I) like fluoxetine (P ro zac) found fa v o u r an d largely d isp laced the T C A s. S ince this tim e the T C A s h av e u n d erg o n e so m eth in g o f a resur g e n c e for the treatm en t o f in trac ta b le neuro path ic pain (such as trigem in al neuralg ia) an d m igraine.

U s in g Tricyclics fo r a Peaceful D eath T h e d ru g s h ave sev eral characteristics that m a k e th em useful as reliable an d lethal drugs. In p artic u la r th e y e x h ib it cardioto xic and central n e rv o u s sy stem (C N S ) effects. C N S sy m p to m s include sedation an d co m a, b u t it is the card ioto xic effects that red u ce cardiac output, lo w e r b lood pressure a n d d isru p t cardiac rh y th m that bring a b o u t death.

Fig 12.1 The tricyclic antidepressant amitriptyline


T h e toxic effects are a c c e n tu a te d i f th e dru g is ra p id ly ab so rb ed from th e g u t a n d this o ccu rs in the alkaline e n v iro n m e n t o f the sm all intestine. Preparation a s a drink facilitates this, a s docs th e u se o f an a n ti-e m e tic like m e to c lo p ra m id e (M a x o lo n - see C h a p te r 9) w h ic h sp eed s gastric em ptying. A m itripty line is o n e o f the m o s t sed atin g o f the T C A s an d p articu larly useful a s a lethal drug. T h e dru g is m a rk e te d a s Endep o r Elavil tablets. T h e am o u n t required is 5gm .

P rep a ra tio n o f A m itrip ty lin e T h e d rug is usu ally p a c k a g e d a s tablets in 10, 25, 50 o r 100m g a m o u n ts (F ig 12.1) an d is usually su p p lied in p a c k e ts o f 50 tablets. T w o p a c k e ts o f 5 0 m g tablets is (1 0 0 x 5 0 m g ) o r 5gm o f th e drug.

Fig 12.2 Amitriptyline with metoclopramide, oxazepam and Gin


F o r a peacefu l death, o p en the b lister p a c k s an d p lace 100 o f th e 5 0 m g tablets in a glass. A d d en o u g h w a te r to c o v e r the d ru g a n d w ith g en tly agitation a llo w th e d rug to dissolve. Take 6 x 10mg m eto clo p ra m id e tablets an d w ait 4 0 m inu tes b efo re drink in g th e d isso lv ed am itripty line. F o llo w this w ith 10 o r m o re b en zo d iazep in e sleeping tablets, then finish by tak ing alcoh ol to potentiate the actio n o f the drug, an d take aw ay th e b itter d ru g after-taste. N o te : A ltho ug h am itrip tylin e is a stro n g sedative a n d sleep will q u ic k ly result, it is c o m m o n to include a b en zo d iazep in e slee p ing d ru g after taking th e am itrip tylin e an d befo re the whisky. S erapax (o x azep am ) is useful (see C h a p te r 11). O n c e the d rin k h as been co n su m ed , settle b ack a n d take the alcohol. T h e d rug cocktail will w o rk q u ic k ly indu cin g sleep in about 15 m inutes. S leep w ill th en d eep en as con scio u sn ess is lost a n d th e c a rd io to x ic p ro p erties o f th e d ru g b rin g about death. T his p erio d can v a ry an d it is a g o o d idea to h av e p re p a re d a situation w h ere there is no lik eliho od o f disturb an ce for a p erio d o f up to 2 4 hours. (F ig 12.2 & Video)


H o w d o es A m itr ip ty lin e score o n th e R P test? E xit h as no c o n firm ed rep orts o f failure using this regim e and it rates 9/1 0 for Reliability. T h e tim e before sleep occu rs is lo n g er than w ith the b arb iturates an d this can c a u se anxiety. P eacefuln ess (7/10). In the m in o r categories: A vailability 2/5. It can be a difficult d rug to acq uire. Preparation is m o re co m p licated th an with o th er ingestibles (P r= 3/5). T h e d ru g is u n d etectab le - unless there is an autopsy. T h e re is n o thin g a b o u t the death that su g gests th e u se o f this dru g - th e person looks as though th ey h ave d ied o f a cardiac arrest (w h ich they have - D=3/5). T he p rocess is h o w e v e r slo w (S p = 2 /5 ) an d the dru g h as a m od erate s h e lf life (St=3/5). T h e dru g p resen ts n o risk to o th ers (Sa=5/5). Total 34 o r 68% R P Test fo r A m itrip ty lin e C rite ria

S core

R eliability

9/10

P ea cefu ln ess

7/10

A va ila b ility

2 /5

P rep a ra tio n

3 /5


3 /5

S p e ed

2 /5

S a fety

5 /5

S to ra g e

3 /5

T o ta l

3 4 (68 %)


In su lin T h e re has b een a lot o f recen t interest in th e u se o f Insulin to p ro vid e a peacefu l death. R ea so n s for this are e a s y to u n derstand . In d e v e lo p e d natio ns there is a hu g e grow th in the n u m b e rs o f p eo p le w ith T ype 2 diabetes, an d a c o rre sp o n d ing increase in th e n u m b e r o f p eo p le w ith re a d y access to this drug. An additional facto r is the c o m m o n chro nic co m p lic a tio n s that often a c c o m p a n y severe form s o f this disease. T hese sy m p to m s can often s o lim it a p e rso n 's q u a lity o f life, that the option o f a peaceful death is so u g h t. This d riv es interest in the u se o f this drug.

W h a t is Insulin, a n d h o w can it end life Insulin is p r o d u c e d in th e p an creas a n d c o n tro ls s u g ar levels in th e body. I f the p an creas fails (ty p e 1 diabetes), o r i f the insulin p ro d u c e d fails to h a v e th e ex p ec ted effect (ty p e 2 diabetes), b lo o d s u g a r levels (B S L ) rise an d disease results. Synthetic in sulin can then be used to d riv e d o w n th e B S L to norm al levels. H o w ev er, i f an o v e rd o se o f this d rug is taken, th e b lo o d s u g ar can be p u s h e d d a n g e ro u sly low, an d diabetic h y po gly cem ic co m a a n d death result. A h y p o g ly cem ic death from Insulin o verdo se, w h e re the brain is s ta rv e d fro m sugar, can b e relatively peaceful. Initial s y m p to m s o f confusion an d incoo rdin atio n (often co n fu se d with d ru n k en n ess) can lead o n to a rap id loss o f co nsciousness.

S ign ifican t p r o b le m s u sin g Insulin T h e big gest pro b le m w ith u sin g the d rug in this w a y is that Insulin m u st be injected. A s y e t there are no oral fo rm s o f the drug.


T h e p rob lem s o f intraven ou s adm inistration h av e b een d escrib ed in C h a p te r 9, an d alth ou g h insulin can also (an d usu ally is) g iv en b y su b c u ta n e o u s injection, try in g to a d m in ister an ex cess o f 1000U o f th e rapid actin g fo rm o f this d rug , b y th e subcu tan eo u s m eth o d can be p ractically im possible. T h e o th er issue is that the g ro w in g n u m b e r o f p eo p le with access to this d ru g h av e the form o f th e disease w h ere their bodies are u n re sp o n siv e to th e d ru g (Type 2 diabetes). W h ile 1000U ad m in istered ra p id ly m ig h t peacefully e n d th e life o f a n o n -diabetic, those w ith the disease n e e d to be m u ch m o re careful. In theory, o n e can p re-sen sitise on eself, b y taking alcohol (w hich restricts the b o d y ’s e m e rg e n c y release o f sugar), fasting, a n d by the adm in istratio n o f a significant d o s e o f oral h y p o g ly cem ics before the in sulin is in jected (eg ~ 5 0 m g G lim ep irid e), th e risks an d u ncertain ties o f th e adm in istratio n o f a large sub cutaneou s injection rem ain.

In S u m m a r y N o t reliable en o u g h to re c o m m e n d i f su b c u ta n e o u s injection is the o n ly m eth o d o f a d m in istratio n available.

Fig 12.3 ʻNovoRapid’ rapid acting insulin ampoule. 1000U in 10ml with 0.5ml syringe for subcutaneous administration NOTE: 20 full syringes would need to be quickly injected to administer 1000U

13 Drug Options - Nembutal I a m h o p in g to g e t a c c e s s to y o u r 'p e a c e fu l p i l l ' - n o t fo r im m e d ia te use, bu t to h a v e o n h a n d s h o u ld m y health d e te rio ra te to o m u ch in th e fu tu re . A rthur, 77 years

In tro d u ctio n T h e barbiturate S o d iu m Pentobarbital is th e d ru g th a t co m es closest to th e c o n c e p t o f th e P eaceful Pill.

Exit defines the

‘P eaceful P illʼ a s a pill, tablet o r m ix tu re that can b e taken orally a n d that is g u a ra n te e d to p ro vide a peacefu l, dignified death at a tim e o f o n e 's choosing.

A S h o rt H isto ry o f B a rb itu ra tes S o diu m Pentobarbital o r N e m b u ta l as it is c o m m o n ly called is an im p o rta n t a n d h isto rically significant d rug .

A lthough

N e m b u ta l is o n e o f o v e r 5 0 b a rb itu ra te d e riv a tiv e s to have b een u sed m edically, it is th e d ru g o f c h o ic e w h e n it c o m e s to dignified, peaceful dying. All Barbiturates a re derivatives o f barbituric acid w h ich w a s first s y n th esized by A dolp h von B ay er in 1864. A ' c o n d e n s a tio n ' o f m alonic acid and urea, barbituric acid is said to have acq uired its nam e after St B a rb a ra 's D a y (4 D e cem b er) - th e d a y on which it is b eliev ed to h ave b een discovered.

D rug O p tio n s - N e m b u ta l

Fig 13.1 Nembutal women's magazine advertisment from 1950’s

Drug Options - Nembutal

O th e r historian s h av e sp eculated that th e d isco v e ry m a y have b een n a m e d after th e c h e m is t's fav o u rite b arm aid , Barbara. E ith er way, th e n am e stu c k a n d barbituric acid h as e n jo y e d an in fam o us histo ry e v e r since (M end elso n , 1980). Barbituric acid w a s found to have n o p hy siolo gical effect a n d it took ano ther 4 0 y ears befo re ch em ists, Em il F isc h e r an d J o sep h v o n M ering, d isco v ered that th e introduction o f tw o additional side-arm s onto th e m o le c u le p rod uced a ra n g e o f c o m p o u n d s with m arked p hy sio log ical activity. It w a s only then that it b e c a m e kn o w n that the nature o f the sedative, hypnotic, o r anaesthetic properties o f th e su b stan ce w e re d e te rm in e d b y the characteristics o f the side-arm s attached. T h e first o f these d i-su b stitu ted b arb iturates w a s Veronal. Here tw o ethyl sid e-arm s w e re a d d e d to pro d u ce d iethyl-barbituric acid a w eak h y p n o tic / d e p ressan t w h ic h w a s m ark eted b y the B a y e r c o m p a n y a s ‘V eronal’ in 1904. T h is w a s fo llo w e d by p h en ob arb ital (L u m in a l) in 1913. W h ile barb itu ric acid is a G erm an discovery, d u rin g th e First W o rld W a r w h en G erm an sh ip pin g w a s b lo ck ad ed , A m erican ch em ists m ad e u se o f the ‘T rad in g w ith the E n e m y A ct,ʼ to co p y th e w o rk o f the G erm ans and m an u factu re th eir o w n m odifications o f barbituric acid .

B arb itura te S le e p in g Pills In th e first h a l f o f th e 2 0 th C en tu ry , b arbitu rates w e re m a n u fa c tu re d around th e w o rld , w ith p ro d u ctio n p e a k in g in the 1950s. B y then there w e re m o re than 2 0 m a rk e te d form s o f b arb iturates, with m o s t sold as slee p in g tablets. Fig 11.2: Pentobarbital (Nembutal) sleeping tablets

The Peaceful Pill Handbook

A lo n g w ith th e o r ig in a l V eronal, there w a s Barbital, A m ytal, Seconal, S o n e ry l, N e m b u ta l an d several others. W h ile th e se b a rb itu ra te s w ere h ig h ly effectiv e slee p in g tablets, a s ig n if ic a n t p r o b le m w a s th e v e ry s e rio u s sid e-effect a s so c ia te d with th e ir o v e r d o s e - d eath . T h is w a s fo u n d to b e e s p e c ia lly tru e i f th e pills w ere taken with alcohol. M any fam o u s p eo p le have d ied - som e

Fig 11.3: Amylobarbilal (Amytal) sleeping tablets

d e lib e ra te ly , s o m e in a d v e rte n tly - fro m an o v e rd o se o f barbiturates.

M a rily n M o n ro e , Jud y

G arlan d an d J im m y H endrix are a few.

B a rb itu ra te s a s D ru g s o f A b u se In the 1960s, the im ag e o f barbiturates su ffered further w hen they w e re fo u n d to be useful m o o d -alterin g drugs. A t this tim e, th e d ep ressan t effect o f th e d ru g s w a s exploited. B y carefully ad ju stin g the dose, a desirable soporific a n d tranquil state could be achieved an d th ey b e c a m e kn o w n a s ' d o w n e rs.' A s dow ners, barbiturates w o u ld often b e in term ix ed w ith ' u p p ers' - drugs like am p h etam in es. T h is ty pe o f u sa g e led to a set o f slang street te rm s fo r these d ru g s such a s ‘P in k L a d ie sʼ, ‘Y ellow B u lle tsʼ, ‘P e a n u ts ʼ an d ‘ D o llsʼ (from B arbie do lls) (M en d elso n , 1980).


W ith o n ly a sm all m argin o f safety in do se betw een th e desired s le e p , e u p h o r ia a n d d e a th , th e r e w a s c o n s id e r a b le d a n g e r a sso ciated w ith the prescription o f these drugs. H istory sho w s they fell o u t o f fav o u r w ith th e m edical p ro fession o n ce newer, safer sleeping tablets b e c a m e available.

T h e A d v en t o f N o n -b a rb itu ra te S leep in g P ills T h e first o f th e n e w class o f sleeping drugs (the benzodiazepines) w a s d ia z e p a m (V alium ), w h ich b e c a m e av ailab le in th e early 1960s. T h e se d ru g s w e re w e lc o m e d b y th e m ed ical profession a s a safe alternative to the barb itu rate sleeping tablets. A t this tim e there w ere m a n y p rescribed form s o f b arb itu rates on the m ark et b u t w ith th e introduction o f th e se n e w benzodiazepines, th e u se o f the b arb iturates stea d ily declined. B y th e m id 1990s in co u n tries like A ustralia, there w e re ju st tw o barb itu rate slee p in g tablets left, am ylobarbital (A m y tal) a n d p e n to b a r b ita l ( N e m b u ta l) . N e m b u t a l w a s w ith d r a w n w ith little n o tice in 1998 w ith A m y tal fo llo w in g s u it in 2003. Today, th e o n ly barb itu rate c o m m o n ly p rescrib ed b y doctors is th e s lo w -actin g P henobarbital. T h is d rug still finds a niche in m e d ic in e a s an an ti-co n v u lsan t, b u t is a p o o r substitute to th e specific b arbiturate sleeping tablets in p ro v id in g a reliable, p eaceful death.

B a rb itu ra te U se in V eterin a ry P ractice T h e veterinary u se o f the b arbitu rates h as persisted. N em b u tal, in particular, is u s e d a s an a g e n t for euthanasia. A large dose delivered intravenously, quickly an d peacefully en ds an anim al's life. T h is g ree n -d y e d fo rm o f th e dru g, k n o w n a s L ethabarb or V alabarb, is also k n o w n a s ‘th e green d r e a m .ʼ


A s te rile f o rm o f N e m b u t a l h as a l s o p e r s is te d a s a u sefu l co m p lete anaesthetic a g e n t that can q uick ly ren d er an anim al unconscious for surgery. Pentobarbital continues to p lay a role in veterinary practice to this d ay even though its u se by the m edical profession h as all b u t disap peared . A d e v e lo p m e n t that h as led to a resurrection o f these o u td ated d ru g s is th eir increasing use as th e d ru g s o f ch o ice for v o lu n ta ry euthanasia.

N em b u ta l in C o u n tries w h e r e A ssisted D yin g is L egal N e m b u ta l is th e d rug o f c h o ic e in co u n trie s w h e r e V E and A s sis te d S u ic id e are legal a n d is u s e d in T h e N e th e rla n d s, B e l g i u m , S w i t z e r l a n d a n d th e U S s ta t e s o f O r e g o n a n d W ashington W h e n th e R ig h ts o f the T e r m in a lly Il l A c t w a s p a s s e d in th e N o r th e rn T e rrito ry , I h ad th e ch a lle n g e o f d e c id in g w h ic h d ru g o r substance w o u ld p ro d u ce th e m o st hum ane, peaceful reliable death. Fig 11.4: The ʻDeliveranceʼ euthanasia machine

A fter m u c h s e a rc h in g an d consultation - a p rocess that even sa w us se e k in g inform atio n a b o u t the d ru g s u s e d f o r execution in th e U S - a decision w a s m ad e to sanction th e u se o f a large in trav e n o u s o r oral d ose o f N em b u tal.

Drug Options - Nembutal T h e fo u r p eo p le w h o died u sin g th e R O T I A ct all injected th e m se lv e s w ith N e m b u ta l - w ith th e help o f th e D eliverance M ach in e, n o w on d isp la y in th e British S cien ce M useum . h t t p : / / e n . w i k i p e d i a . o r g / w i k i / F i l e : E u t h a n a s i a _ m a c h i n e_ (A u s tra lia ).J P G

W h ile these p eo p le could also h av e sim p ly d runk th e liquid N e m b u ta l, each p referred in trav e n o u s adm inistration. W h e n delivered in this way, loss o f consciousness is alm ost im m ediate (seconds), w ith death fo llo w in g a sh o rt tim e later. D rink ing N e m b u ta l is often th e preferred option an d m eans n o o t h e r p e r s o n n e e d b e in v o lv e d in a d m in is tr a tio n . F o r exam ple, in th e state o f O rego n in the U S , a d o c to r is on ly allo w ed to p re sc rib e a s o p p o s e d to a d m in iste r a 10 g m oral d ose o f b arbitu rates to a patient. T h e p a tie n t m u st drink the d ru g them selves. In S w itzerland , too, it is the client w h o m u st adm in ister the d ru g h im /h e r self. In H o llan d an d B elgium , it is lawful to p ro vid e b arbitu rates a s an injection to a dying patient. T h e d ru g u sed in each these p laces is N em b u tal.

Fig 11.5: Sterile veterinary Nembutal

The Peaceful Pill Handbook H o w B a rb itu ra tes W ork B arb itu rates effect th e action o f th e brain chem ical G A B A in that they enh an ce the effect o f G A B A on the brain, an d m ay even act in its place. G A B A slo w s the activity o f the brain. E nh ancing its action causes sedation an d sleep. In larg er doses, the b arbiturate m a y even rep lace th e G A B A in the brain. An o verdo se o f a barbiturate can d epress brain function so severely that respiration ceases an d the person dies. A s d iscu ssed ab o v e , th e depressan t effect o f b arbiturates can b e useful in co u nteractin g the irritability an d p aran oia that can resu lt from the u se o f am p h etam in es. B arbiturates h ave also been reported to be effectiv e in alleviating th e s y m p to m s o f h ero in w ith d raw al. In th e 1960s, injecting d ru g users w ere rep o rted to h av e su b stitu ted barbiturates for o p iates like heroin an d m eth ad o n e i f such d ru g s w e re n o t available.

A v a ila b le F o rm s o f N em b u ta l F o r h u m an use, N em b u tal w a s exten siv ely m ark eted a s sleeping tablets o r capsules in th e 1950s & 1960s. Even though N em butal disappeared o f f the m ark et ov er a decade ago, m an y people have o ld sto ck s w h ic h are still potent. O n e h u n d red o f these capsules ( 10 0 x 100m g = 10gm o f barbiturate) is a lethal dose. B arbiturates are also well a b so rb e d rectally a n d so m e countries h ave m ark eted form s o f suppositories. ‘N o v a R ec ta lʼ in C an ad a is o n e such ex am p le. S terile a m p o u le s o f injectable N em butal for in tram u scular an d intrav en ou s adm inistration a s a hypnotic, an ti-c o n v u lsan t an d pre -o p e rative sed ativ e still find a small p lace in m e d ic in e in so m e co u n tries in clu d in g th e US. T h e v eterin ary fo rm s o f th e d ru g a re a lso still u sed in eith er the sterile in jectab le form for anaesthesia, o r a no n -sterile form (V alabarb o r L ethabarb) for an im al euthanasia.


T h e s te r ile fo rm o f th is v eterinary barbiturate (fig 11.5) is m a r k e t e d in s m a ll, s e a le d 10 0 m l bottles that are protected w ith a m etal seal. T h is m etal cap m a k e s tam p erin g obvious. T h e N e m b u ta l inside is a clear liquid w ith co n cen tratio n o f 60 m g/m l. Each 100ml bottle has a total o f 6 g m o f N e m b u ta l enough to p rov id e a peaceful death. N o n - s t e r i l e N e m b u t a l liq u id

Fig 11.6: Non-sterile coloured

(ʻL e th a b a rb ʼ F ig 11.6) is used veterinary Nembutal (Lethabarb) for anim al euthanasia, is colour d y e d f o r sa fe ty , a n d h a s a m u c h h i g h e r c o n c e n t r a t i o n o f b arb itu rate (3 0 0 m g /m l). 30m l taken o rally is lethal. Since 2010, the pow dered form o f the drug (sodium pentobarbital) has b e c o m e in creasin g ly available a s an a ssa y g ra d e laboratory reagent. F o r d etails o f this useful form o f the d ru g - see C h 12.

P e n to b a rb & P h e n o b a r b - C o n fu sin g N a m es N e m b u ta l is th e co m m ercial o r trade n am e for th e barbiturate w h ose chem ical nam e is pentobarbital ( 'p ent-o-barb-it-а l ' ). This d ru g is d ifferen t to an o th e r barbiturate called phenobarbital. P h eno b arb ital is a s lo w -a c tin g d rug , u s e d p re d o m in a n tly as an an ti-c o n v u lsan t to stabilise p eo p le su fferin g fro m epilepsy. W h ile p h e n o b a r b can b e lethal in o v e rd o se , it h as a m u ch slo w er actio n than N e m b u ta l an d is n o t an ideal m eth o d for self-deliverance. T hese tw o barbiturates should not be confused.


S o u r c e s o f N em b u ta l In m o st w estern countries there are n o w n o m ed ically prescribed b a r b itu r a te s le e p in g ta b le ts . W h a t r e m a i n s in th e p u b lic c o n s c io u s n e s s , h o w e v e r , is th e b e l i e f th a t a n o v e r d o s e o f slee p in g tablets - an y slee p in g tab let - will cause death. T his m isc o n c e p tio n leads to m a n y failed suicide attem p ts a s elderly o r serio u sly ill p eo p le often stockpile, then take, large num bers o f m o d e m , non-lethal slee p in g tablets. Let u s b e c l e ar. T h e re is n o p o in t in a sk in g y o u r d o c to r for slee p in g tablets i f y o u plan to e n d y o u r life. Tablets ob tain ed this w a y w ill n o t be b arbitu rates an d the d ru g s o b tain ed w ill be unlikely, ev en in significant ov erd ose, to c a u se death. T h e c o m m o n e s t s o u rc e o f life -e n d in g b a rb itu ra te s in m o st w estern co u n tries is th e v eterin ary profession, a n d even this s u p p ly is likely to d im in ish in tim e. T h e re is n o legitim ate or p lau sib le reason fo r a v e t to p rov id e this d ru g to an y m e m b e r o f th e public. You can h ard ly tell y o u r vet that y o u 'r e plan nin g to op erate on the cat this w eekend!

N em b u ta l and Vets Veterinary N em butal h as b een used b y vets to euthani z e anim als o r as an anaesthetic in su rg ery for m a n y decades. B efo re 1998, w h en N e m b u ta l w a s still b e in g p rescrib ed b y d octo rs, it m ay ju s t h av e b een p o ssib le to argue that y o u r insom nia w a s s o bad that o n ly th e rare an d d a n g ero u s N e m b u ta l c o u ld h elp y o u g et a g o o d n ig h t's sleep. B u t there is sim p ly no ex cu se o n e can give a v et to o b tain this drug!

Drug Options - Nembutal I f a v e t w e r e e v e r to p r o v id e N em butal - know ing w h a t the person has in m in d - th ey could face a charge o f assisting a su icide o r ev en murder. D e - re g is tra tio n a n d a priso n term w o u l d be th e lik ely c o n s e q u e n c e . In 2001 th e A u s tra lia n V eterinary B oard b ecam e c o n c e rn e d about th e i n c r e a s i n g u s e o f v e t e r i n a r y N e m b u ta l a s a h u m a n e u th a n a s ia o p tio n a n d p u t o u t a w a r n i n g to its m e m b e r s u rg in g ca u tio n in the s to r a g e a n d u s e o f th e d r u g (see Fig 11.7: Non-sterile veterinary Nembutal (Valabarb)

Veterinary S u rg eo n s Board, 2003).

E xit k n o w s o f only a handful o f c ases w h e re serio u sly ill people h a v e been able to obtain N em b u tal fro m th eir Vet. W h e n there is public m ention o f this possibility, th e V eterinary A ssociations h a v e reacted qu ickly d e n y in g the practice. M o v e s to further restrict th e u se o f v eterin ary N e m b u ta l has m eant that the anaesthetic fo rm o f th e dru g (see Fig 11.5) is b e c o m in g m o re difficult to obtain. T his is th e form o f th e drug fav ou red b y th o se w a n tin g it f o r th eir o w n use, c o m fo rte d by th e fact that it c o m e s in a clearly -lab elled sterile sealed bottles. T h e non-sterile green d y e d fo rm is m o re co n cen trated than its clear counterpart. M ark eted a s Valabarb (F ig 11.7) o r Lethabarb (F ig 11.6) the co n cen tratio n o f this typ e o f p en to b arb ita l is 300m g/m l (five tim es higher than in the sterile anaesthetic form). A sin g le 3 0 m l sam p le will con tain 10gm o f N em b u tal an d be lethal. T h is non-sterile green liq uid n e e d s to be d e can ted from a larg er 50 0 m l bottle. I f drunk it can stain the lips a n d tongue. W ith su ch stain in g it is u nlikely that an atten d in g d o c to r will cite n atural c a u s e s o n th e death certificate!


A C a se S tu d y in N em b u ta l W h e n a sk e d a b o u t N e m b u ta l at E xit w o rk sh o p s, I tell people that it can b e v e ry h a n d y to k n o w a vet. S o m e tim e ago, I w a s m a k in g a clinic v isit to the b ed side o f Harry, a dying patient. W ith his w ife a t h is side H arry a sk e d m e a b o u t ‘the best d r u g s ’, th e on es th a t w o u ld let him peacefully en d his o w n life. I ex p lain ed that the ‘b e s tʼ d rug w a s N e m b u ta l, but that this w a s on ly av ailab le from a vet. ‘H o w m a n y vets d o y o u k n o w really w e l l ʼ I asked, ‘o n e s that w ill risk ja il helping y o u ? ’ H is silence an sw ered m y qu estio n, a n d w e w e n t on to talk a b o u t o th er m ore easily available, but less effective, drugs. A fter th e visit, 1 left th e b ed ro o m an d h ad a cu p o f tea in the k itch en w ith H a rry 's w ife , E s m e . T entativ ely sh e said, ‘you k n o w w h en y o u a sk e d a b o u t k n o w in g a v e t? ʼ I looked at her, confused. She w e n t on ‘w e ll, I k n e w a vet, v e ry well in d e e d .ʼ I w aited , n o t k n o w in g w h a t w a s to follow. S h e co ntinued. ‘ In fact, s o m e tim e b ack I h ad an affair w ith a vet. M y h u sb an d k n o w s n oth ing a b o u t it, an d I w a n t to k eep it that way. But that v et o w e s m e s o m e b lo o d y b ig favo urs an d I 'm g o in g to call th em in ! ’ A few w e e k s later, H arry d ied o f h is disease. I heard that Esm e did indeed call in the favour, obtaining th e 100ml bottle o f liquid N em b u tal. She told m e th a t the bottle sat in the b ed ro o m w ith H arry d u rin g his last w e e k s an d that he d rew im m e n se com fort from k n o w in g it w a s there. A s he faced every n e w day, he w as re a ss u re d b y the k n o w led g e that i f th e d ay b e c a m e to o difficult, h e c o u ld leave a t an y tim e. Indeed, th e p resen ce o f the drug p ro lo n g e d H a rry ’s life.

The Peaceful Pill Handbook T h e n u m b e r o f p eo p le w h o have a v et a s th eir best friend, a friend prepared to risk ja il for th em is very small. T here h as only b een a handful o f occasio n s w h e n I h a v e seen h elp p ro v id e d in this way, an d H a r ry ’s w a s one o f them . P erh aps the qu estio n p u t to p atien ts sh o u ld b e rephrased, p erh ap s I sh o u ld be asking ‘h av e y o u e v e r h ad an affair w ith a v e t ? ʼ W h e n I told this story a t a recen t public m eetin g , o n e elderly w o m a n sh o u ted b ack ‘I w is h y o u 'd to ld m e th a t 4 0 y ears a g o .ʼ

N em b u ta l and th e B la ck M ark et E xit receiv es o ccasio nal repo rts o f p eo p le p ay in g a v e ry high p ric e on th e b la c k m a rk e t for N e m b u ta l. D esp erate f o r the d ru g, so m e h ave p a id o v e r $ 5 0 0 0 fo r a sin g le 100ml bottle o f v eterin ary N e m b u ta l. T h is sam e bottle w o u ld retail to a vet f o r less th an S50. D espite th e h u g e potential profit to a d ealer, N e m b u ta l is rarely found this w ay. T h e usual law s o f supply an d d e m a n d that g o v ern th e illegal d rug tra d e do n o t apply, as n o o n e will e v e r w an t m o re than o n e bottle o f this d rug . S upply ch ain s do n o t therefore develop. T h e N em b u tal that d o e s find its w a y on to th e street is usually in the form o f th e sterile veterinary liquid. It is p re su m e d that it is o b tain ed w h e n v eterin ary clinics a re broken into b y people loo kin g for tradeable veterinary steroids. I f th e seal an d labelling o f a N e m b u ta l bottle is intact an d the ex p iry date n o t ex c e e d e d , the d rug is likely to b e effective. N e v e rth e le ss, o n e is a d v ise d to te st th e substance i f p lan n in g to u se su ch sou rces. T h e Exit barbiturate te st kit is av ailab le at: h ttp ://b it.ly /9 sw O x k


T h e E xit T est Kit en a b le s p eo p le w h o h ave a c q u ire d liquid N e m b u ta l to self-test th e drug. Note: T h e ' Exit Spot Test K it' only p rovides qualitative evidence o f th e p r e s e n c e o f th e dru g. Q u a n tita tiv e te s tin g (ie . dru g co ncentration an d strength) is n o t y et av ailab le as a h o m e test.

T h e S h e lf L ife o f L iq u id N em b u tal E vent th o u g h m o st liquid N e m b u ta l will h a v e an e x p iry d ate o f a ro u n d tw o years, this is o n e su b stan ce that is k n o w n to rem ain effective f o r m u ch longer. I f sto red in a co ol p lace an d kept in its sterile, s e a le d bottle, liqu id N e m b u ta l can be ex p e c ted to h av e a shelf-life o f m a n y years. A d e t a i l e d d is c u s s io n o f th e s h e l f life o f b o th liq u id an d p o w d e re d N e m b u ta l can be found in C h a p te r 15.


N em b u ta l - S u m m a ry T h e barbiturate pentobarbital (N em b u tal) is th e best euthanasia d rug an d c o m e s closest to th e co n cep t o f th e P eaceful Pill. In co u n tries w h e re it is lawful to h elp so m eo n e to d ie a n d an y dru g o r s u b sta n c e could be used, th e ch o ice is alw ay s N em b u tal. Yet N e m b u ta l is a h ard dru g to obtain w ith d o c to rs in m o st w estern co u n tries no longer ab le/ w illin g to p rescribe the drug. N e m b u ta l's restricted u se by vets m akes it in creasin g ly difficult to access. H ow ev er, N em b u tal can be o b tain ed from o v erseas, in South A m erica, S E Asia, an d in p o w d e re d form from China. T h e next ch a p te r g iv es a d etailed o u tlin e o f w h e re to g o an d h o w to buy N em butal. T h is inform ation c h a n g e s frequently an d is regularly u p d a te d for the o n lin e versio n o f The P e a cefu l P ill eH a n d b o o k.


E x it R P T est - N em b u ta l C rite ria

S core

R e lia b ility

10/10

P e a ce fu ln e ss

10/10

A va ila b ility

2 /5

P rep a ra tio n

5 /5


4 /5

Speed

4 /5

S a fe ty

5 /5

S to ra g e

4 /5

T o ta l S co re

4 4 (88% )

14 Obtaining Nem butal

In tro d u ctio n F o r so m e y ears n o w , N em b u tal h as b een available in a n u m b e r o f countries. M a n y elderly p eo p le s e e k this d ru g an d lock it a w a y as th eir ʻinsurance p o lic y ʼ for the future. In m o st w estern c o u n tr ie s th e d ru g r e m a in s h e a v ily r e s tr ic te d w ith a n y o n e im porting d rug a lm o st inev itably b rea kin g th e law. H ow ever, this c rim e ten d s to be ov errid d en b y the co m fo rt o f k n o w in g th ey are b ack in control o f th eir life (an d death). T h e option o f a p eaceful death, sh o u ld o n e 's h ealth ' take a turn fo r th e w o rse ' g iv es significant on to log ical security. A n insurance p o licy for th e future. P eace o f m in d for the present. W h ile N e m b u ta l is a v a ila b le in co u n tries rang ing fro m Peru in S outh A m e ric a to C h in a , in fo rm atio n on h o w an d w h e re to p u rch ase th e dru g is co n sta n tly changing. S in c e th e first ed ition o f this H a n d b o o k w a s p u b lish ed in 2006, E xit h as e sta b lish ed a global n etw o rk o f tra v elle rs w h o have p u rc h a se d N em b u tal a ro u n d th e w orld. S u m m arisin g , upd atin g an d p u b lish in g this inform ation has m a d e this H a n d b o o k and th e o n lin e P e a c efu l P ill e H a n d b o o k th e lead ing au th o rities for su ch inform ation.

O btaining N em butal

W h ile there w ill be so m e w h o argue that it is im po ssible to g et N em b u tal in th e w a y s w e d escrib e - the truth is that i f y o u p ersev ere an d learn fro m the ex p erien ces o f o thers (as reported in this b o o k ), y o u will inv ariably s u c c e e d . E x it a c k n o w le d g e s th a t th e a v a ila b ility o f N e m b u t a l ca n c h a n g e w ith o u t w a rn in g . O ld stores close an d n e w stores open. W eb sites a p p e a r a n d disappear, se e m in g ly o vernight. A s the w ell-kn ow n expats C arol Schm idt, N o rm a H air an d Roily Brook w rite o f M exico: w h a t is tru e to d a y m a y n o t b e tru e tom orrow , o r tru e to th e b o rd er a g e n t in th e n ext lane, o r even to th e sa m e a g e n t before a n d a fte r lu n c h ... th e a u th o rs can p ro v id e no g u a ra n te e s that w h a t w e p u b lish to d a y w on t c h a n g e to m o r r o w ... A s o n e U S tourist to M exico p u t it: Mexican border towns are depressed and scruffy-looking and it is almost always possible to get ju s t about anything yo u want. This is all the more so given the currently depressed economy —and this is im portant to remember. N o m atter what the governm ent m ay do. it will always be possible to g et Nembutal here unless its manufacture gets prohibited. How to g et it is the challenge! In past years, m o st people visited countries such as M exico, Peru or T h a ilan d to p u rch ase N e m b u ta l ov er-the-counter. In recent y ears, th is h as begu n to c h a n g e . W h ile N e m b u ta l continues to be av ailab le in th e se co u n tries (esp ecially in Peru), it is the Internet that h as altered th e w a y p eo p le are o b tain in g the drug.


T ypes o f N em b u ta l on Sale N e m b u ta l (P en to barbital S o d iu m ) can b e p u rch ased bo th overth e-co u n ter an d b y m ail order, eith er in solution as a veterinary liquid, o r as the w h ite crystalline salt. R arely the drug can still be found as tablets o r capsules for h u m an use as a sleeping agent. T h e liquid fo rm is a veterin ary p ro d u c t that is u sed for anim al anaesthesia an d u s u a lly p a c k a g e d a s a sterile liquid in either 50m l o r 100ml b o ttles. It is alw ay s at th e s a m e concentration o f 6 0 m g /m l ( ie a 5 0 m l/1 0 0 m l b o ttle c o n ta in s 3 g m /6 g m o f N em bu tal). T h e w h ite cry stallin e so lid p o w d e r is th e form that is generally av ailab le fro m China. N e m b u ta l tab lets fo r h u m a n u se are still a v a ila b le in so m e co u n tries (eg. T h a ilan d ) on prescription as a slee p in g tablets.

D r u g L a b ellin g W h e re veterinary N e m b u ta l is s o ld o v er-th e-co u n ter in liquid fo rm , it is m ark eted u n d e r a range o f retail n am es. T h e key ingredien t to look for on th e label is ‘ Pentobarbital S o d iu m ʼ. In M ex ico, veterin ary N e m b u ta l is sold o v er-the-co un ter and o n lin e a n d lab elled as: A n e s t e s a l , B a rb ith a l, S e d a lfo r m a , S ed a lf o r te , P en to vet, P e n to m a x (see F ig 14.1 - 14.9). In Peru a n d B olivia, veterin ary N em b u tal is retailed as H alatal o r P e n ta -H y p n o l (see F ig 14.23 - 14.24) In T h a ilan d it is m a rk e te d a s N e m b u ta l.( see F ig 14.25)


M ail o rd er C h in ese N e m b u ta l is s o ld as re a g e n t grade ‘S od ium P en to b arb ital’, C A S N o . 5 7 -3 3 -0 (see Fig 1 4 .1 4 - 14.8). L e g a l C o n s i d e r a ti o n s I f y o u c h o o se to p u rch ase N em b u tal in an o th e r country, y o u s h o u ld b e a w a r e that im p o rta tio n o f the d ru g b ack to y o u r co u n try o f origin is likely to b e a g a in st th e law . I f y o u take this c o u rs e o f action y o u w ill be b reak in g th e law. T h e legal p e n a ltie s f o r th e im p o rta tio n o f N e m b u t a l v a ry d ep en d in g on the country. In s o m e jurisdictions, th e im portation o f a sin g le bo ttle o f N e m b u ta l w ill b e dealt w ith su m m arily (b y a sin g le M ag istrate o r Judge). In o th ers it m a y b e referred to the crim inal courts, w ith the c a s e h e a rd by a j u d g e an d jury. In g e n e ra l, th e w a y in w h ic h th e im p o rta tio n o f a b ord erc o n t r o l l e d s u b s t a n c e s u c h a s N e m b u t a l is d e a lt w it h by a u t h o r i t i e s w ill d e p e n d o n th e a m o u n t a n d p u r ity o f th e su b stan ce that y o u are a lle g e d to h av e im p orted. T h e offence o f im p o rtin g a b o rd e r-c o n tro lle d d ru g w ill d e p e n d on how au th o rities m e a s u re th e a m o u n t im ported, an d w h e th e r it can b e classified a s ‘m a rk e ta b le ’, ‘trafficableʼ o r ‘c o m m e r c ia l’ in q u a n tity ? C lassifications w ill v ary d ep en d in g o n ju risdictio n, w ith legal p en alties v ary in g accordingly. T h e s e r io u s n e s s / c r im in a lity o f a n a lle g e d im p o rta tio n o f N e m b u ta l w ill a l s o d e p e n d o n th e d r u g 's purity. In s o m e c o u n trie s , th e ‘m a r k e ta b le q u a n t i t y ʼ o f N e m b u ta l (ie. the a m o u n t w h ic h m a k e s the im po rtatio n o f this d ru g a seriou s o f f e n c e ) m ig h t b e 5 0 g m . W h ile o n e b o ttle o f v eterin ary N e m b u ta l c o n ta in s only 6 g m o f pento barbital so d iu m (with th e rem ain in g m ix tu re b e in g alcohol), th e au th o rities m a y have the p o w e r to c h a rg e th e p erso n w ith im porting a full 100g m / 100ml c o n ta in e d even in th e bottle, even th o u g h only 6 % o f th e m ix tu re is th e actual bo rder-co ntrolled drug.


Fig 14.1: Mexican veterinary sterile Nembutal: Anestesal

Fig 14.2: Mexican veterinary sterile Nembutal: Sedal-Vet


Fig 14.3: Mexican veterinary sterile Nembutal: Pentobarbital Injectable

Fig 14.4: Mexican veterinary sterile Nembutal: Sedalphorte


Fig 14.5: Mexican veterinary sterile Nembutal: Barbithal

Fig 14.6: Mexican veterinary sterile Nembutal: Sedalpharma


Fig 14.7: Mexican veterinary sterile Nembutal: Pentovet NRV


Fig 14.8: Mexican veterinary sterile Nembutal: Sedalpharma

Fig 14.9: Mexican veterinary sterile Nembutal: Pentomax


Fig 14.10 Australian Government publication March 2011


T h u s, an y person w h o ch o o s e s to im p o rt a sin g le b o ttle o f N e m b u ta l m a y fin d t h e m s e lv e s fa c in g s e v e r e p e n a ltie s i f th e a m o u n t is d e e m e d to be ' m a rk e ta b le .' O n e w a y a m in o r im portation o ffen ce can turn into a significant c rim e w o u ld be to tell authorities the d rug is for an o th e r person, ra th e r than for p erso nal use, a s this is ad m ittin g o f d rug trafficking. N ote: D ru gs su ch a s barbiturates are often o f s eco n d ary concern to authorities w h o seem far m ore interested in substances such as cocaine, cannabis, am ph etam in es an d party drugs such as ecstasy and G H B . It is th e distribution o f these latter drugs, ra th e r than b arbitu rates w h ic h is linked w ith international o rg an ised crim e syndicates. T h e b arb iturates h ave lost their appeal as d ru g s o f addictio n/ a b u se an d feature little in b lackm ark et trade. A fter all, o n e person w ill only e v e r n eed 10gm o f N em b u tal. D esp ite this, the efficacy o f E xit International in pro m o tin g th e acquisition o f this dru g b y th e eld e rly an d sick h as led the A ustralian g o v e rn m e n t to issue a statem en t in M arch 2011 that refers to ' so m e e u th an asia g ro u p s ... a d v o c a t[i n g ] pu rch asin g th e d ru g o v erseas an d en co u rag in g travellers to conceal it from C u s to m s a n d B o rd e r P ro tection on th e ir return h o m e '. T h e d o c u m e n t se e m s d esig n e d to d isco u rag e p eo p le fro m taking this co u rse an d refers to th e penalties for im porting a borderco ntro lled d ru g a s ra n g in g from im p ris o n m e n t to fines u p to A $ 8 5 0 ,0 0 0 . (F ig 12.10) http ://w w w .customs.gov.au/ webdata/resources/files/ImportingBarbiturates.PDF

Exit h as p u t con siderable effort into en su rin g that readers o f The H a n d b o o k a n d P e a c efu l P ill e H a n d b o o k h av e all inform atio n n ecessary to m ak e in fo rm e d choices. W e m ak e it clear that in p ro v id in g this inform ation w e a re n o t e n c o u ra g in g the read er to break th e law.


L e g a l Iss u e s w i th th e P u r c h a s e o f N e m b u t a l o v e r t h e N et To date, E xit k n o w s o f o n ly o n e person w h o h as been charged w ith im p ortation offences a n y w h e re in the w o rld . T h is person w a s a m e m b e r o f E xit (A n n ) fro m M elb o u rn e, Australia. A nn w a s charge d w ith im portation o f tw o b o ttles o f N e m b u ta l after h e r c o n s ig n m e n t w a s in terc ep ted by C u s to m s an d referred to th e A u stralian F ed eral Police (A F P ) in early 2009. T h e first A n n w a s aw are that her N em butal w o u ld not be arriving w a s w h e n the A F P cam e to h e r h o m e, an d s e rv e d a search w arrant. A t h er co u rt h earin g in A pril a y e a r later, sh e pleaded guilty. S in c e this w a s h er first o ffence, th e M a g istra te issued h e r w ith a fine o f S500, a 12 m o n th go o d b eh av io u r b o n d and o rd e re d she p ay $ 1 0 0 0 to the co u rt fund. N o co nv ictio n w a s recorded. S ee: h ttp ://b it.ly/b E C n zG

N e m b u t a l O v e r t h e I n t e r n e t : M e x ic o S in c e 2 0 0 8 , Exit has h ig h lig h ted th e serv ices o f one M exican m ail-ord er serv ice, M e troflog, w h ic h can b e fo u n d at: http://www.metroflog.com/mo_cuisher

S in c e le a rn in g o f th e M e tro flo g w e b s ite , E xit h as receiv ed o n -g o in g feed back a b o u t its efficacy. F eed b ack co n tin u es to b e receiv ed a lm o s t w e e k ly g e n e ra lly reads ‘T o w h o m it m ay co n cern . A s a su b scrib er o f th e P e a cefu l P ill e H a n d b o o k I w an t to let y o u k n o w that I receiv ed very g o o d attention an d the d elivery o f th e p rod uct on tim e fro m D o rian ʼ. Exit h as received sim ila r repo rts from h u n d red s o f p eo p le a ro u n d th e w orld. O v er 9 0 % o f th e re p o rts receiv ed h av e b een positive.


Fig 14.11: Nembutal mail-order website

Fig 14.12: Liquid Nembutal as shipped from Mexico


T h e p u rch ase p ric e o f N e m b u ta l from M etro flo g has recently risen fro m U S $ 3 5 0 to U S $4 5 0 for o n e bottle an d from $ 5 0 0 to $ 6 0 0 fo r two. O n e o f the m o s t c o m m o n rep o rted p ro b le m s w ith this serv ice is th e d e la y in th e sh ip p in g o f th e product. T h is h as been explained b y th e s u p p lie r as a c o n s e q u e n c e o f irre g u la r a n d sp o rad ic supplies. A lthough som e purchasers report ordering, being given a co n sig n m en t n u m b e r a n d then th e n u m b e r disappearing before d elivery is e v e r m ade. To d ate, successful d eliveries can take an y w h e re from 10 days to a few m onths. S h ipp ing is m ad e b y reg ular mail. T h e parcel size (2 x 100ml glass bottles plus p a ck ag in g w ith w e ig h t o f ~ 3 0 0 - 4 0 0 g m - see F ig 14.12). T his h as m e a n t that a n u m b e r o f th e p arcels are intercepted b y c u s to m s authorities. M etroflog h as in d icated to E xit that this loss is cu rren tly ru n n in g at around 10-15% . O n e recen t suggestion to o v e rc o m e such p ro b le m s h as b een to o ffer to su p p ly those w h o travel in person to M e x ic o City. The p ro b le m o f sh ip p in g is th en the responsibility o f the purchaser. T h is issu e is u n d e r discu ssion a t the P eaceful Pill F o ru m s at: h ttp ://w w w .p ea ce fu lp illh a n d b o o k.co m /fo ru m


N e m b u ta l O v e r th e I n te rn e t: C h in a F ro m early 20 1 0 , the s u p p ly o f p o w d e r N e m b u ta l from C hin a b y m ail o rd er began to flourish. M a rk e te d a s re a g e n t g ra d e p e n to b a rb ita l s o d iu m (C A S No. 57-3 3-0) this w ater-so lub le, w h ite crystalline so lid is stated as h av in g a purity o f better than 99% . A dm inistration is a m atter o f dissolving ~10g m o f the p o w d er in ~ 50m l o f w a te r an d drinking. W hile the source com panies h av e long claim ed that their product is pu re, it w a s n o t until m id 2011 that E xit w a s able to verify, th ro u g h lab o rato ry testing, that th e N e m b u ta l s h ip p e d from th e so u rc e s listed in this book is p u re an d h as not b een diluted or ad u lterated pu rity stated. I f ingested in th e reco m m en d ed am o u n ts th is N e m b u ta l leads to a relia b le an d peaceful death. (See C h a p te r 15 for th e full discussion o f th e lab oratory test results u n d ertak en b y Exit).

Fig 14.13: Powder Nembutal as shipped from China


T h e cost o f C h in ese p o w d e r N e m b u ta l h as fluctuated m arkedly since it w a s first available. S o m e folk h av e p a id a s little as U S $ 2 6 0 fo r 2 0 g m . am ount.

O th ers h av e p a id U S $ 9 0 0 fo r the sam e

In 2 0 1 2 re p o rts are ten din g to s u g g e s t that 2 5 g m can b e o b tain ed fo r U S S 38 0 + S25 p o stag e / h an d lin g with p a y m e n t m a d e b y W estern U n io n o r ev en P ay P al. D e l i v e r y to th e U S a n d A u stralia has b een w ith in 3 days o f o rd ers b e in g placed in so m e cases b u t generally 1 0 - 2 0 d ay s. A d etailed b re a k -d o w n o f prices and shipping details is provided later in this Chapter. M o s t re p o rts re c e iv e d by Fig 14.14: Nembutal from 3B Scientific E xit s h o w th a t p o w d e re d International N em b u tal fro m th e sou rces listed u s u a lly s h ip s at a m in im u m q u a n tity o f 2 5 g m . T h e

m in im u m lethal d ru g d o s e is 6 g m . I f th e su b stan ce is pure, a p u rch ase o f 2 5 g m o f 9 5 % pu re so d iu m pentobarbital is m ore th an en o u g h for tw o adults. In 2 0 1 2 th e p o w d e r is b e in g s h ip p e d in o n e o f tw o w ay s. E ith er p a c k a g e d in small plastic screw -to p con tainers holding ap p ro x im a te ly 12 gm (see F igs I 4 . 1 4 & 1 4 .15) o r th e p o w d e r is sh ip pin g flat-packed. Here th e p o w d er is o ccasio n ally v acu u m sealed flat in foil p ack ag in g , o r m o re c o m m o n ly as a sim ple soft p lastic s a c h e t a n d sent on to its d estination a s a letter in either re g u la r m ail o r b y co u rie r (S ee F ig s 14.15, 14.16 & 14.17.)


Fig 14.15: 12 gms powder from China

Fig 14.16: Sample 1: Flat-packed powder from China


Fig 14.17: Sample 2: Envelope of flat-packed powder from China.

Fig 14.18: Sample 3: Package of flat-packed powder from China


Sources o f the Chinese Nembutal O v e r the past tw o y ears Exit h as h ad positive rep orts fro m m o re than 14 chem ical co m p an ies in C h in a . In d ep en d en t lab oratory te s tin g h a s b een c a r rie d o u t o n a n u m b e r o f s a m p le s from different so urces an d consistently sam ple purities o f g reater than 9 5 % h ave b een found. N o c o n ta m in a te d o r ad u lterated sam ples h a v e been found. D uring this p erio d there h as been a n u m b e r o f changes noted. S o m e co m p an ies that had been reliable suppliers h ave since d isc o n tin u e d this trade w ith o thers co m in g into the m arket. Exit h as not h ad the oppo rtu n ity to establish th e viability o f so m e o f the n e w e r sup pliers (A u g u st 2012). A s u m m a ry o f co m p an ies that h av e su p p lied o r w h o claim to su p p ly lab o rato ry -g rad e so d iu m pen tob arb ital p o w d e r is listed b e lo w u n d e r fo u r headings: T e sted S u p p liers - C u rre n tly active w ith p o sitiv e testing U n teste d S u p p liers - R eliability n o t y e t established U ncertain S u p p liers - P ro blem s reported, tre ad carefully! N o n -re s p o n d e rs - N o lo n g er re sp o n d in g to em ail enquiries

Tested S u p p lie rs - C u rren tly activ e w ith p o sitiv e testing

See Contacts in Legal Version

http://peacefulpill.com


U n tested S u p p lie rs - Reliability n o t yet established

See C ontacts in Legal Version

http://peacefulpill.com

U n certa in S u p p lie rs - P r o b le m s reported, tread carefully!


N o n -r e sp o n d e r s - no lo n g er re sp o n d in g to em ail enquiries B M C h e m ic a l, H a n g zh o u W e b : w w w .b m ch em ica l.co m C h e m h e re C h em ica ls, W e b : w w w .ch em h e re .co m C h e r r y C h em ica l, H a n g zh o u W e b : w w w .ch errych em ica l.co m E m ail : ch e rry c h e m ic a ls@ g m a il.com Q in g d a o H en ley C o , Q in g d a o Em ail : in fo @ sin o h en ley.co m W eb: w w w .sinohenley. com K erry W in Intern ation al T ra d in g C o., S h ijia zh u a n g W e b : w w w .kerryw in .co m /en b /in d ex.a sp L o tu s C h em ica ls, C h o n g q in g W e b : w w w .lo tu sch em .co m 3 B Scientific C o r p o r a tio n , W u h a n* Em ail: sw c h sj@ h o tm a il.c o m o r helen .xia o @ 3 b sc.co m W e b : w w w .3bsc.com N in g b o E st C h e m ic a l C o. L td., N in gb o* T h is c o m p a n y has recently a d v ise d Exit that it on ly supplies for laboratory purposes.


W h ile s o m e o f the so urces listed h ave re sp o n d e d to requests to p u rch ase the dru g o n ly interm ittently, o thers h ave insisted on d o cu m en tatio n s h o w in g that th e pu rch aser is a registered laboratory. A n o th er c o m p a n y h as b een rep o rted as insistent on an ' e n d - u s e r ' statem ent, ie. that th e recipient will on ly u se the d rug w ith anim als. A typical c o p y o f the C ertificate o f A n aly sis a c c o m p a n y in g the s h ip p e d p ro du ct is s h o w n in C h a p te r 15 in Fig 15.10.

Testing o f Chinese Powder In th e first instance, the E xit D ru g Test K it available at: http://w w w .peacefulpillh a n d b o o k.c om /page/D rug+ T est+ K it? p ro v id e s an accu rate q u a lita tiv e test (this tests for th e presen ce y es/n o o f sodium pentobarbital in th e p o w d e r) o f th e product in p o w d e r fo rm (as it can for liquid N em butal). T h e qualitative test fo r p o w d e r can b e carried o u t b y dissolving a sm all am o u n t o f p o w d e r (~ 0 .0 5 g m ) in water. I f p o sitiv e, a single, red line sh o u ld form on the test cassette. (See C h a p te r 15 f o r an in-depth discu ssion an d d em o n stratio n o f th e qualitative test.) In th is re g a rd to q u a n tita tiv e te s tin g , E x it's p la n s f o r D IY q u an titative a ssa y are d isc u s s e d a t length in C h a p te r 15. N o te : W h ile th e im po rtatio n o f this d ru g is usu ally an offence, penalties asso ciated w ith the im p ortation o f q u an tities < 5 0 g m , f o r ‘person al u s e ʼ m a y be m inor. Q uan tities > 5 0 g m m a y be d efin ed a s ‘traffick in g ʼ w ith m o re seriou s penalties attached.


P u rc h a sin g N e m b u ta l in P erson : M exico O v e r recen t y ears, E xit s ta f f a n d m e m b e rs have v isited m an y M e x ic a n c itie s w i t h th e p u r p o s e o f re s e a rc h in g s o u rc e s o f re lia b le e n d -o f-life d ru g s. D u rin g th is tim e , E xit h a s also receiv ed acco u n ts from travellers re g a rd in g th eir experiences in this country. T h is sectio n includes m aterial that relates to tra v e lle rs o b ta in in g N e m b u ta l in M e x ic o from 2 0 1 0 to the present only.

M azatlan In 2 0 1 1 , Exit r e c e iv e d its first re p o rt o f th e a v a ila b ility o f N e m b u ta l in th e b e a c h s id e re so rt o f M a z a tla n in th e state o f S in aloa acro ss from th e Baja C alifo rn ia peninsula. A fter u n su c c e ssfu l a tte m p ts to p u rch ase N e m b u ta l in T iju a n a the y e a r before, an E xit m e m b e r w h o w e shall call 'B o b ' to ok a v acation at M azatlan. His p u rch ase w a s straight fo rw ard . T h e price w a s ex cellen t at U S $ 30 for a 100ml, sealed bottle w ith an ex p iry d ate o f July 2013.

Fig 12.19: Playa Norte in Mazatlan, Mexico


T h e outlet w h e re the p u rch ase w a s m ad e w a s the hole-in-thew all E l A rca d e N o e ( N o a h ’s A rk ) p h a rm a c y located at: E jercito M e x ic a n o N o. 5 (n ear Playa N o rte ) area o f M azatlan B ob s a y s that he used the p h o to s in th e H a n d b o o k to explain to the sales atten d an t the p recise d ru g he w a s after. T h e retail b ra n d he p u rch ased on this occasio n w a s ' Sed a lp h a rm a '.

P lay a del C a rm en In late 2 0 1 0 , E xit receiv ed its first rep o rt o f th e availability o f N em b u tal in th e tourist resort tow n o f P laya del C a rm e n . T h is Exit m e m b e r wrote: On m y recent trip to Playa del Carmen we visited 5 o r 6 shops and were always turned away; I was about to g ive up when the driver said he knew o f one other place. I don't remember the nam e o f the p e t store but it was on the outskirts o f town. It was ju s t a hole in the wall. I told the owner I had a large dog with Displazia and he was sympathetic and produced a 100 m l bottle o f Barbital which I purchased fo r about US$40. I already have a test kit fro m Exit International which I w ill use when the tim e comes. The bottle, though, is sealed correctly, fresh fro m the factory. I w ill keep it in a cool, dry place until needed - i f it is needed. I cannot thank yo u enough fo r a ll o f y o u r help and yo u r book. I am 83 years old and I live now with a great sense o f relief.


V alladolid Valladolid is a sm all city in Yucatan, about 2 hours drive from C an c u n . Best kn o w n for its colonial architecture, esp ecially its cath ed ral, th e to w n is also u s e d as a tou ring b a s e for visiting th e n earb y M ay a ruins. N em b u tal w a s first reported as being available ov er-the-counter in V allado lid b ack in 20 1 0 . S in c e then, o th e r re p o rts h av e e m e rg e d stating th e sam e, but w ith so m e variatio ns. In 2010, th e cost o f tw o bottles o f N e m b u ta l w a s 180 p e so s e a c h . In 20 1 2 the p ric e h ad risen to 6 0 0 pesos for two. O n e s to r e w h e r e N e m b u ta l is a v a ila b le o v e r-th e -c o u n te r is F arm a c ia V eterinaria Los P otrillos at: C a lle 41 177-1 Col Valladolid C entro Yucatan M exico A t th is a n im a l p h a rm a c y , th e retail b r a n d o f N e m b u ta l is P isabental. D o n 't b e su rp rised i f th e sto re d o es n o t h ave any b ottles o n the shelves. It is n o t u n c o m m o n for a store to send a m essen g er to the d e p o t f o r collection. F o r th e c u s to m e r this m a y m ean a return visit in an h o u r o r tw o 's tim e.


Fig 14.20: Farmacia Veterinaria Los Potrillos

Fig 14.21: Pisabental: Mexican sodium Pentobarbital


Tijuana

Tijuana h as a chec k e re d history as a destination fo r the over-thec o u n te r sale o f veterinary, liqu id N em b u tal. W h ile in the p a s t, Vet p h arm acies o p en ly a d v ertised th e availability o f N em b u tal fro m store w in d o w s , in th e past f e w y ears th is trade h as all b u t clo se d d o w n . R ea so n s fo r this include th e o n g o in g bo rd er v io len ce an d s u b se q u e n t d rop in to u rist trade, a s w ell as the controversial death a f e w y ears b a c k o f A ustralian psychiatric patient, E rin Berg. T h e ability o f travellers to b u y N em b u tal o v er-th e-co u n ter in T ijuan a re m a in s hit an d miss. T hat said, in early 2 0 1 0 , K en w rote: A couple o f days ago I visited San Diego during a vacation in the US, and look the trolley to San Ysidrof o r a short walk into the downtown area seeking Nembutal. Being apprehensive about approaching taxi drivers (& bearing in m ind the

Fig 14.22: A Tijuana veterinarian window si gn at the peak of the trade in 2007


current anti-drug campaign by the Mexican authorities) I "grabbed the bull by the horns" and walked into a veterinary supplier 2 blocks from the central plaza with the high arch. No problem in purchasing, and without prescription, but the price at $U S 120 was a bit higher fo r the 100ml than expected. No doubt a current m arket adjustm ent a n d a sm all p rice that this "insurance" offers. This side street has the sign/nam e 'Callejon, Del Travieso, 2 2 0 0 0 'It . is only a single block street, one way fo r vehicles but bi-directional fo r pedestrians. In m id 2010, a C a n a d ia n Exit m e m b e r wrote: This m orning I crossed over to Tijuana and proceeded to the suggested spot. Sure enough, on the street corner stood Jose, a sm all m iddle-aged man wearing eyeglasses, who asked i f he could help in any way. ʻH abla E nglais?ʼ I asked in m y best high-school Spanish. ʻU n p o co ʼ he replied - a bit o f English, which was g o o d enough fo r me. I show ed Jose m y photos o f the bottles I was after, and he nodded knowingly. We ju m p e d into his nearby taxi and we tried at three veterinarias in the downtown area. NO LUCK - NO TH ING DOING. I show ed them the photos, he talked to them in Spanish, they replied (in Spanish) sternly shaking their heads no A fter we left, Jo se explained that they d been saving there d been a recent Government clampdown. M y wife and I are not overly perturbed by m y failure. I am 73 years old and in g o o d health. I have relatives in the States and on a visit in a y e a r or two, I m ight try crossing again.


A ro u n d the s a m e tim e, R on w ro te in g lo w in g term s: A s soon as I hopped o f f the Blue Line tram and crossed the two footbridges into Tijuana, I g o t it. Walk 50m from the second footbridge and yo u re at Avenuida Negrete. Turn left and it's 15m on the other side o f A. Negrete, a tiny veterinary pharm acy hole-in-the wall, last store in the block. I walked in. asked " Anestesal" and held up 2fingers. The man went into the back and cam e out with 2 fresh un-expired bottles o f Sedalfo rte and asked fo r U S$250. I offered $175 and he sa id $200. D one ju s t like that, not h a lf an hour ago. In late 2 0 1 1, Exit received a new Member report o f Nembutal's availability at this particular outlet. Judith wrote: I am contacting you to let yo u know that 4 weeks ago we were able to obtain our requirements from Tijuana, Mexico. I have included y o u r description o f the address fro m the handbook which was Avenuida Negrete. Weju s t made sure there was nobody in the shop and no coppers in the street before we went into the shop, show ed him photographs from the handbook a n d it was a done deal. O f all M exican cities w h e r e N e m b u ta l h as b een k n o w n to be available, T ijuana is definitely the m o st ch an g eab le streetscape. R e m e m b e r w h a t o n e traveller said: [In] Mexican border towns ... it is almost always possible to get ju s t about anything you w a n t... No m atter what the governm ent m ay do, it will always be possible to g et N em butal here unless its manufacture gets prohibited. How to g et it is the challenge!


O th e r C ities in M ex ico In y ears g o n e by N e m b u ta l h as v a rio u sly b een av ailab le in N u e v o Progreso, Juarez, N u e v o L aredo, N o g a le s an d C ancun. Exit h as n o k n o w le d g e o f N em b u tal e v e r being av ailab le in R ey n o sa, Del Rio o r M atam oros. Film s taken o f L aredo an d Ju arez in 2 0 0 8 -9 are in clu d ed in this Chapter.

SO U T H A M E R IC A P u rc h a sin g N em b u ta l in P erson : Peru F o r s o m e y ears now , E xit h as received repo rts co n firm in g the ready, o v er-the-co un ter sale o f veterinary N em butal in P eru and Bolivia. S o m e positive acco u n ts fro m E c u a d o r an d C o lu m b ia h ave also b een received , an d th e se are b e in g investigated. In Peru, so d iu m pen tob arb ital is kn o w n b y u n iq u e Peruvian n am es. T h e m o s t c o m m o n b ra n d in this part o f th e w o rld is ‘H alatalʼ. A less c o m m o n b ra n d is called P en to-H y pn o l. In Peru (u nlike M ex ic o ) N e m b u ta l is sold in small 5 0 m l bottles a s o p p o s e d to 100ml bottles. H ow ev er, th e concentration is the sam e a s that for the larger M exican bottles. T h e concentration o f bo th H alatal an d P en to-H yp no l in P eru is 6 .5 g m p e r 100ml.


L im a - Peru A s a sp raw lin g capital city o f 10 m illio n , it is n o t surprising that N e m b u ta l is easily av ailab le in L im a i f o n e k n o w s w h e re to look. A s in m u ch o f S o u th A m erica, it is th e A gro-V eterin arias w h ic h readily sell N e m b u ta l over-the-counter. T h e se sto res differ from M ex ic an F arm a c ia V eterinaria in that th ey sp ecialise in m ed icin es an d tre atm e n ts f o r the rural secto r a n d for farm an im als, ra th e r than dom estic pets. Such stores are located all o v e r L im a b u t one o f th e e asiest to find is on a b u s y intersection ad jacen t to th e ‘N o r te ʼ (o r n o rth ern ) entran ce o f the ‘ Estadio N a c io n a lʼ (national stad iu m ), th e h o m e o f the P eru national football team . L o cated at the intersection S anta B eatriz in central Lim a, Z o o F a rm a is a n A g ro V eterinaria w hich tak es 20-30 m inu tes by taxi ride from the p o p u la r tourist ho tels o f the Mirafl o res district, d ep en d in g u p o n the traffic. (In Lim a, taxis are relativ ely cheap w ith th e av erag e rate p er h o u r costing betw een 25 and 30 Peruvian soles. H otels ro u tin ely o rg an ise cabs fo r guests w h ich is o n e w a y o f gu aran teein g g u est safety fo r the in ex p erienced traveller).

Fig 14.23: Suni Agro in Lima - Peru


Fig 14.24: Zoo Farma Agro Veterinaria

T h e entran ce to Z o o F a rm a can b e fo u n d a t street level o n the front co rne r o f th e large brig h t blue, s ix -sto ry lan dm ark b u ild ing (see Fig 14.23), d ire ctly acro ss the street from the stadium . In early 2 0 1 2 , a stan d a rd 50m l bo ttle o f ‘H a la ta l’ a t Z o o Farm a retailed for 27 soles. T h e bottles are sto red in the g lass display cabin et u n d e r th e counter, to the left o f th e en tran ce a s one enters th e store. T o p u rch ase N em b u tal a t Z o o Farm a, sim ply ask for ‘H a la ta lʼ (silent H ) a n d th e store atten d an t w ill oblige, issuing a receipt w ith y o u r purchase.


C u zco - Peru F o r those w h o are u p fo r ad v en tu re, th e U N E S C O w o rld herit a g e city o f C u z c o m a k e s for an e a s y s h o p p in g trip. A n h o u r ’s flight S E o f Lim a, th e c ity o f C u z c o is m o stly kn o w n a s the ju m p in g o f f p o in t for visitors to the stu n n in g ly beautiful h id d en Inca village o f M a c h u Picchu. T h a t C u z c o is also an e x tre m e ly e a s y p lace to p u rch ase N e m b u ta l is a bonus.

In C u zco, it is sto res called ‘A g ro Vet erin a ria s ʼ w h ic h stock Halatal (th e o n ly retail b ra n d available). E xit h as receiv ed trav eller rep orts that th e H otel C asa A n d in a is particularly helpful in th e pu rchase o f N em b u tal (organisin g a cab etc), b u t travellers w ill likely find m o st hotels helpful. T h e A gro Veterinarias in C u z c o are all quite clo se to th e to u rist area o f th e o ld colonial city. D ep en d in g on th e location o f y o u r h o tel,

F i g 1 4 .2 5 : M a c h u P ic c h u


Fig 14.26: Calle Tres Cruces de Oro in Cusco

(an d o n e 's ability to deal w ith th e 3 5 0 0 m altitu d e o f C u z c o ) it is possible to w a lk to these stores. In daylight hours, this area o f C u z c o is safe for to u rists to stroll around. H o w ev er, i f you p re fe r to take a taxi, th e hotel w ill call a tru ste d o n e for you. T h e cost fo r the cab w ill b e a ro u n d 10 so les (~ U S $ 3 ) w h ic h w o u ld in clu de th e 5 m inu tes w a it tim e n eed ed for y o u to do y o u r shopping. In C u zco , an u n re m a rk a b le street called ‘C a lle T res C ru c e s de O r o ’ (the three g o ld en crosses) is h o m e to w ell o v e r 10 veterinaras. A lm o st all o f these A g ro V eterinarias stock Halatal. M o s t sto res h a v e th e b o x e s on o p en display either on th e s h e lf b e h in d o r in front o f th e counter, o r in a g lass c a b in e t u nder th e counter. In 2 0 1 2 the c o s t o f a single 50m l bottle o f Halatal ran g es b etw een 22 an d 25 so les (U S $ 8-$ 9). It is ad v isa b le to p u rch ase tw o - three bottles (6 - 9 g m o f N em b utal). To p u rch ase H alatal from an y o f the sto res in these streets, one n e e d s only to k n o w th e d ru g nam e, altho ug h a p hoto o f a b ottle can be useful. S panish is n o t required a s there will be n o q u estio n s a sk e d a b o u t w h a t the d ru g is u s e d for; the store attend an ts s im p ly w a n t to m a k e a sale.


Fig 14.27: One of the many Agro Veterinarias in Calle Tres Cruces de Oro in Cuzco, Peru

Stores w h ic h sell N e m b u ta l (alw ays called H alatal) in C alle Tre s C ru ce s de O r o in clu d e : C asag rov eto , El P ro g reso at N o . 461 •

A g ro v eterin aria Belen (P rincipal) at N o. 4 9 6 P ro g e n sa E IR L at N o . 485 S u cu rsal (B ran ch ) a t N o : 421


In 2 0 1 1, J e f f fro m C an a d a reported: I j u s t re tu r n e d fro m a o n e w e e k s ta y in C uzco, P eru w here I w as su c c e ssfu l in o b ta in in g H a la ta l. The s tr e e t C a lles Tres C ru ces h a s a lo n g lin e o f veteri n a ry sh o p s ... I w e n t to A g ro veterin a ria ... There I g o t tw o fifty m L b o ttles f o r U S $20. I h a v e to s a y th o u g h co m in g b a c k th rough cu sto m s w as a b so lu te ly terrifying. A t C uzco In te rn a tio n a l A irp o rt, m y b a g w a s s e a rc h e d a n d th e m an c h e c k in g m y b a g h e ld th e tw o b o ttles u p a n d a s k e d m e w h a t it was, a n d I re sp o n d e d 'p e r fu m e ' a n d h e le t m e go. U.S. C u sto m s w a s even m o re te rrifyin g b e c a u se th ey w ere se a rc h in g th e b a g s fra n tic a lly ; h o w e v e r th e m a n at th e d e s k le t m e g o w ith o u t even lo o k in g in m y bag. Very bizarre.

Fig 14.28: The interior of a typical Agro Veterinaria


Fig 14.29: Nembutal boxes on display under the counter

Fig 14.30: Peruvian Halatal in its new packaging


Fig 14.31: Peruvian veterinary sterile Nembutal: Note - this packaging has been superseeded by that displayed in Fig 14.30

Fig 14.32: Peruvian veteri nary sterile Nembutal: Penta-Hypnol as it is occasionally retailed in Peru & Bolivia


In 20 1 2 , H e a th e r w ro te o f C uzco: A fte r b u y in g th re e b o ttle s o f H a la ta l a t various sto res in C a lle Tres C ru ces d e O ro (a n d a m a rv e llo u s v isit o n th e O rien t E x p r e s s ' H ira m B in g h a m to M a ch u P icchu), I w as s h o c k e d to b e s to p p e d b y p o lic e a t C u zco a ir p o r t on m y w ay b a c k to Lim a. A s it tu rn e d o u t it w a s a ra n d o m s p o t ch eck. I w as s u b je c t to a cu rso rу g o in g -th ro u g h o f m y ba g s d u r in g w hich tim e th ey o f c o u rse fo u n d m y b o ttles o f N em b u ta l. I w a s n e v e r a sk e d w h a t th ey w ere for, o n ly i f I h a d b een s ic k fr o m th e altitude. W hen I n o d d e d th e b o ttles w ere c a refu lly re -w ra p p ed b y th e p o lic e m a n in m y s w e a te r a n d th a t w as that. I m u s t s a y I w a s in itia lly q u ite s h o c k e d to b e s in g le d out. M e - a d ru g ru n n er - never. A t le a st n o t th e ty p e o f d ru g s th ey w ere lo o kin g for.


L a Paz - Bolivia La Paz in B o livia is the h ig h e st capital city in the w o rld and, a s such, its altitude m a y n o t suit all travellers. Like C usco, N e m b u ta l is re a d ily av ail able in La Paz i f y o u know w h a t to ask for. In La Paz, N e m b u ta l is s o ld under th e trade n am e ‘H a la ta lʼ. A cab ride to a local v et store should p ro v e a sim p le w a y to m a k e y o u r pu rch ase. If the sto re you visit do es n o t have an y in stock, th e y sh o u ld o ffer to o rd er it in. To p u rch ase N em b u tal in B olivia, y o u n e e d n o papers, n o p re scription, there are few rep o rted co m p licatio n s. O n e traveller even h a d th e v e t o ffer to d e liv e r h is N e m b u ta l o rd er to his hotel. H e p aid U S $ 1 0 for each 5 0 m l bottle. O th e r travellers to this co un try h ave rep o rted p ay in g u p to U S $4 0 for a 100ml bottle. E ith er w ay, th e price is ap pro priate a n d th ere is no sign o f profiteering. In La Paz, o n e pentobarbital is c o m m o n ly s o u rc e d from the v eterin ary outlet at: Av. S aav ed ra N o 1004 Z o n a M iraflores, La Paz


A S IA S ince 2009, Exit has receiv ed m an y positive repo rts o f the overth e -c o u n te r sale o f N e m b u ta l in Asia. H ow ev er, a s w ith South A m erica, th e availab ility o f this d ru g se e m s to ch an g e with a larm in g frequency. W h at w a s true last m o n th , is n o t true now.

B a n g k o k - T h a ilan d In 2 0 1 1, repo rts o f successful p u rch ase o f N em b u tal over-theco u n te r fro m veterinary p h a rm a c ie s in B an g k o k ceased. T h e E ien g S e w T u n g D isp en sary - on R atch apraro p R o ad in B an g k o k that h ad been a reliable source is n o w claim in g it no lo n g er sells N e m b u ta l, not even to T h ai nationals. I f y o u 'd like to p rove u s w r o n g how ever, here are th e details: E ieng S e w T u n g D ispensary 4 7 5 /9 R atchap rarop Rd, M ak k asan , R atch atew e e , B an g k o k 10400 T e l : + 6 6 -2 2 5 1 -1 4 8 2 Fax: + 6 6 -2 2 5 1 -7 2 3 8 In the past travellers p a id 850 T h ai B ah t (U S $ 2 5 ) p e r 100 ml bottle. T h e retail n am e w a s N e m b u ta l an d the d ru g w a s m a n u factu red b y th e F ren ch c o m p a n y CEVA.


Southern Thailand E xit o c c a sio n a lly receiv es rep orts o f the availability o f liq uid, veterin ary N e m b u ta l from v eterin ary sto res in the tow n o f T ra n g (n ear P h u k et Island). T h e n earb y to w n o f H at Yai (a larger to w n on th e b o rd e r o f M ala y sia) in S o uth ern T h a ila n d is o n e o th e r n o te d possibility. In both these tow n s, the liquid, v eterin ary N em b u tal h as been p u rc h a se d fro m v et p h a rm a c ie s/ hospitals. Both these tow n s arc serv iced b y airp o rts m ak in g access straig h t forw ard.

Fig 14.30: Sterile veterinary Nembutal as it is retailed in Thailand


C o n c lu d in g C o m m e n ts N e m b u ta l co n tin u es to be sold o v er-th e-co u n ter a n d o v e r the Internet fro m several co u n tries a ro u n d th e world. H o w ev er, w h ile th e p u rc h a s e o f N e m b u ta l m ig h t be q u ic k a n d legal in so m e co u n tries, the im p ortation o f N em b u tal to y o u r h o m e co u n try is a lm o st c e rta in ly ille g a l an d m a y attract penalties. Y ou w o u ld need to ch eck th e p articular law s o f the ju risd ictio n in w h ic h y o u resid e to be certain. H ow ever, i f a serio u sly ill person p u rch ases N e m b u ta l law fully in o n e co u n try a n d then takes the d ru g an d e n d s th eir life in th a t co u n try , it is likely no law s w ill be broken.

15

Using N em butal for a Peaceful Death A vailable fo rm s o f N em b u tal Storage an d the s h e lf life o f N em butal Testing the sam p le b efo re use T aking a sam p le for testing O p e n in g th e bo ttle o f veterinary N em b u tal U sin g th e dru g fo r a peaceful death E xten din g N e m b u ta l s h e lf life (C o n v ersio n & R econstitution) Interaction o f N e m b u ta l w ith o th er drugs O th e r useful barbiturates

A v a ila b le f o r m s o f N e m b u t a l Since 20 1 0 , the availability o f reag en t grade so d iu m pentobarbital p o w d er from C h in e s e m a n u fa c tu re rs h as m e a n t that this form o f the d ru g has su p ersed ed less re a d ily av ailab le form s. (F ig 15.1) F o r th e past d ecad e, sterile veterin ary liquid has b een the c o m m o n e st form used for a peaceful death. (F ig 15.2)

Fig 15.1:25gm of Chinese powdered sodium pentobarbitol

U sing N em butal

Fig 15.2: Sealed veterinary Nembutal

Fig 15.3: Pharmaceutical Nembutal tablets

O c c a sio n a lly p h a rm a c e u tic a l g rad e N e m b u ta l ta b le ts or c a p s u le s , o r ig in a lly p re sc rib e d a s s le e p in g m e d ic a tio n , a re o b tain ed alth o u g h this is u n c o m m o n . (F ig 15.3) R eag en t g ra d e N e m b u ta l is m a rk e te d a s a w h ite crystalline p o w d e r w h ic h re a d ily abso rb s m o istu re a n d is v e ry s o lu b le in water. It is non sterile an d p a c k a g e d in sm all tightly s e a le d s c re w top plastic containers. M o st people ordering in this w a y fro m China (see C h 14) re c e iv e 2 5 g m a s loose p o w d e r p a c k a g e d in a screw to p plastic c o n ta in e r (see F ig 15.1). N o te that this is m o re than enough o f the d ru g to p ro vide a p eaceful death f o r 2 - 3 people. T h e veterinary liquid form o f the dru g is designed for intravenous adm inistration in anim als to provide anaesthesia for surgery. It is m a rk e te d a s a sterile clear liquid w ith a co ncen tration o f 6 0 m g / ml o f so d iu m pentobarbital in alkaline buffered solution with 10 % methyl alcohol an d ethylene glycol. T h e usual pack ag ing is a glass 10 0 m l bottle (c le a r o r tinted glass), s e a le d w ith a ru b b er sto p p e r an d m etal seal.


Pharm aceutical grade N em b u tal tablets o r capsules are normally su p p lied in a s c re w to p plastic container, s h o w in g a date o f m a n u factu re o f m o re than 20 years ago, usu ally lo ng past their ex p iry date.

S to r a g e and S h e lf L ife o f th e B a rb itu rates T h e so lu ble barbiturate salts (pentobarbital s o d iu m ) are v ery stable drugs, an d i f sto red co rre c tly m aintain th eir p o te n c y for d ecad es. T h is is a particularly useful p ro p erty o f N em b u tal, as it m e a n s that o n e can obtain the d ru g m a n y y ears before it is called up o n to p rov id e a p eaceful death. T his is partly w h y it m akes sense to go to the trouble o f obtaining this d rug for p o ssib le future u se i f needed. Too often people fail to p rep are. W h e n s e rio u s illness occu rs, to o m a n y find th e m se lv e s h av in g to ask o th ers to obtain th eir d ru g s an d thus e x p o sin g th o se they lo ve to u n n ecessary legal risks. In p o w d e re d form , so d iu m p en tob arb itol sh o u ld be k ept in a tig h tly -se a le d airtig h t c o n ta in e r so that it is n o t effected by a tm o sp h eric m o istu re. It is often useful to split the do se o f drug at this p o in t into tw o, 10 - 12gm lots an d v a c u u m seal (using read ily av ailab le fo od s to ra g e system ). T h e p o w d e r sh o u ld be kept cool ( <20°C) an d aw ay o f the light. Refrigeration (~2-5°C) is fine, prov ided th e c o n ta in e r is tightly sealed . D o n o t freeze. Veterinary liquid com es in sealed sterile glass 10 0 m l containers a n d sh o u ld b e left u n d istu rb e d until it is to b e needed. D o not b re a k th e seal an d d ecan t th e liqu id into a n o th e r c o n ta in e r a s this w ill e x p o se the d ru g to the air. S tore the bottles in a cool dark place. R efrigeration is fine b u t again d o n o t freeze. T h e liq uid sh o u ld b e clear an d co lo urless. A n y co lou ratio n or precip itatio n after lo ng storage period s indicates that testing an d a ssa y is necessary.

U sing N em butal

P h arm aceu tical g ra d e N e m b u ta l cap su les o r tablets are likely to h ave d eterio rated b ecau se o f th eir ag e an d sh o u ld b e tested befo re use. Note: T h e barbiturates in their acidic, w a te r insoluble, crystalline form are ex trem ely stable (eg. the free acid, pentobarbital, C A S N o. 76-74 -4 ). Indeed i f o n e carefu lly d rie s these cry stals and places th em in a sealed c o n ta in e r that is sto re d in a d ark dry place, o n e c o u ld ex p ect little deterioration, even o v e r several decades. N ote: T h e insoluble, free a c id cry stallin e form o f th e d ru g m u st be co n v erted to the w a te r s o lu b le salt (S o d iu m p ento barb ital/ N e m b u ta l) i f it is to b e u s e d f o r a quick an d peaceful death. T his is a v ery so lub le salt that is q u ick ly a b so rb e d from the sto m ach an d u p p e r gut.

Testing th e S a m p le B efo re U se T h e re are a n u m b e r o f r e a s o n s w h y o n e m a y w is h to test th e q u a lity o f th eir acq u ired N e m b u ta l befo re u sin g it fo r a p eacefu l death. For ex am p le, the dru g m a y h ave c o m e from a q uestionable source. O r it m a y h av e b een kept for a n u m b e r o f y ears a n d m a y b e th e risk o f significant deterio ratio n. The question o f reliability is o f p a ra m o u n t im portance. P eople do n o t w an t to take a su b stan ce i f there is an y qu estio n a s to the o u tc o m e . T here are tw o tests o f significance: # 1 : Is th e d ru g th e barb itu rate N em b u tal? T h is is th e qualitative test #2: Is the d rug pure, o r h a s it d eterio rated o r b een adulterated? T h is is a q u antitativ e test.

U sing N em butal

The Q u alitativ e Test: T h e E xit N em butal S pot Test T h e Exit S p ot Test Kit is an ex trem ely useful screen in g test that can be qu ick ly u sed i f th ere is a n y d o u b t th a t N em b u tal p o w d e r from C h in a o r liquid N em b u tal fro m P eru o r M ex ico is, in fact, N em b u tal. O n ly a v e ry sm all sam p le is n e e d e d for th e test (~0. 1gm o f pow der, o r 0.01m l o f veterinary liquid). In the case o f p o w d e re d N e m b u ta l, tak in g a sm all sam p le for th e E xit S po t Test is sim p ly a m atter o f o p e n in g th e screw top container. U s in g a clean k n ife , p la c e a sm all sam p le o f the p o w d e r o n digital scales (see F ig 15.4).

Fig 15.4: Weighing out Nembutal powder for testing

U sing N em butal

A sam p le o f v eterin ary liquid N em b u tal for th e S p ot T est can b e o b tain ed a s follow s: Sterile veterinary packag ing is designed s o that variable am ounts o f th e dru g can b e w ith d ra w n from the 100ml bottle using a syring e a n d h y p o d e rm ic n eed le w ith o u t b reak in g the sterile seal. A lth ou gh there is n o n e e d for th e N e m b u ta l to be sterile, th e d rug keeps lo n g er i f th e seal is n o t d a m a g e d an d th e solution rem ain s sterile. T h e bottle sh o u ld on ly be o p en ed w hen the drug is either to be used o r discarded. T h is is d o n e b y b reak in g the seal a n d re m o v in g the ru b b er sto pp er

Fig 15.5: Removing a sample of Nembutal

U sing N em butal

To take a sm all sam p le o f the liquid f o r testing, rem o v e the p lastic cap fro m th e tip o f the bo ttle ( i f p resen t) a n d then u se a small knife o r screw d riv er to rem o ve th e small central circular m etal p ie c e co v erin g th e ru b b er sto p p e r (F ig 15.5). T h is will e x p o se the ru b b e r seal. T h e n e e d le o f the h y p o d e rm ic can th en b e p u s h e d th ro u g h th e sto p p e r into the bottle. U se the h y p o d e rm ic 0 .5 m l sy rin g e su p p lied w ith th e E xit N em b u tal Test Kit ( o r an equ iv alen t). W ith th e n eed le in place, in vert the b ottle an d carefu lly w ith d ra w the syrin ge p lu n g e r until there is 0.01m l o f liquid in the syringe.

T he E xit N e m b u ta l S p o t Test Kit T h e Kit c o n sists o f a 0.5 ml h y p o d erm ic syringe, a red-topped co n tain er o f buffer, a test cassette, p a ir o f g lo v es an d full set o f instructions. (F ig 15.6)

Fig 15.6: Exit Nembutal Test Kit

U sing N em butal

U se the syring e, re m o v e a sm a ll sam p le from th e bottle o f drug to be tested u sin g th e m eth o d s h o w n in Fig 15.5. O p en the redcapped co n tain er o f extraction b u ffer a n d in tro d u ce tw o to three drops o f this sam p le to the bu ffer container. S c re w b ack the red cap an d s h a k e th e bottle (F ig 15.7a). P o w d e re d N e m b u ta l can be tested by tak in g th e sm all am o un t o f p o w d e r (0.1g m ) an d d issolv ing it in 5m l o f w ater. U se the 0.5ml sy rin g e in the Exit Test Kit to in tro d u ce 2 -3 d ro p s o f this solution into th e b u ffer p ro v id e d in th e kit. A p o sitiv e resu lt is recorded in the sam e w a y a s w ith th e veterinary form o f the drug. U sin g th e C a ssette B reak o f f th e tip o f th e red cap o f the extraction b u ffer co n tain er (Fig 15.7b). Place the cassette on a clean su rface an d apply three or fo u r d ro p s o f th e liquid onto the sam p le w ell o f the cassette. W ait five m in u te s before re a d in g th e test. R e a d in g th e Test (F ig 15.8) N e g a tiv e Result: T w o lines appear. A red line in th e control reg io n (C), an d a red o r pin k line in the test region (T).

Fig 15.7a

Fig 15.7b

Fig 15.7c

U sing N em butal

Positive: O n e red line in th e control region (C). N O line app ears in the te st reg io n (T). T h e ab sen ce o f a test line indicates a positive resu lt fo r N em b u tal. In v a lid : N O line a p p e a r s in th e c o n tro l reg io n (C).

Fig 15.8: Reading Spot Test Results

The P eaceful P ill H andbook T h e M e ltin g P o i n t T est T h e M eltin g P oint test is a useful test b u t it m u st be carried out on th e free acid - n o t the so d iu m salt. Item s n eed ed for the test include a sealed g lass cap illary tube, th e rm o m e te r (m e rc u ry or d igital) w ith ra n g e > 150°C, an d a glass c o n ta in e r o f co o k in g oil that can be heated slo w ly on the stove. (F ig 15.9) I f o n e h as the p o w d e re d salt fro m C hin a, o r a bottle o f liquid solution o f th e salt, th e p ro c e ss is a s follow s: Take a sam ple (~ 0 .5 g m o f th e pow der, o r 3-5 m l o f liquid, ad d a dilu te acid (v in e g ar w o rk s w ell) to p recipitate the free acid from solution, filter with a coffee filter p a p e r th en dry gently at ~ 100°C - 110°C. Place s o m e o f the d ry pentobarbital cry stals into th e capillary an d s u sp e n d in the oil. Heat th e oil s lo w ly o n th e stove and w a tc h f o r th e point a t w hich m elting o f th e cry stals occurs. The crystals sh o u ld ch an g e co lo u r qu ick ly fro m w hite to transparent at 1 3 1 ° C + /- 1°C. A v id e o o f this p rocess w ill be inclu ded in a future eH a n d b o o k update. A d etailed d escription o f the p ro c e ss w ith clear p ho tog rap hs h as b een p o sted on th e Exit F o rum by ‘h tv e ld ʼ. T h is site can be v isited in th e E xit F oru m ‘P rim e P o s ts ’ listing o r see F ig 15.9a a n d Tab. http://bit.ly/HGv8tH

Fig 15.9: Digital thermometer with glass melting point capillary attached

U sin g N em b u ta l

M e lt in g P o in t Test

Fig 15.9:a Step by Step test of Nembutal Purity using melting Point Test by ʻhtveld’ Exit Forum


T h e Q u a n tita tiv e Test o f N em b u tal T h e Q u a n tita tiv e T est is a h a r d e r task. R e lia b le te s tin g to establish the p resen ce o f ad u lteran ts o r deg rad ation products req u ires sop histicated equ ipm ent. T h e E xit labo ratory operates su ch e q u ip m e n t (see F ig 16.7). E xit is e n d eav o u rin g to dev elo p a h o m e-te st k it w h e re an accu rately m e a su re d sam p le o f the d rug can be tested to estab lish the d r u g 's purity. A t presen t, a reliable test kit fo r quantitative a ssa y is not available. Exit h as b een a b le to te st a n u m b e r o f s a m p le s o f N em b u tal so u rced from C hin a an d M ex ico using G a s C hro m atog rap hy and h as seen no evid ence o f significant adulteration o r deterioration, even in s a m p le s that h av e b een sto red for long perio ds (so m e o v e r 15 y ears). R ecent test runs h av e lo o k ed at seven p o w d e r N e m b u ta l sam p les from different C h in ese sources, all delivered pu rity results > 9 5 % . T h e results for th e seven a n aly sis a n d the A nalysis C ertificate a c c o m p a n y in g o n e o f th e sam p les is show n (see F ig 15.10). C h in ese sup p liers w h o have h ad sam p les tested b y E xit are listed w ith an ‘* ʼ (see C h a p te r 14) F o r th e enthusiastic am ateur, a titration test o f purity is available a n d can b e carried o u t at hom e. It is nec essary to accu rately w eigh o u t a sm all sam p le o f p o w d e r ( ~ 2 0 0 m g + /- 0 .5 m g ), dry in an o v en a t 10 0 °C to d eterm in e the p resen ce o f an y significant a m o u n t o f w a te r in th e sp e c im e n , then titrate w ith hyd roch loric acid, u sin g m ethyl o ran g e as an indicator. A detailed step b y step acco u n t o f this process has been provided to E xit by ‘h tv e ld ʼ an d is av ailab le on th e ‘P rim e P o sts’ section o f the E xit F o rum (o r see Tab). http://bit.ly/HGv8tH

U sing N em butal Gas Chromatography Analytical Results Specimen Code

Specimen Type

Pentobarbital-Na %w/w 95.2 96.2

LossonDrying %w/w 2.5

A

White Powder

B

White Powder

C

White Powder

95.2

1.8 3.2

White Powder

95.0

2.6

E

White Powder

95.2

2.4

F

White Powder White Powder

95.6

2.7

96.0

1.9

D

G

C e r t if ic a t e o f A n a ly s is

F i g 1 5 .1 0 : G C A n a l y s i s o f 4 C h i n e s e s a m p le s a lo n g w i t h s a m p le ʻB ʼ A n a l y s is certifa

Endpoint in sodiumpentobarbital titration:

Fig 15.10a: Methyl Orange titration for Nembutal purity by ʻhtveldʼ


T ak in g N em b u ta l fo r a P eacefu l D eath U s in g N e m b u ta l to obtain a peacefu l death is straight-forw ard. U sually, an anti-em etic (an ti-v o m itin g ) d rug is taken eith er for 2 d a y s p r io r o r a s a single stat d o s e 4 0 m in b efo re th e N em butal is to be taken (see C h a p te r 9). A p eaceful secu re e n v iro n m e n t w h e re o n e w ill n o t be disturbed is re c o m m e n d e d (fo r further discu ssion , see the F A Q ʻIs one bottle o f N em b u tal e n o u g h ? ʼ at the en d o f this C hapter). Usually this is b e s t a c h iev ed a t night. H av e so m eth in g light to cat so y o u r sto m ach is n o t em pty. T h is redu ces th e chance o f reflex vom iting from th e bitter drug. W hen a p erso n w is h e s to die, 10 o r m o re gm o f p o w d e re d N em b u tal can b e p laced in a glass. A ro u n d 5 0 m l o f co ld w a te r is then add ed . T h e p o w d e r is stirred until it is fully dissolved. The liquid in th e g lass will be clear. In the case o f veterinary liquid, th e bottle is o p en ed b y b reak in g the seal a n d p o u rin g all the co n ten ts (1 0 0 m l) into a clean glass. T h e bottles arc sealed an d the liquid inside is sterile. B reaking th e seal can so m e tim e s be difficult esp ecially i f visio n is poor, o r o n e h as arthritis in th e hands. O n e m eth o d o f o p e n in g the b ottle is s h o w n in the a c c o m p a n y in g video. T h e liq uid in the glass is d ru n k q u ic k ly in 2 o r 3 sw allo w s. The b itter after-taste can then b e alleviated b y drin kin g so m e alcohol, usually spirits o r liqueur. T h e alco ho l n o t o n ly re m o v e s the b itte r after-taste o f th e N e m b u ta l b u t it sp eed s the d r u g 's action. A s th e d rug is a b s o rb e d from the sto m ach , an d the level in the b lo o d rises, s o m e c ro sse s th e bloo d-brain b a rrier an d h as its first effect on that part o f the brain that c o n tro ls sleep: w ithin a f e w m in u te s o f tak in g th e drink th e p erso n falls into a deep slee p , often q u ite suddenly, even m id-se nte nce w h e n talkin g to friends!

U sing N em butal A s the level o f dru g in th e b lo o d stream rises, m o re m o v e s into the brain a n d sleep b e c o m e s d e e p e r an d deeper. A t that point, a n o th e r area o f the brain is effected; that w h ic h controls the rate o f breathing. T h e p e rso n 's breathing slow s, an d eventually stops altogether. A t that point, w ith no o x y g en en terin g the lungs, the person dies o f ‘respiratory a rre s tʼ, w h e r e there is n o t en ough o x y g en in th e c irc u la tin g b lo o d to m ain tain brain function. A nd, lastly, th e h eart sto p s beating. R arely is there an y b lad der o r bow el m otion. It is th e m o st p eaceful o f d e a th s to w itn ess. W ith N em b u tal, o n e a lw a y s d ie s in th eir sleep.

A M eth o d for E x ten d in g the S h e lf L ife o f N em b u tal I f y o u r so d iu m pen tob arb ital is n o t to be used for m a n y years c o n s id e r co n v ersio n o f the salt to th e m o re stable crystalline form. V eterinary N e m b u ta l s o lu tio n s o f so d iu m p e n to b a rb ita l are buffered so lutio ns a t an alkaline pH , usu ally stabilised with 10% alcoh ol an d eth y len e g ly co l. R e d u c in g th e p H b y the addition o f dilute hy d ro ch lo ric acid ( o r vinegar) will force the so d iu m salt b ack into th e insoluble cry stallin e fo rm . Similarly, p o w d e re d sodium pentobarbital can b e d isso lv ed in w a t e r (it is v ery soluble), an d then acidified to p ro d u ce th e sam e result. O n e can w a tc h th e pH d ro p u sin g acid/ alkali indicator sticks. W h e n all precipitation h as o c c u rre d a n d the p H h as re a c h e d 2 - 3, th e cry stals can be filtered u sin g a coffee filter paper. The rem ain in g sodium ch lo rid e is w a s h e d o u t an d the filter paper left to d ry in the sun. W h e n fully dry, the cry stallin e form can be v ac u u m -p a c k e d in a sealed co n tain er for p o ssib le future use. T h e crystalline form m u s t be reco nv erted into the solub le salt to p ro v id e a fast and peaceful death. To do this, the pentobarbital is


d isso lv ed in w a rm alcohol (sp irits like v o d k a o r w h isk y can be u sed ) an d the solution m ad e alkaline by th e addition o f sodium b icarb o n ate (b ak ing soda). T h e acid fo rm o f the b arbiturate (w h ich is in equilib rium w ith th e salt) reacts w ith the alkali n eutralising it. M o re o f th e a c id c h a n g e s to the salt a s alkali is ad ded. W h e n all is c o n v e rte d to th e so d iu m salt th e solution can then b e d runk to b rin g a b o u t a p eacefu l death. N o te : D o n o t ad d m o re alkali th an that n eed ed to co n v e rt the free a c id to salt. 10g m o f pentobarbital req u ires ~ 4 g m o f so d iu m bicarbonate.

In tera ctio n w ith O th e r D ru g s T h o s e w h o take N e m b u ta l for a peaceful death are often taking o th er drugs fo r vario u s health problem s. W h e n ap p ro ach in g the chosen tim e to take the N e m b u ta l, the qu estion is often asked a b o u t w h e th e r an y intercurrent m ed icatio n s sh o u ld cease. T h e re are few d ru g s that interfere sig nifican tly w ith th e action o f N em b u tal

m a k in g it less effective. T his is w h y there is no a b s o l u t e n e e d to c e a s e t a k in g o th e r d r u g s in th e p r e c e d in g days. H o w e v e r , it is c o m m o n f o r th o s e p lan n in g th eir death to cea s e all but th e essential m edication in the w eek b efo re th eir p la n n e d exit. T h e re is s o m e e v id en ce that chronic h e a v y alcohol u se m a y lead to crosst o l e r a n c e a n d s ig n if i c a n tl y im p a ir th e action o f the barbiturate. A n o th er instance w o u ld be th e rare case w h ere s o m e o n e h a s b e e n ta k in g a n o t h e r

Fig15.11: Dilantin 100mg capsules

U sing N em butal

b a rb itu ra te for s o m e tim e a n d h a s d e v e lo p e d a b arb ituratetole rance in this w ay. T h is is u n c o m m o n alth ou gh o ccasionally p eo p le take th e an ti-co n v u lsan t barbiturate, p h eno b arb ital, for lon g periods. In th e se cases, a larg er d ose o f th e N em b u tal (12 g m p o w d e r o r 2 x 100ml b o ttles) w o u ld b e advised. S o m e d ru g s en h an ce th e effect o f th e N e m b u ta l an d can even b e em p lo y e d for that specific pu rp o se. An e x a m p le is th e antico nv ulsan t D ilantin (p h en y to in so d iu m F ig 15.11). Dilantin is useful as the d ru g d isso lv es in w a te r fo rm in g an alkali so lu tio n w h ic h is c o m p a tib le w ith the liquid N em b u tal. I f y o u h a v e a bottle o f N e m b u ta l w h ic h is o f uncertain quality, th e p o ten cy can b e e n h a n c e d b y disso lving 1- 2 g m o f phenytoin sodium in th e liquid N e m b u ta l b efo re drink in g . T h is process is sh ow n in the acco m p an y in g v id e o “ M a k in g N e m b u ta l even m o re effective” . A lth o u g h Dilantin is a dru g th a t is co ntro lled , it is relatively easily o b tain ed through Internet m ailing sources. It is n o t a drug th a t attracts attention.

O th er u sefu l B a rb itu ra tes Two o th er barbiturates that still find w id e (alth o u g h d ecreasing ) u s e in m e d i c i n e c a n a l s o b e u sefully em p lo y e d for a peaceful d e a th . T h e s e a re th e a n t i c o n v u lsa n t P h e n o b a rb ita l, an d the an aesth etic induction agent Pentothal. Fig 15.12: 30mg tablets of Phenobarbitone


Phenobarbital A s discussed in C h a p te r 13, phenobarbital an d pentobarbital are d ru g s that are often co n fu se d b ecau se o f th e sim ilarity o f their nam es. A ltho ug h both a re barbiturates, pentobarbital sodium (N e m b u ta l) is th e fast-acting s o lu b le salt. T h is is th e euthanasia d ru g o f ch o ice in all co u n tries that a llo w a ssisted su icid e and euth an asia. Phe n o b arb is a d ifferent d ru g . In its usual form p h e n o b a rb is a s lo w -actin g an ti-co n v u lsan t, p rescrib ed w h en th ere is a risk o f co n v u lsio n s (eg. brain tra u m a etc). S o m e p eo p le will h av e access to p h e n o b a rb , either from their o w n d o cto r o r from o verseas pharm aceutical suppliers. 10gm (~ 2 5 0 o f th e w h ite 3 0 m g tablets sh ow n in Fig 15.12 ) o f crushed w h ic h is then m ix e d w ith w a te r an d taken as a drink w ill be lethal. N ote: T h e re is n o rap id loss o f co n scio u sn ess, as in the case o f N e m b u ta l. T h e tim e to death u sin g p h en o b arb ito n e can be sev eral hours. I f one is fo u n d befo re death, resuscitation is very possible. P h en o b arb can, how ever, b e m ad e m o re effective b y forcing up th e pH o f th e solution o f the cru sh ed tablets. T h is is done u sin g S o d iu m C a rb o n a te to co n v e rt the Phe nobarbital to the m o re read ily -ab so rb ed so d iu m p henobarbital. I f available, 1g m o f D ilantin can be a d d e d to this d rin k w ith g o o d effect. T o reduce the tim e from taking the drink to loss o f consciousness, a s e c o n d d rin k m a d e fro m a b e n z o d ia z e p a m s le e p in g d ru g is r e c o m m e n d e d ( e g , Se r a p a x , o x a z e p a m o r M o g a d o n , n itraz ep am ). A g ain , alcohol can b e an effective supplem ent.

U sing N em butal

Pen toth al (th io p e n to n e sodiu m ) F o r m a n y y ears, Pentothal w a s the m ain in trav e n o u s induction a g e n t u sed in a n aesth esia. Its u se h as d eclin ed in recen t years. W h e n g iv e n in trav e n o u sly , m o s t p a tie n ts a r e a s k e d b y the an aesth etist to c o u n t b ack from 10.

F e w g et p a s t 7 before

co n scio u sn ess is lost. N o te : T h is is th e p r im a r y d ru g u s e d in lethal in je c tio n s in ex ecutio ns in th e US. In N o v e m b e r 2010, a w o rldw id e shortage o f th e d rug p ro m p te d th e state o f O k la h o m a to investigate using N em b u tal a s an alternative. See: h ttp ://a b cn .w s/d P u 2 Z r Pentothal is m a rk e te d as a so lu ble th io p en to n e so d iu m p o w d er in sterile am p ou les. T h e se are d esig n e d to be m ix e d w ith sterile w a te r b efo re b e in g a d m in iste re d intravenously.

Fig 15.13 500mg ampoule of dry Pentothal


T h e p o w d er can be d iss o lv e d in w a t e r an d taken w ith rapid effect orally. 10g m o f th e d ru g (the co n ten ts o f 2 0 am p o u les) d isso lv es rapid ly in ~ 5 0 m l o f w ater, an d i f drunk leads to rapid loss o f consciousness an d death. A lcohol is a useful supplem ent. E x it h a s lo o k e d a t v a c u u m - p a c k i n g 10g m o f d r y s o d iu m p entothal p o w d e r m ix ed w ith 1g m o f p henytoin so d iu m . T h is can be readily tra n sp o rted a n d stored. R e c o n stitu tio n is c a r rie d o u t b y b re a k in g th e v a c u u m seal a n d d isso lv in g th e sach et o f p o w d e r in ~ 5 0 m l o f w a te r before d rin k in g . T ria ls are c u r r e n tly b e in g c a r rie d o u t b y E xit to establish o p tim u m storag e an d s h e lf life o f these d ru g s w hen p a c k a g e d in the m a n n e r describ ed .

C o n c lu d in g C o m m e n t W h e n rig o ro u s scientific p ro cesses are u s e d to establish the p u rity an d efficacy o f k n o w n drugs, th u s en su rin g a reliable and p eacefu l death, the n eed f o r legislative ch an g e is significantly d im in ish ed . T h is is b e c a u s e the act o f d y in g well a n d a t a tim e an d p lace o f o n e 's c h o o sin g is in reach o f th o se w h o seek it, a s lo ng a s certain ly step s are taken. T h is not o n ly rem o v es th e dying p ro c e ss fro m th e h a n d s o f the m ed ical p ro fession but e m p o w e rs th e eld erly an d th e serio u sly ill to m ak e th eir ow n end-o f-life d ecisio n s, sh o u ld th e n e e d e v e r arise. W h eth er legislation that provides controlled access to assistance to die ex ists o r n o t, it is u n lik ely to effect th e p erso n w h o has th eir P eaceful Pill locked in the cup bo ard. W h e n the tim e is right, th ey w ill sim ply g o to th e cupboard!


Is one 100ml bottle o f veterinary Nembutal enough fo r a peaceful death? W h ile there are several florid acco u n ts o f failure b y people taking a full 100ml bottle o f veterinary N em butal, clo ser scrutiny sh o w s a m uch m ore c o m p lex situation. Exit h as e x a m in e d the details an d m ed ical reco rd s o f several such cases. In th e v a s t m ajo rity o f cases, o n e bottle (100m l @ 6 0 m g /m l) o f v eterin ary N e m b u ta l will a lw a y s b e satisfactory. H ow ever, th ere is a sm all g roup (estim ated a t < 1 % ) w h o m a y ex hibit a p ro lo n g e d c o m a to se p h a se b efo re death (so m e tim e s u p to 24 hours). O u trig h t ‘ failuresʼ rem ain ex trem ely rare. Indeed, all o f th e reported failures investigated w ere associated w ith discovery a n d m edical intervention. T h is e m p h a sise s the n e e d for careful selectio n o f the p la c e o f death. In s o m e o f the a n a ly s e d c ases, th e lo ng c o m a to s e p h a se is a sso ciated w ith the p ro lo n g e d u se o f an ti-p sy ch o tic m edication o r chro nic h e a v y alco ho l use, p rio r to tak in g th e barbiturate. It is p re s u m e d the induction o f liver e n z y m e s b y these drugs cau ses in creased deg rad ation o f the N e m b u ta l, lo w ering the c o n c e n tr a tio n in th e b rain . In th e s e s itu a tio n s , in creasin g th e q u an tity o f drug taken (eg. to 2 bottles, 12gm) m a y not n ecessarily hasten the death. E x it h a s e x a m i n e d th e u s e o f s e v e r a l p o t e n t i a t i n g d r u g s w h ic h m a y b e d isso lv ed into the liquid N e m b u ta l, rem o v in g a n y possibility o f ex te n d e d co m a. T h e m o st useful, Dilantin, (p h en y to in so d iu m ) is d iscu ssed in this Chapter.

U sing N em butal

Should one eat a meal before taking Nembutal ? T h e cha n c e o f reflex v o m it in g brou ght o n by drin kin g the bitter N e m b u ta l liquid is red uce d i f the re is s o m eth in g in the stomach. Th is s hould not be a significant meal that will slow the abs orption o f the drug. S o m e t h i n g light is preferable, like tea a n d toast, an h o u r o r s o bef or e taking the drug.

Is there something that can he added to the Nembutal liquid to take away the bitter taste? It is a l w a y s b etter to take o n e ' s N em b u ta l straight. T h e likely result o f m ix i n g the N e m b u ta l with s o m eth in g else (eg. yogur t) is t h e c r e a t i o n o f a g r e a t e r v o l u m e o f s o m e t h i n g e q u a l l y unpalatable. Furthermore, using a spo on to c o n s u m e the drug, rather than drin king it, ca n m e a n a lon ger ti m e to ingest the 100ml. Exit has re ceived reports o f people falling as leep before all o f th e d r u g is c ons um e d. T h i s is da ngerous. It is best to drink the 100ml in a f e w sw allow s, then drink alcohol.

16

The Peaceful Pill D ev elo p in g a P ea cefu l Pill T h e o n g o in g d ifficu lties in o b t a i n i n g t h e b e s t euthanasia drug, Nembutal h a s p r o m p t e d E x i t to e s ta b lis h an a m b itio u s r e s e a r c h p r o j e c t - th e s y n t h e s i s o f o n e ’s o w n ‘ P eaceful P illʼ.

T h e P eacefu l Pill P ro je c t h as ru n f o r se v e ra l y e a r s . M an y strategies have b een ex plo red an d rejected w ith so m e significant a d v a n c e s m ade. In this C h a p te r w e detail this E xit research a n d discuss in m o re detail th e u se o f the d rug N em b u tal for a p eacefu l death. T h e syn th esis o f a barbiturate-like pill, in v o lv es the acq uisition o f restricted an d h ard -to -g et c h e m ic a ls a n d th e u se o f processes that are difficult an d o c c a sio n a lly d a n g e ro u s fo r th e novice. N ev erth eless, a s th e p a th w a y s are e sta b lish ed an d sim plified, s afer p ro cesses are d e v elo p ed an d recorded. A n ou tline o f the step s req u ired for b arb itu rate sy n th esis an d a ssa y are described a n d illustrated w h e re p o ssib le w ith video.

The P eaceful Pill

The Nicky Finn E x it's first trials o f th e h o m e -m a d e P eaceful Pill - th e ‘N icky F in n ’ - w e re c o m p le te d in 2004. N a m e d after the fam ous M icky Finn drink o f th e L o n e S tar Saloon in C h ic a g o in th e early 1900s, E x it’s N ic k y Finn w a s m ad e fro m alcohol a n d nicotine. M a n u f a c tu r e d b y c h lo r in a tin g alc o h o l a n d c o m b in in g this ch lo ra l h y d r a te w ith pu re n ic o tin e , th e N ic k y Finn sh o u ld p ro v e h ig h ly effective an d h ig h ly lethal w h e n taken a s a drink. A l t h o u g h s y n th e s i s w a s s tr a i g h t f o r w a r d , th e d i f f i c u lt y in testing this u n trie d p ro d u c t left q u estio n s a b o u t this strategy u nan sw ered.

C h a n g in g Focus Exit International la u n c h e d th e ‘P eanut P ro je c t’ in early 2005. N a m e d a f te r an o l d - f a s h i o n e d s tr e e t te rm f o r b a r b itu r a te (Peanuts), th e Peanut Project brought together a g ro u p o f elderly p eo p le to create th eir o w n barbiturate. C o u ld th ey synthesise N em b u tal? H o w c o u ld th e y m a k e so m eth in g that: th ey c o u ld take orally •

c o u ld b e m a n u fa c tu re d w ith o u t ou tsid e assistance w o u ld p rov ide a p eaceful an d dignified death w o u ld b e reliable w ith n eg lig ib le risk o f failure.

T h e first W o rk sh o p w a s h e ld in late 2 0 0 5 on a rem o te property in the A ustralian cou ntry sid e. T h e a v e ra g e ag e o f participants w a s 80 y ears, altho ug h so m e w e re in th eir 90s. Several w h o p articipated w e r e serio u s ly ill.


Legal Issues S etting o u t to m a n u factu re o n e 's o w n b arb itu rate P eacefu l Pill e x p o s e s those invo lved to significant legal risk. In Australia, th e m a n u factu re o f b arb itu rates is g o v e rn e d b y law s such as the D r u g M isu se a n d T rafficking A c t 1985 (N SW ) w h ich m a k e s it a crim e to m an u facture, p o sse ss o r s u p p ly su ch a d ru g . The p enalties that a p p ly d ep en d up o n the am o u n t o f th e prohibited d ru g involved. I f the a m o u n t is less than 10gm , the p e n a lty is tw o y ears j a il an d a fine o f $5,500. If am ounts greater than 20K g are inv olv ed , the p e n a lty is life in ja il an d a fine o f $ 550,000. In m ost w estern countries there will also be other laws that m ake it an o ffence to m an u factu re, p ossess, sell, su p p ly an d im port certain narcotic an d p sy ch o tro p ic drugs. P enalties w ill depend up o n th e a m o u n t o f th e d ru g involved, an d again range from tw o y ears ja il an d a fine, to life im prison m ent. Finally, there is th e o th er additio nal generic legal question. I f one m e m b e r o f th e g ro u p e v e r too k th e su b stan ce the g ro u p m a d e a n d died, w o u ld the re m a in in g m e m b e rs be a c c u s e d o f having assisted w ith th a t p e r s o n 's suicide? It w a s stated cle a rly a t th e start, that n o o n e in th e initial group w o u ld m ak e m o re than th e y n eed ed for them selves. N o one w a s m ak in g a Pill for so m eo n e else, a n d no o n e w o u ld sell any o f the su b stan ce m an u factu red . Finally, no o n e w o u ld acquire m o re th an 10gm o f th e m an u factu red b arbiturate (the c o m m o n lethal dose) a n d an y ex cess w o u ld b e destroyed. T h e first P eanut sta g e failed w h e n a g ro u p m e m b e r b ecam e d ise n c h a n te d w ith th e p roject an d d e n o u n c e d those involved. T h re a ts w e re m a d e to in fo rm th e a u th o ritie s o f the g r o u p ’s a c tiv itie s a n d th e p r o je c t w a s f o r c e d to c l o s e f o r se v e ra l y ears. T h e death o f the m e m b e r in 20 1 0 led to the p ro je ct's reestab lish m e n t in 2011.

The P eaceful Pill

The C hem istry T h e p ro cesses u s e d for the b arbiturate P eaceful Pill synthesis h ave b een k n o w n fo r m a n y years. B arb itu rates are derivatives o f barb itu ric acid, w h ic h w a s first s y n th e s ise d b y A dolph von B a y e r in 1864, by c o n d e n sin g m alo n ic a c id with urea. An e a s ie r m eth o d m a k e s u se o f th e di-ethyl este r o f m alo n ic acid (di-ethyl m alo n ate) w h ic h reacts w ith urea in the presen ce o f a cataly st so d iu m eth o x id e ; a b a s e is fo rm ed b y dissolving m etallic so d iu m in ab so lu te alcohol (ethanol). T h is sy n th e sis can b e d ep icted a s follows.

T h e reaction tak es place u n d e r reflux fo r a n u m b e r o f h o u rs at 110°C. C rystals o f barbituric a c id are ob tained by acidifying the reaction m ixture, then filtering and cooling the filtrate. Barbituric acid, how ever, h as no physiological activity. T h e p rocess needs to be taken further to d ev elo p a b arbiturate that can peacefully en d life. T h e sedative, hyp n otic, an d anaesthetic pro p erties o f the b arbitu rates arc d e te rm in e d by th e characteristics o f tw o additional s id e -a rm s ( o r side-ch ains) attach ed to the barbituric acid m olecule.

The P eaceful Pill

T h e d i - s u b s ti t u t e d b a r b i tu r a t e s o f p a r t ic u la r in t e r e s t are am ylobarbital (A m y ta l) an d pentobarbital (N em butal). T h e p r o c e s s o f a d d in g s id e -a rm s (d i-s u b s titu tio n ) n e e d s to be u n d ertak en before the c o n d en satio n o f th e m a lo n a te a n d urea. In A m y tal, th e tw o alkyl side a rm s are (a) ethyl, in tro d u c e d as e th y l-b ro m id e an d (b) 3-m eth y lb u ty l, in tro d uced a s 1-brom o3 -m e th y lb u tan e . In N e m b u ta l, the tw o alkyl sid e-arm s are (a) ethyl, in tro d u c e d a s e th y l-b ro m id e a n d (b) 1- m e th y lb u ty l, p rod uced from 2-brom o pentan e. In both substitution reactions th e m a lo n a te is h eated , e ith e r in a c lo se d p ressu re system (au to clav e) o r u n d e r reflux first w ith o n e an d then the second alkyl brom ide. In bo th reaction s so d iu m eth o x id e is u s e d as th e catalyst. T h e final step in th e p ro d u ctio n o f so d iu m pento barbital or sodium am ylobarbital is heating o f th e resultan t di-sub stitu ted m alon ate w ith d ry u rea in an au to clav e o r u n d e r reflux for an o th e r 12 hours. T h is is again do n e in the p resen ce o f dry alcohol a n d sodium . E xcess alcohol is re m o v e d b y distillation an d th e re sid u e - p r e d o m in a n tly s o d iu m p e n to b a rb ita l, or s o d iu m a m y lo b a rb ita l - is d is s o lv e d in w a te r to f o rm the Peaceful Pill. In all o f the di-substitution reaction s an d in the con den satio n w ith u rea, it is essential that there be a b s o lu te ly n o w a te r present. C are m u st be taken to en su re n o atm o sph eric m oisture reaches the au to clav e o r reactor vessel. All su b sta n c e s u sed m u st b e dry. In particular, th e alcohol u sed in the production o f the so d iu m eth o x id e needs to b e as d ry a s possible (su p e r dry).


E q u ip m e n t In th e original p roject, the p e rio d o f p ro lo n g e d reflux w a s carried o u t u sin g a tw o-litre glass reaction vessel w ith three Q uickfit tap er n e c k s (2 4/2 9), fitted w ith an efficient double surface c o n d e n s e r (F ig 16 . 1). A heating m an tle a n d a m e a n s o f stirring th e m ix tu re an d m o n ito rin g th e tem p eratu re w e re also required. T o p rotect the reacting sub stan ces from atm ospheric m o istu re, calciu m ch lo rid e g u a rd tubes w e re used. T o rem o v e ex cess alcoh ol in the final stage, the d o u b le-su rface condenser w a s attach ed to th e rea c to r vessel b y m e a n s o f a distillation head. T h e alcohol that w a s d istilled w a s co llected in a glass receiv in g vessel that w a s also fitted w ith a calcium chloride g u a rd tub e (F ig 16.5). An accu rate chem ical b alance, cap ab le o f m easu rin g to 0 . 1g, w a s req u ired to w e ig h o u t the necessary reactants. In th e s u b se q u e n t ‘S in g le S h o tʼ p roject, a sp ecialised stainless steel p ressu rised reaction v essel (a u to c la v e ) w a s em ployed. T h is rep laced the g lassw are an d th e reflux co nd en ser. T his sealed stainless steel vessel (autoclave) a llo w e d th e reaction to take p lace u n d e r pressure, sh o rten ed reaction tim e an d reduced the p ro b le m o f co n tam in atio n from atm o sp h eric m o istu re (F ig 16.2). P ressu re w a s read d ire ctly fro m th e g a u g e w i th the tem perature in th e reaction vessel read v ia a th erm o c o u p le (w ith an in frared th e rm o m e te r used as backup). To re m o v e th e substituted m alonates from the reaction vessel a c o n d e n s e r w a s e m p lo y e d . T h is w a s m ad e from stain less steel tu b in g s u rro u n d e d b y a w a te r ja c k e t. C o n n e c te d to a receiving vessel o f stainless steel this w a s th en v e n te d u sin g a calcium chloride g u a rd tub e an d p laced u n d e r red u ced pressure in the distillation p ro c e ss u sin g a w a te r tap v a c u u m attachm ent.


T h e setup o f the g lassw are fo r reflux u s e d is s h o w n in Fig 1 6 .1. N o te : th e presence o f th e g u a rd tub e on th e to p o f th e reflux condenser. T h e d istillatio n se tu p is s h o w n in F ig 16.3. T h e single shot eq u ip m en t is sho w n in F ig 16.2. T h e distillation set-u p s h o w n in Fig 16.4

S p ecia l D an gers A s w ith all chem ical pro cesses, care a n d attention to detail w a s n eeded at all times. T h e equ ipm ent w a s clean an d d ry before use. M a n y o f the liquids used in the syn th esis w e re fla m m ab le and n a k e d flam es w e re n o t used. H eating o f the reaction vessel w a s b y w a y o f an electric hotplate. T h e m o st d a n g e ro u s substances u s e d in the p ro c e ss w ere m etallic sodium an d th e s tro n g ly basic in te rm e d ia ry so d iu m etho x id e. S ta n d a rd org an ic c h em istry tex ts (eg. S o lo m o n s & Fryhle, 2 0 0 4 ) spell o u t th e d a n g e rs o f h an d lin g these s u b sta n c e s . C A U T IO N : S o d iu m m u s t be han d led w ith g reat c a re an d u n d e r no c ircu m stan ces s h o u ld th e m etal b e a llo w e d to c o m e into contact w ith w a te r a s an e x p lo sio n a n d fire m a y result. S od ium is sto red u n d e r paraffin o r x y len e an d sh o u ld on ly be handled w ith tongs o r tw eezers, n o t with fingers. Sm all w a ste o r scrap p ieces o f so d iu m can be d isp o sed o f by placing them in a bottle containing large quantities o f m ethylated spirits. T h e co m m ercial so d iu m is c o v e re d w ith a n o n -m e ta llic crust. A so d iu m p ress can be c o n stru cted to re m o v e this an d produce clean so d iu m w ire fo r the reaction vessel. S e e ‘B etty cooks w ith S o d iu m ʼ F ig 16.6).


P recu rso rs The list o f n ecessary p recu rso rs (w ith th e ir C h em ical A bstract S ervice num b er, ‘C A S N o . ʼ) includes th e follow ing: D i-ethyl m alon ate C A S N o : 105-53-3 Alkyl sidechains: a ) E thyl brom ide C A S N o : 74-96-4 an d b ) 1 -b ro m o -3 -m eth ylb utan e C A S N o : 107-82-4 or c) 2-B r o m o p e n t a n e C A S N o : 107-81-3 Catalyst S o diu m ethoxide C A S N o : 141-52-6 or S o diu m m etal C A S N o : 7440 -23 -5

& A b so lute alcohol C A S N o : 64-17-5 U rea C A S N o : 57-13-6

The P eaceful Pill

Fig 16.1: Reflux system used for barbiturate synthesis


N o n e o f th e c h e m i c a l s r e q u i r e d a r e s u b j e c t to s p e c i f i c g o v e rn m e n t restriction. A pplication to a rep u tab le chem ical s u p p lie r for ethyl m a lo n a te an d the c h o sen sid e-ch ain alkyl b ro m id e s is g e n e ra lly s u ccessfu l p ro v id e d o n e can detail a legitim ate p u rp o se in th e re q u ire d e n d -u se r statem en t. S om e e n d e a v o u r m a y be req u ired to o b tain the so d iu m m etal an d dry ethyl alcohol. A lternatively, th e catalyst so d iu m eth o x id e can b e purchased. A u th o r s ' n o te - th e ch e m ic a ls req u ire d to m a k e a P e a cefu l P ill m a y b e c la ssified a s 'p r e c u rs o rs ' f o r th e sy n th e sis o f a restricted su b sta n ce. P o ssessio n o f sig n ific a n t q u a n titie s o f th e se item s m a y b e a n in d ic ta b le o ffe n c e a n d c o u ld resu lt in sig n ifica n t pen a lties.

A c q u ir in g N ecessa ry E q u ip m en t L ab o rato ry g lassw are is b ec o m in g increasingly h a rd to obtain. T h is is a reactio n on the part o f th e authorities to the existence o f c la n d e s tin e la b o r a to rie s th a t m a n u f a c tu r e illegal d r u g s ( p r e d o m in a n tly a m p h e ta m in e s ) f o r c o m m e r c ia l g a in . T h e aw ard-w inn ing T V series ‘B reaking B a d ’ is an excellent exam ple o f w h a t can o c c u r in th e dark u n d erw o rld o f b lack m ark et drugs. S o m e o f th e chem ical te c h n iq u e s used in the sy n th esis o f a P eaceful Pill are the s a m e as those u sed to m ak e illicit drugs. T h e syn th esis in E xit's p ro je cts req u ired a p ro lo n g e d p erio d o f reflux (F ig 16.1). A glass reaction vessel w ith 3 Q uickfit taper necks (2 4/29 ), fitted w ith an efficient d o u b le su rfa c e c o n d en ser w a s needed. A heating m an tle an d a m e a n s o f stirring the m ixture a n d m o n ito rin g the tem p eratu re w e re a lso used. T o p ro tect the reacting substances from atm ospheric m oisture calcium chloride g u a rd tu b es are needed. T h e d o u b le surface c o n d e n s e r can be attach ed to th e rea c to r vessel b y m e a n s o f a d istillation head.

The P eaceful Pill

Fig 16.2: The ʻSingle Shot’ Auto c lave A: Pressure Gauge B: Distillation coupling C: Pressure coupling D: Pressure safety valve E: Heat + Stirring F: Thermocouple G: IR thermometer patch Fig 16.3: Autoclave pressure head Fig 16.4: Vacuum distillation setup A: Autoclave B: Heat + Stirring C: Condenser water jacket D: Calcium chloride guard tube E: Vacuum line F: Collection vessel


Fig 16.5: Glass distillation system

Fig 16.6: Single Shot on YouTube

The P eaceful Pill

A glass receiv in g vessel, fitted w ith a calciu m chloride g uard tu be, is n eed ed to c o llect th e distillate (F ig 16.5). A n accu rate chem ical b alance cap ab le o f m e a s u rin g to 0.1 g is required in o r d e r to w e ig h o u t th e ne c e ssary reactants. D istributors o f this sp ecializ ed g lassw are (eg. reactio n vessels w ith Q uickfit n e c k s, d o u b le -su rfa c e c o n d e n s e rs , distillation heads, g u a rd tubes etc) are often req u ired to in fo rm authorities o f ‘su sp icio u sʼ p u rch ases. F o r this reaso n it can be helpful to k n o w so m e o n e w h o h as access to lab o rato ry g la ss w a re an d g lass-b lo w in g skills. The m a n u factu re o f s p e c ia lis e d e q u ip m e n t in stain less steel a v o i d s s o m e o f t h e s e d i f f i c u lt i e s . T h e s t a i n l e s s r e a c t io n autoclave u sed in the ‘Single S h o tʼ p rocess h as been adapted from a coffee pot. T h is m eth o d h as since b een m o dified as p ro b le m s w ith th e p ro cess w e re realised. T h e eq u ip m en t now u s e d consists of: a stainless steel pressure rea c to r vessel w ith p ressu re an d tem peratu re m o n ito r an d stirring facility a stain less c o n d e n s e r u s e d for reflux an d s o lv e n t extraction a stainless re c e iv in g c o n ta in e r fitted w ith calciu m chloride g u a rd tubes

The P eaceful P ill H andbook S tages in B a rb itu ra te S yn th esis T h e re are three b a sic step s in the sy n th e sis o f a barbiturate P eaceful Pill: S tep 1: A ttach in g the first sidechain to th e di-ethyl m alo nate S tep 2: A ttach in g th e s eco n d sid ech ain to th e p ro d u c t o f s te p 1 S tep 3: C o n d e n s in g th e d i-su b stitu ted m a lo n a te w ith urea to fo rm th e req u ired barbiturate L o o k in g at th e se steps in m o re detail S te p 1 In th e case o f th e targ et b arb itu rates, N e m b u ta l o r A m y tal, th e first sidechain to be attach ed to th e di-ethyl m alo nate is an ethyl halide, u s u a lly ethyl b ro m id e is u sed . T o form the mono-substituted m alonic ester, ethyl b ro m id e is h eated w ith the di-e thyl m alon ate in th e p resen ce o f th e required catalyst - the b ase, so d iu m ethoxide. T h e cataly st m a y be p u rch ased o r m ad e a s part o f th e process. T o m a k e th e required eth o x id e ad d 5.7g o f m etallic so d iu m that h as b een c le a n e d b y p a s sin g th ro u g h a p ress - see ‘B etty cooks w ith S o d iu m ʼ - an d 125ml o f v ery d ry alcohol. Into this m ixture o f d ry alcohol an d sodium ethoxide add 38ml o f di-ethyl m alo nate an d 2 6 g o f b ro m o eth an e. H eat is app lied and th e m ix tu re stirred using a m ag netic stirrer. In an o p en system a reflux c o n d e n s e r m u st be fitted an d a calcium chloride guard tu be u s e d to ensure n o co n tam in atio n b y atm o sp heric m oisture.

Note: Super Dry Alcohol A lcohol (ethan ol) o f th e req u ired d ryn ess can be m a d e using m ethylated spirits a s the starting point (9 5 .6 % alcohol). Absolute ethanol (> 9 9 .5 % ) is o b tain ed b y heating this u n d e r reflux with

The P eaceful P ill dry (recen tly fired) calciu m oxide. T o sign ificantly im p ro v e th e y ield in the sy n th esis o f barbiturates, even d r y e r alcohol is required. T o rem o v e m ore o f th e w ater, th e re b y converting th e 9 9 .5 % eth an o l to ‘s u p e r d r y ʼ alcohol (> 9 9 .8 % ), use 5 g m o f m a g n e siu m tu rn in g s w ith 0 .5 g m o f iodine in a b oilin g vessel. L e t th e m a g n e s iu m react w ith ~ 5 0 m l o f th e 9 9 .5 % ethanol p ro d u cin g h y dro gen an d m a g n e siu m ethanolate. W h e n all o f the m a g n e siu m h as b een c o n su m e d , th e re m a in d e r o f the ab solute alcohol is add ed, refluxed for 30 m in u tes, a n d d istilled directly into th e plan n ed storage vessel. T h e resultin g ethanol sh o u ld be b e tte r th an 9 9 .9 5 % . S ee th e V id eo ‘M a k in g s u p e r d ry alc o h o lʼ.

Step 2 S o diu m eth o x id e catalyst is again n eed ed in th e reaction vessel, and this tim e 4 7 g o f th e m o n o su b stitu te d e s te r fro m S tep 1 is co n v erted to a d i-su b stitu ted este r b y reflux (or reaction in an a u to clav e) w ith th e s e c o n d s id e chain. F o r th e sy n th e sis o f A m ytal, this s eco n d sidechain is l-b r o m o - 3 m e th y lb u tan e. In th e case o f N e m b u ta l, it is 2 -b ro m o p en tan e, in each case 38g is required. A t the en d o f this sta g e the d i-su b stitu ted m a lo n a te is rem o v ed again b y v a c u u m d istilla tio n . T h i s is 3 - m e th y l- b u ty l- e t h y l m a lo n ic este r in the c a s e o f A m y tal syn th esis; 1-m ethyl butylethyl m alo n ic este r i f N e m b u ta l is b e in g m anufactured.

Step 3 S o diu m etho xid e is again n eed ed in the reaction vessel. F o r this final step 5 8 g o f th e d i-su b stitu ted m alon ate fro m step 2 is allo w ed to react w ith 15 g o f d ry urea that h as b een d iss o lv e d in h o t d ry alcohol. T h e m ix tu re is stirred an d h eated u n d e r reflux. A fter 4 hours, th e ex cess alcohol is b o iled o f f an d th e residue d isso lv ed in w a te r an d acidified (w ith dilute hyd roch loric acid) to p recip ita te th e insoluble b arbiturate cry stals w h ic h can be w a s h e d a n d dried.


Fig 16.7: Exit gas chromatography equipment

Fig 16.8: Vials of barbiturate solution for assay

The P eaceful P ill

T esting th e P rodu ct A s w ith an y h o m e -m a d e p ro du ct, careful testing is necessary. F ull re a ss u ra n c e can on ly c o m e fro m detailed, q uantitativ e a n a ly s is u sin g g as c h r o m a to g ra p h y a n d m a s s s p e c tro s c o p y (G C -M S ). E xit to o k p o sse ssio n o f this n e c e s s a ry e q u ip m e n t in 2008. A p a rt from th e ability to test the p ro d u cts o f h o m e synthesis, the eq u ip m en t is useful in verifying th e veracity o f o ld sto ck s o f p rescrib ed b arbiturate sleeping tablets, o r s a m p le s o f veterinary N em b u tal that h av e b een p u rch ased f ro m d u b io u s so urces or h av e lon g past th eir q u o ted s h e lf life. Finally, the Exit Barbiturate Test Kit can be u s e d to dem onstrate the presence o f synthesised barbiturate. In addition, the purity o f dried barbiturate crystals can b e tested u sin g a glass capillary in an oil bath. F o r N e m b u ta l, th e m elting point s h o u ld b e 129°C. D etailed instructions on th e u se o f the N e m b u ta l m e ltin g point test will be p ro v id e d in future e d itio n s o f the eH a n d b o o k.

17

The Swiss Option In tro d u ctio n T h e r e is o n l y a h a n d f u l o f p l a c e s in t h e w o r l d w h e r e Voluntary E u th an asia an d / or A s sis te d S u ic id e is cu rren tly legal. In the US, citizens an d residents o f th e sta te s o f O re g o n an d W ashin gton w h o qualify, can o b ta in a p re sc rip tio n fo r the lethal d ru g N e m b u t a l . T h e state o f M o n tan a is d u e to suit with sim ilar legislation. In these states, however, a doctor cannot p ro v id e m o re assistance than this, w ith voluntary euthanasia rem ain in g illegal. It is so lely P hysician A ssisted D y in g (PAD) o r Physician A ssisted Suicide that is legal (see K illin g M e Softly: V E a n d th e R o a d to th e P e a ce fu l P ill f o r m o re d iscu ssio n o f the difference b etw een V E , PAD o r PAS). To m ak e u se o f O rego n o r W a sh in g to n 's D eath w ith D ignity laws, how ever, a p erso n m u s t be a resid en t o f that state an d be able prove this w ith su itab le d o cu m en ts. It is not en ough to be a C alifo rn ian . Rather, th e law is o n ly open to ‘tru e ʼ O reg o n ian s an d W ash in g to n ian s respectively.

The Sw iss Option

In th e N e th e rla n d s, the Term ination o f L ife o n R e q u e st a n d A s s is te d S u ic id e A c t 2 0 0 2 a llo w s v o lu n ta ry e u th an asia, but th ere are strict resid en tial re q u ire m e n ts . In th is cou ntry , a p erso n w a n tin g to m a k e use o f the law m u st satisfy m edical requirem ents an d h av e a lo n g -sta n d in g relationship w ith a D utch d o cto r. T h is effectively restricts th e u se o f th is e u th an asia law to D utch citizens. In B elgium a n d L u x em b u rg , w h e re v o lu n ta ry eu than asia w a s legalized in 20 0 2 an d 2 0 0 9 respectively, th e person m u s t be a citizen o f that country.

S w itzerla n d - L a w s a n d L oo p h o les In S w itz e rla n d , a s sis te d s u ic id e is a llo w e d b y law as long as the person p ro v id in g th e assistan ce h as no selfish motive. Im portantly, the person receiv in g th e assistance d o e s n o t need to b e a S w iss citizen. G iv e n that v o lu n tary euth an asia rem ains illegal in Sw itzerland, it is interesting that S w iss law has allowed assisted suicide since the 1940s. In S w itzerland, the penal cod e states that ‘a person w h o , for selfish m o tiv es, p e rsu a d e s o r assists an o th e r p erso n to co m m it suicide will be p u n ish e d w ith im p riso n m en t u p to five y e a r s .ʼ P eople o th er than th e ‘selfishʼ, c o m m it no crim e in assisting others to suicide. It is n o t s u rp risin g , then, to find that S w itz e rla n d h arb o u rs several right to d ie o rg an izatio n s each o f w h ic h h ave th eir ow n m e m b e rsh ip s an d differing m o d u s operandi. Such g ro u p s in clu de th e little-know n E x i t - T h e S w iss Society for H u m a n e D yin g an d the m u ch m o re w ell k n o w n , Dignitas. D ignitas is th e m ain o rganization to accep t foreigners as clients.

The Sw iss Option

Dignitas D ignitas w as established b y L u d w i g Minelli in 1998 as a S w iss, organization.

n o n -p ro fit

Based in Zurich, Dignitas aims to p r o v id e its m e m b e r s with the option o f a dignified death. R e c o g n iz in g the lim itations

Fig 17.1: Dignitas Director, Ludwig Minelli

o f or ganizations such a s Exit D eutsche Schw eiz, w hich o n l y p ro vide their services to

S w is s nationals, Minelli has created a service that caters for an increasing d e m a n d around the world. Dignitasʼ gu ideli nes state that t h e y assist people w h o have been d i a g n o s e d with a terminal illness, an incurable disease, o r w h o ar e in a m ed ically hopeless state. S u ch people m ay have intolerable pain o r an unreaso nable handicap. A person do es not n e e d to h a v e a terminal illness to b e a ccep ted a s a client by Dignitas. Interestingly, Minelli has r e c e n tl y g one furt her sug g estin g that people with mental illness s hould n ot b e automatically ex clud ed from the Dignitas service as their suffering is real and des erv es to b e ad dress ed as such.


A W ord o f W arn in g W hile th e th eo ry o f allo w in g a d e m e n tia su fferer to d ecid e on h is o r h e r o w n suicid e is o n e thing, th e reality o f d o in g this is q u ite different. S uicide by the m en tally ill, n o t sim p ly those affected by d isea ses such as A lz h e im e r's , is a n area fraught w ith danger. T h e re is n o b e tte r e x a m p le o f w h a t can go w ro n g than th e 2 0 0 8 case o f S y d n ey Exit m em b ers, S hirley Justins an d C a re n Jenning. In O c to b e r 2 0 0 5 , d e m e n tia su fferer G ra e m e W ylie ap p lie d to u se the D ig n itas service to die. D ignitas c o n ta c te d the au th o r to r e v ie w G ra e m e . In o u r report w e m a d e cle a r that although G ra e m e suffered from ‘significant dem entia, he retain ed insight into h is condition. O n e m on th later, how ever, D ignitas w o u ld reject G r a e m e 's app licatio n, say in g they h a d con cern s about his capacity. W h ile the organization s y m p ath ized with h is w ish to p u t an en d to h is suffering, they w e re u n c o n v in c e d that he had th e ability to m ak e a clear a n d co n sisten t decision in reg ard to his o w n death. U pon rejection from D ig nitas, G r a e m e 's frien d o f 30 y e a r s C a re n J e n n in g - trav elled to M e x ic o in search on N em butal. U p o n h er retu rn to A u stralia C a re n J e n n in g g ave G r a e m e 's p a rtn e r o f 19 y e a r s , S h irle y J u s tin s , a b o ttle o f N e m b u ta l. Later that w eek , S hirley Justins g av e the bottle o f N e m b u ta l to G ra e m e W ylie, saying ‘i f y o u d rin k this G ra e m e y o u w ill d i e . ʼ A fter an inv estigatio n o f s o m e 18 m o n th s, a n d a court case lastin g s e v e n w e e k s , in J u n e 2 0 0 8 th e w o m e n w e r e fo u n d g uilty o f th e m a n s la u g h te r a n d ac c e sso ry -b e fo re -th e fact o f m a n sla u g h te r respectively, o f G ra e m e Wylie.

The Sw iss Option

T h e co u rt d e te rm in e d that b e c a u s e o f his dem entia, G ra e m e W y lie lacked the cap acity to m a k e the d ecision to die. H e did n o t therefore suicide, rather he w a s m urdered. (S h irley Justin h as since h a d an appeal ag ainst the v erdict an d se nte nce upheld. H o w ev er, by th is tim e s h e h ad s e rv e d h e r entire cu sto d ial sen tence o f w e e k e n d detention for 18 m onths. In m id 2 0 11, the Public Prose c u t o r de cid ed ag ainst a retrial. C a r en Je n n i n g d ied o f a N em b u tal ov erd ose befo re sen ten cin g in S e p te m b e r 2008). I f D ignitas d oes reject a client on the b asis o f a lack o f capacity, th a t p e rs o n a n d th e ir fam ily n e e d to b e v e ry carefu l about alternative strategies. T h e D ign ita s Process A s those w h o h av e u sed th e D ignitas service h av e discovered, n o thin g h ap p en s quickly. T h e S w iss are, rightly, v e ry particular. T h is is w h y it is b e s t to app roach D ignitas well a h e a d o f the date o f a p e rc e iv e d need. T h e ap plication p ro c e ss for D ignitas can b e leng thy an d draw n out. T h e first s te p to u s in g th e D ig n ita s s e r v ic e is to jo in th e organization. F o r a o n e - o ff jo in in g fee o f E uros 50 an d a yearly m em b ersh ip fee o f E uros 25, a person can b e c o m e a m em ber. F ro m there the person can c h o o se to a p p ly to m a k e use o f the service at so m e tim e in the future, w h e n / i f the n eed sh o u ld arise.

Fig 17.2: The Dignitas Doorbell


You can jo in D ignitas b y w riting to th em , em ailin g o r p h o n in g (co n tact details a re given at the e n d o f this C h ap ter). W h ile a proficiency in G erm an is n o t m an d ato ry on the telephone, it will h elp w h en dealing w ith m o re c o m p lex questions. T h e D ignitas p h o n e reception do es h a v e an English la n g u a g e op tio n , b u t this c an lead to an a n s w e rin g m ach in e, d ep en d in g o n the tim e o f d ay y o u call. To m ak e an app lication to D ignitas, there is a form idable list o f d o c u m e n ts required. To be c o n s id e re d b y D ign itas, y o u m u s t h a v e h ad y o u r illness fu lly investigated, d ia g n o se d and re co rd ed an d an official m ed ical case h isto ry c o m p ile d in y o u r h o m e country. D o cu m en ts w h ic h m a y b e required b y D ignitas u p o n application include: • B irth c e rtificate (issu e d in past 6 m onths) • Passport • M a rria g e certificate (issu ed in p a s t 6 m onths) • M edical re c o rd s (tests an d results) • M ed ical specialist repo rts • G eneral P ractition er m ed ical reports • C u rre n t local g o v e rn m e n t rates n o tice (to p ro v e place o f resid en cy ) • C urrent drivers license • Statem ents fro m fam ily m e m b e rs (children, grandchildren) To a p p ly to u se the D ignitas service, a client needs to com plete th e ap plication fo rm an d fo rw ard this, along w ith c o p ie s/ and o rig in als to the D ignitas office in Zurich.

The Sw iss Option

N o te - S w is s a u th o ritie s in s is t th a t a t le a s t s o m e o f th e se d o c u m e n ts a re c e r tifie d extra cts, a n d s o m e m a y n e e d to b e w itn e sse d b y a J u s tic e o f th e P e a ce o r P u b lic N otary. O thers m a y n e e d to h a v e b een is s u e d w ithin th e la s t 6 m onths. B e p r e p a r e d to d o a f a i r b it o f r u n n in g a r o u n d to g a th e r th e p a p e r w o r k together. U p o n receipt o f this ap plication form , D ig n itas re v ie w s each ap p lic a n t's situation. I f d e e m e d suitable, a pro visio nal letter o f acceptance will be m ailed to the client (ca lle d th e ' green light'). It is at this point, p lan s for travel to Z u rich can be m ade.

U p on A rriv a l in Z u rich U p o n a rriv al in Z u r ic h , th e c lie n t c o n t a c t s D ig n ita s. An ap po intm en t is then m ad e w ith one o f a n u m b e r o f consulting p h y s ic ia n s w h o w o r k in co n ju n ctio n w ith th e o rganization. T h e se m ed ical do cto rs are in d ep en d en t o f D ignitas a n d w ork from th eir o w n room s.

Fig 17.3: The Dignitas House in Zurich


T h e re is a d etailed m e e tin g w ith th e con su ltin g d o c to r an d the m ed ical re c o rd s are re -e x a m in e d (also by a s e c o n d doctor). If relatives o r loved o nes h ave acco m p an ied the clien t to Dignitas, th e d o c to r m a y w is h to in terv iew th e se fam ily m e m b e rs and/ or friends as well. D o n ’t be s urp r is e d i f y o u are interview ed together, then individually, then to g eth er again. O n c e the m ed ical consultation h as taken place a n d i f the d o cto r is satisfied, a p rescrip tio n for p en to b arb ita l w ill b e w ritten. T h e d ru g is n o t h an d ed o v e r to th e client at th e tim e o f the co n su ltatio n w ith th e doctor. Rather, ap p ro v al at this stage m e a n s th a t th e final ap p o in tm en t - th e tim e w h e n th e death can take p la c e - is then a b le to be m ad e. T h e d o c to r ’s approval m e a n s that th e d rug will be av ailab le for co n su m p tio n by the client at th e D ignitas h ouse on th e chosen day.

T h e F in al A p p o in tm e n t T h e final ap p o in tm en t is held at the D ignitas house in an o u ter s u b u rb o f Zurich. T his ap p oin tm ent can take p lace quite qu ickly after the m edical review, so m e tim e s th e fo llo w in g day. T w o D ig n itas s ta f f will b e present. A third m e m b e r o f th e D ignitas team m a y arrive d u rin g the ap p o in tm en t a n d d e liv e r the d ru g s that will be used.

The Sw iss Option

The Drugs A s is th e c ase in all places (N etherlan ds, B elgium , O regon) w h e re a ssisted suicide o r v o lu n tary e u th an asia is legal, the drug th a t is u s e d at D ignitas is pentobarbital sodium (N em butal). A prescription will h av e b een w ritte n o u t fo r this d rug b y the con sultin g d o cto r w h o s a w the client. T h e p rescriptio n w o u ld h ave b een tilled on y o u r b e h a lf by D ignitas s ta f f It is th e D ignitas s ta f f w h o bring the N e m b u ta l to th e house for th e final ap p ointm ent. A t th e ap p o in tm en t, s ta f f dissolve the pentobarbital so d iu m p o w d e r in w a te r to form a drink. T his is d o n e w h en the person indicates that it is th eir w is h to g o ah ead w ith th eir death. The Pentobarbital u s e d b y D ignitas is th e s o lu b le so d iu m salt and 15gm are d isso lv ed in ~ 5 0 m l o f w a te r ju s t befo re use. The concentration o f N em butal in th e liquid co n s u m e d is 300m g/m l.

Fig 17.4: One of two rooms at the Dignitas House


T h e a m o u n t co n s u m e d is ~ 50 m ls w h ic h is no m o re than a few m outhfuls. N ote: T h is d ose differs significantly in concentration from the sterile v eterin ary anaesthetic N e m b u ta l. A naesthetic N e m b u ta l h as a co n centratio n o f 6 0 m g /m l, about 5x w e a k e r than that used by Dignitas.

D y in g at D ignitas O n c e th e c lie n t a n d th e ir f a m ily a n d frie n d s a r r iv e a t th e D ignitas house fo r th e final ap po intm en t, a few further tasks m u s t be atten d ed to. Firstly, additional legal p ap erw o rk m u st b e c o m p le te d c o n c e rn in g in fo rm e d co n s e n t, p o w e r o f attorney an d fo rm s to release th e body. T h is final h u rd le clears th e w ay f o r the death to take place. At this tim e, th e clien t read s, a p p ro v es a n d o n c e m o re signs p ap ers indicating th a t th e y k n o w w h a t th e y are a b o u t to do a n d in d ic a tin g th a t th e y a re a c tin g o f th e ir o w n fre e will. T h e ir signature is w itn essed b y those present. F o llo w in g the p ap erw o rk , th e D ignitas s ta f f explain th a t the person can o p t out o f the p rocess at an y tim e. T h e client is a sk e d i f t h e y 'd p refer to s ta y seated a ro u n d th e table o r i f th e y ’d like to lie dow n. E ith er w ay, it is th e client w h o d e te rm in e s w h a t h ap p en s and h o w it happens. T h e D ignitas ro o m s are bright, airy w e lc o m in g ro o m s. T h e y are d eco rated in w arm colo urs. T h e re is a co ffee m a c h in e and C D p lay er fo r those w h o w is h to h av e m u sic. A n d in case you fo rg et to bring y o u r o w n m usic, there is even a D ignitas C D com pilatio n o f well k n o w n relax in g p o p u la r m u sic, in case you feel that m u sic m ig h t be a v alu ab le last m in u te addition. I f th e clien t w is h e s to g o ahead , th e s ta f f then set u p a video

The Sw iss Option

re c o rd e r on a trip o d in the c o m e r o f th e ro o m . All p roceed ing s from this point on w ill be reco rd ed . T h is is do n e to provide evidence about the death i f questions are asked as to its voluntary nature. A fter th e death, th e police m a y v ie w th e tape to ensure that n o pressure o r coercio n to ok place. W ith the c a m era rolling th e clien t is then given access to th e first o f tw o drugs. T h e first d ru g is an an ti-em etic (a n ti-v o m itin g d ru g ) an d is taken in the form o f a small drink. T h e d rug p ro v id e d is m eto clo p ra m id e (see C h a p te r 8). T h is dru g is ta k e n as a stat dose. T h e D ignitas s ta f f p lace th e g lass on th e table a n d th e client can re a c h fo r the glass a n d take th e d ru g i f they w ish . A fter this d rug is sw allow ed , a h a lf an h o u r is n eed ed for it to take effect befo re proceeding. T his tim e can be very stressful and th e D ignitas s ta f f are skilled in p ro v id in g a calm en v iron m ent for th e client a n d o thers w h o m a y be present. W h e n th e tim e h as p assed, th e client is then g iv e n access to the N em butal. O n ce again, the D ignitas s ta f f ask i f the clien t w ishes to proceed, re m in d in g th em that th ey can still o p t out o r change th eir m ind. I f th e clien t w a n ts to p ro ceed , the s ta f f p lace the small glass o f th e pentobarbital sodium solution on the ta b le. In J a n u a ry 20 0 7 , th e au tho rs a c c o m p a n ie d U S -born, S ydn ey doctor, John Elliott, to the D ignitas clinic. D y ing o f m ultiple m y e lo m a (a c a n c e r o f the bo n e m arrow ), this 7 9 -y ear o ld m a n 's last w e e k s h ad been a n ig h tm are an d he w an ted release from h is suffering. Joh n w a s v e ry keen to find peace. W h e n p resen ted w ith the g lass o f N e m b u ta l, he re a c h e d for it quickly. H o w ev er, John had a pro b le m w ith gastric reflux, a condition a sso ciated with th e palliative radiation therap y he h ad u n d erg o n e s o m e w eeks earlier.


A fraid that h e w o u ld v o m it, J o h n n eed ed som e re a ssu ra n c e and w as pleased w h en he w a s able to c o n s u m e th e 5 0 m l drin k w i t h little d ifficu lty . P rep ared fo r a bitter a fte rtaste, he finished the Nembutal, saying ‘that d id n 't taste too b a d .’ Because

John's

fa v o u rite d rin k w a s Fig 17.5: Dr John Elliott and his wife Angelika in Switzerland shortly before his death

cognac, everyone sh ared his final moments with a

toast. N o t only d id the c o g n a c take a w a y th e d r u g ’s after-taste, it m ad e th e N e m b u ta l w o rk faster. We clin k e d g lasses and, w hile h is w ife A n gelik a held him , John n o d d ed peacefully o f f to sleep. Jo hn Elliott died w ithin th e hour. J o h n 's jo u r n e y h as been cap tu red in a short film called ‘Flight to Z u r ic h .’ See: http://www.youtube.com/watch?v=1j4c6aVFfUk

A fte r i t ’s O ver After about an hour, one o f the Dignitas staff m em b ers perform ed several sim ple tests to confirm death. O n ce this w a s established, th e s ta f f called the police w h o arriv ed w ith a m edical d o cto r and an officer fro m the C o r o n e r 's d ep artm en t. T h e funeral hom e w a s also co n tacted a t this tim e. In all deaths, th o se p re se n t are

The Sw iss Option asked to leave the ro o m w h ile th e d o cto r ex am ines the bo d y , The p o lice m a y v i e w th e v id e o tape o f th e death an d in terv iew those p resen t a b o u t the n atu re o f th e death. W a s th e death peaceful? W as it v o lu n ta ry ? D id it go acco rd in g to the p e r s o n 's w is h e s? O nce all questions are answ ered an d the officials are com fortable, th e fam ily an d friend s o f the d ec e a se d person can leave. The b o d y is then re m o v e d to th e funeral hom e, in preparation for eith er crem ation o r tran sp ortatio n b ack to th e p e r s o n ’s country o f origin.

D ign ita s a n d th e S w iss L a w W h ile the statistics te n d to vary, D ignitas s ta f f confirm that a ro u n d 3 0 0 p eo p le u se th eir a ssisted su icide serv ice each year. Well o v e r h a l f o f th e se p e o p le are from co u n tries o th er than Sw itzerland.

Fig 17.6: John Elliott on arrival at Zurich Airport


A lthough there have been a handful o f situations w h e re a client's f a m ily has b e c o m e d isg ru n tled w ith D ignitas (these c ases have b een reported at length in the international m edia), m o s t people are grateful to L u d w ig M inelli an d h is c o m p a ssio n a te team o f w o rk e rs w h o m ak e th is ch o ice in dignified d ying possible. I f y o u are th in k in g a b o u t u sin g the D ignitas service, there are several p o ints to note. Firstly, it is im p o rtan t to u n d e rsta n d that D ignitas doe s not provide voluntary euthanasia. S w iss law doe s n o t a llo w a d o c to r to a d m in ister a lethal injection to a client. T h e client m u st be able to act fo r th e m se lv e s an d c o n s u m e the lethal dru g unassisted. T h is m e a n s th a t u n less a person is able m o v e th eir a rm s to lift the g lass to th eir lips, o r s u c k on a straw, o r sw allow , o r e m p ty the dru g into th eir o w n sto m ach ' p e g ', th en D ignitas is n o t th e service for them. R em em ber, at D ignitas th ere is no d o c to r present a t the death. O n c e a person h as b een a c cep ted b y D ignitas, this is very m uch a D IY m o del o f operation. Interestingly, D ig n itas F o u n d e r L u d w ig M inelli - h as a p ro fessio n al b a c k g ro u n d in law n o t m edicine. D ignitas p rovides a s de-m edicalised a m odel o f dying a s S w iss law w ill allow. F in a lly , D ig n ita s is u n iq u e in t h a t it r e p r e s e n t s th e o n ly legal o p tio n fo r dignified d y in g f o r p eo p le livin g outside o f ju risd ic tio n s w h e r e v o lu n tary e u th an asia a n d a ssisted suicide are legal. In E x it's o pin io n th e p op ularity o f th e serv ice is likely to con tin ue, alth ou gh the d istan ce those suffering m u s t travel en s u re s that D ignitas will n e v e r be first ch o ice fo r those in the so uth ern hem isphere.

The Sw iss Option D ig n ita s’ F u tu re In M arch 2011, the g o o d p eo p le o f th e C an to n o f Z u rich w en t to referen d u m to d ecid e i f the D ignitas serv ice sh o u ld be able to con tin ue accep tin g foreig n ers as clients. D e s p ite g r a v e fears, th e p o p u la tio n v o te d o v e r w h e lm in g ly (78 % ) to m aintain the statu s q u o allo w in g foreigners access to S w itz e rla n d 's assisted su icid e services. M edia re p o rts a b o u t this p o sitiv e d e v e lo p m e n t can b e found at: http://w w w .bbc.co.uk//n e w s /w o r ld -e u r o p e -13405376 h ttp ://b it.ly/lc p jp b

D ign ita s C osts A t the c u rre n t tim e, th e D ignitas o rganization charges a o n e - o ff jo in in g fee o f ap p ro x im a te ly E uros 50 an d an annual m e m b e r contribution o f at least Euros 25. T h e current cost o f the Dignitas service is a ro u n d E uros 6000.

D ign ita s C o n ta c t D etails A ddress: P O B ox 9, C H 8127 Forch, S w itzerlan d T elephone: 0 0 1 1 41 4 4 9 8 0 4 4 59 F ax : 0 0 1 1 41 4 4 9 8 0 14 21 E m ail: d ign itas@ d ign itas.ch W ebsite: http://w w w .d ig nitas.ch

18

After it’s Over

Introd u ction F o r th o se left b eh in d , th e p e rio d im m ed iately fo llo w in g the death o f a loved o n e can b e an intensely sad an d stressful time. A n e le c te d death - a rational su icide - can p re se n t an additional an d u n iq u e set o f circum stances. O n the one hand, fam ily an d friends m a y be eno rm ou sly relieved that th eir loved o n e w a s able to d ie peacefully an d w ith dignity. O n th e o th er hand, there m a y b e feelings o f re se n tm e n t, even a n g e r that th e person th ey loved h as c h o sen to leave them . W h ile it is o n e th in g to k n o w th a t a p erso n y o u love is about to d ie b y their o w n hand, it is an o th e r to be able to p red ict how this will m a k e y o u feel. T h e re w ill a lso b e a n u m b e r o f practical issues that those left b e h in d h ave to confron t. In th e case o f a well p la n n e d death, s o m e o f th e se w ill h a v e b een d iscu ssed before th e death. For exam ple, w ill an y o n e b e respo nsib le for clearing a w a y an y used e q u ip m e n t fro m th e scene o f d eath ? A n d w h a t about a suicide note? W h o w ill k eep h o ld o f it, sh o u ld o n e be required?

A fter it's O ver

T h e n there is the issu e o f h av in g th e death certificate signed, an d w h e th e r o r n o t an a u to p sy w ill b e c o n d u cted . W ill there will be a coronial investig ation ? M a n y o f th e se issues can be an ticip ated a n d p rep ared for. In this C h a p te r w e u se the real life ex am p le o f A ustralian fo rm er Q a n ta s p ilo t G ra e m e W ylie to illustrate w h a t not to do w h e n so m e o n e d e c id e s to take their o w n life. W e p o in t id e n tify s o m e o f th e factors w h ic h will co ntrib ute to w a rd s a w ell p la n n e d death.

B a ck g ro u n d to G r a e m e W ylie In M a rc h 2 0 0 6 G ra e m e W ylie d ied drink in g a lethal do se o f v eterin ary N e m b u ta l that his friend o f o v e r 30 y ears, C aren Jen n in g, h ad b rou gh t back fo r h im from M exico . W h ile the p la n a n d C a r e n ’s m o tiv e f o r h e lp in g h e r o ld frie n d w e re straig h t fo rw ard , G ra e m e W y lie ’s death w a s alw ay s going to b e co m p licated . In J u n e 2 0 0 8 , G ra e m e W y lie 's p a rtn e r o f 18 y ears S h irle y Justins, to g eth er with C aren , w a s found gu ilty o f h is m a n sla u g h te r a n d a c c e s so ry to m a n sla u g h te r respectively.


G ra e m e W y lie w a s su fferin g from d em en tia, an y th in g from ‘m ild to m o d e r a t e ʼ to ‘m o d e r a te to s e v e r e ʼ d e p e n d in g on w h ich d o c to r carried out th e assessm en t. In th e co u rt case that follo w ed his death, G ra e m e W ylie w a s d e e m e d n o t to have h ad th e ‘c a p a c ity ʼ to k n o w w h a t h e w a s d o in g b y d rin k in g the N em b u tal. G ra e m e d id not, therefore, take his o w n life. R ather th e court found he w a s ‘k ille d ʼ by S h irley a n d Caren. T h e first issue that a person c o n sid e rin g taking their o w n life s h o u ld co n sid e r is w h e th e r th ey h ave th e cap acity to m ak e the d ecisio n ? W h ile th e W ylie case is an e x tre m e ex am p le, to keep loved o n e s safe th e question s h o u ld b e asked. A n o th e r sensible step is to pen a suicid e n ote in o n e 's o w n hand.

T h e S u ic id e N ote I f G ra e m e W ylie had w ritten, s ig n e d an d d a te d a suicid e note stating that his actio n s w ere entirely his ow n, that he understood th e co n s e q u e n c e s o f w h a t he w a s a b o u t to d o a n d g av e the reaso ns for dying, S h irley an d C a re n w o u ld h av e been m uch less likely to h av e fo u n d th e m se lv e s in front o f a ju d g e an d jury. T h e law a ro u n d suicid e an d a ssisted -su ic id e is grey. T h o s e left b eh in d b y a death are a lm o st a lw a y s at risk o f so m e form o f inquisition from authorities. W riting a n ote an d sto ring it in a safe place o r w ith a trusted friend m a k e s a g o o d deal o f sense. In a w ell-p la n n e d death, a d o cto r s h o u ld sim p ly sign the death certificate, b eliev in g that th e death is natural a n d a resu lt o f the u nd erly in g disease. In c ases like these, th e s u ic id e no te will n e v e r be needed.

A fter it s O ver

If, how ever, like G ra e m e W ylie, th e d o c to r refuses to sign the death certificate, th e c o r o n e r is c o n ta c te d an d an a u to p sy is arranged, then this is th e tim e for th e sig n ed su icide n ote to be ‘fo u n d ʼ. In this scenario, th e su icide n ote w ill p ro vid e a very useful safeg u ard i f loved o n e s find th e m se lv e s im p licated in the death. I f on th e o th er h an d , the person tak in g th eir life d oes not care that th eir death be a kn o w n suicide, the no te can b e left alongside th eir body.

T he P rocess o f a D eath I f a death takes p la c e outside o f a hospital, h o spice o r other m ed ical institution (eg. at ho m e), it is n o rm a l practice upon ‘d is c o v e rin g ʼ th e death, that a d o cto r be called. U pon arriving at the house, the d o cto r w ill then h av e tw o options. I f th e death looks to be natural, an d th e patient h a s b een seen by th e d o cto r in the past tw o m o n th s, th e d o c to r will certify death and sign the death certificate citin g th e p e r s o n 's u nd erly in g disease as the c a u se o f death. T h e re w ill b e no red tape. The b o d y w ill be released, an d funeral a rran g em en ts can be made. If, on the o th er han d , th e d o c to r su sp ects that the death is n o t natu ral (eg. i f the death is p o ssib ly a suicid e o r i f the cause o f death is u nclear) the d o cto r can c ertify death, b u t w ill not sign th e death certificate. In this case th e d o cto r w ill call the c o ro n e r's office an d th e police w ill be involved. T h o s e close to th e d ec e a se d m a y be required to be interview ed b y the police a b o u t th eir re la tio n s h ip w ith the d e c e a s e d , a n d a b o u t th eir p o ssib le role in th e p e r s o n 's death.


I f th e d ec e a se d w a s k n o w n to b e serio u sly ill a n d i f that person h as m ad e a n effort to c h o o se a m eth o d that leaves no obvious p hysical signs, o r i f th e person a n d /o r frien ds a n d fam ily have en s u re d that an y e v id en ce o f suicide is re m o v e d from the scene, th e d o c to r w ill likely certify death a n d sign the death certificate. W h ile G ra e m e W ylie h ad dem en tia, he h ad no o th er underlying p hysical illness that c o u ld h av e e x p la in e d his c a u se o f death. H e w a s 71 y ears o f a g e an d p h y sica lly fit w h en he died. His death w a s , therefore, im m ed iately su sp iciou s. K n o w in g this in ad v an ce, C aren an d S h irley a tte m p te d to su gg est that the cause o f his death w a s d o w n to th e m ed icatio n he w a s taking, a drug called A ricep t. T h e y d id th is b y sh o w in g the atten d in g police an article from th e N e w York Times. T h e article h ig h lig h ted a link betw een A ricep t an d heart attack in dem en tia patients. T he p o lice d id n o t b u y th eir story. A t autopsy, G ra e m e W y lie 's body w a s found to co ntain lethal levels o f pentobarbital (N em butal). W h e n atten d in g a death, p o lice are usually v e ry sensitive and respectful. H ow ever, they are there to d o a j o b an d this m ay involve th e q u estio n in g o f those w h o w ere in th e house a t the tim e. T h e p o lice m a y also look at th e d eg ree o f incapacitation o f th e p erso n w h o has died. I f an o b v io u s su icid e th ey will n ote w h e th e r o r n o t the m e th o d u s e d c o u ld h av e b een carried o u t so lely b y th e individual. A n y n eed for help o r assistance to su icide is evid en ce o f a crime. I f there is an y d oubt, th e q u estio n in g o f those left b e h in d m ay intensify. T h e issu e o f w h e th e r a n y o n e w a s present w h en the su icide to ok p la c e m a y also arise. In this situation, there is no gu aran tee that legal action will n o t be taken a g a in st a person w h o a d m its to sim p ly being present, even i f th ey say th ey did n o th in g to assist.

A fter it's O ver

N ote: Police d o n o t atten d all deaths. T h e y w ill o n ly attend deaths th a t are suspicious. In recen t m o n th s, E xit h as learned o f at least tw o m e m b e rs w h o h av e d ied w h o s e fam ilies have th en been q u iz z e d by th e authorities. T h e re a so n ? T h e y w ere m em b ers o f Exit. I f th is h a p p e n s to y o u , say n o thin g on o r o f f th e reco rd a n d n e v e r s u b m it to a p o licy in terv iew u n less you have an atto rn e y present. S eek legal ad v ice im m ediately.

C lea n in g A w ay T h e re are sev eral practical steps that can be taken to increase th e lik eliho od that a death w ill be seen a s ʻn a tu ra lʼ ( i f th a t is w h a t th e d ece ase d person w ish ed ). T h e first o f th e se is the act o f cleaning up after a death. G iven that th e d eath s that w e a re talk ing a b o u t are p eaceful and dignified, the act o f clean in g u p g en erally in v o lv es the rem oval o f eq u ip m en t su ch a s an E xit B a g o r e m p ty dru g p a c k e ts from th e death scene. In s o m e situations, this can b e d o n e w ell ahead o f tim e. M an y people e n d in g their lives clean aw ay them selves. T h e y rem o v e d ru g -p ack ag in g , a n d rinse g la sse s after a lethal d ru g h as b een co n su m ed . I f this is do n e, th e atten d in g d o cto r w ill be m o re likely to assu m e that the c a u se o f death is the u n d e rly in g disease. H ow ev er, i f th e p erso n w h o h as d ie d w a s n o t k n o w n to be suffering fro m a life th re aten in g illness, th e a c t o f clean ing aw ay m a y cause m o re pro blem s. In th e case o f G ra e m e W ylie, b e c a u s e there w a s n o illness (o th er than d em en tia), th e fact that there w a s n o o b v iou s c a u se o f death on ly serv ed to h eigh ten the m y ste ry o f h o w he died?


I f G r a e m e W ylie h ad w ritte n a n o te a n d left th e b o ttle o f N e m b u ta l alo n g sid e h im , instead o f the bottle b e in g rem o v ed b y h is w ife s o it w o u ld n e v e r b e found, the p o lice w o u ld have k n o w n im m ed iately that his death w a s a suicide. I f a person en ds th eir life using an Exit B ag, then the clean ing a w a y will in v o lv e the rem o v al o f the b ag fro m the p e rso n 's h e a d a lo n g w ith th e helium c y lin d e r an d tubing. O ccasion ally at H eliu m d eath s th e b ag , g as control fitting an d tu b in g a re all that is rem o v ed . I f the b la c k an d w h ite plastic n o zzle that c a m e w ith the balloon kit is re-attached, th e cy lin d er re-b ox ed an d re-sto red in th e cup bo ard , it is u n lik ely th e c y lin d e r will be linked to the death. F o r a death to a p p e a r n o rm a l, there m u s t b e n o e v id en ce o f eq u ip m en t that c o u ld h av e been used in the suicide. W h ile som e p eo p le m ight not care w h e th e r their death is listed as ‘s u ic id e ʼ or ‘n a tu ra lʼ, th e legal risk to o thers will b e h ig h er i f it is know n a s u ic id e has taken place.

C le a n in g A w a y and th e L aw W h ile it is a c rim e to interfere w ith the ‘circu m stan ces o f a d e a th ʼ, in th e s ch em e o f th ing s it is n o t a p articu larly serious crim e. F o r ex am p le, re m o v in g an Exit b ag fro m a lo v e d o n e 's h e a d o nce th ey h ave d ie d is a v ery differen t m a tte r to helping that sam e p erso n p u t the b ag on th eir head. It is cle a rly assisting a su icide to h elp a person position a b ag on their head. In m ost w estern countries, a ssistin g a suicide is a seriou s crim e.

A fter it's O ver

If, by ch an ce, th e authorities do learn that so m e ‘c lea n in g - u p ʼ h as taken place, fam ily an d friends often explain their actions by saying th a t they w e re p ro te ctin g th e fa m ily 's reputation. T h e y say it w o u ld b e a b lem ish on th e p e r s o n 's g o o d n a m e i f their suicide w e re e v e r to be m a d e public. G en erally sp eak in g , the act o f ‘clean in g a w a y ʼ is u n lik ely to attract an y th in g m o re than a legal slap on the wrist.

D ea th C ertificates U pon a rriv in g at th e scene, the atten d in g fam ily d o cto r will p erfo rm tw o tasks. Firstly, they w ill confirm death. T h e y will do this b y carry in g out a n u m b e r o f sim p le tests to establish that th e person is indeed dead, n o t sim p ly in a catatonic o r com ato se state. H av in g c o n firm ed death, th e nex t issue is th e sign in g o f th e death certificate. T h e re are a n u m b e r o f req u irem en ts that m u st be satisfied b efo re th is can b e do n e. T w o are o f particular interest. 1. T h e d o c to r m u s t k n o w th e patient. U s u a lly th ere is the r e q u i r e m e n t t h a t th e d o c t o r h a s s e e n th e p a tie n t in a p ro fessio n al cap acity - n o t ju s t to say h ello a t th e g o l f club

2.

- in the p a s t tw o m o n th s (the tim e p e rio d varies depend ing o n th e jurisd ictio n). T h e d o cto r m u st be satisfied that th e death is natural.

T h e req u irem en t that the patient be k n o w n to the d o cto r can so m etim es c a u se difficulty. O ften, v e ry sick p eo p le h ave little contact with th e m edical profession. T h is m e a n s that finding a d o c to r w h o c o u ld ev en sign the certificate can be a problem . It m a y th erefo re be w is e to call y o u r d o c to r f o r a v isit prior to th e p la n n e d death, c o m p la in in g o f a d e v e lo p in g fev er o r b reath lessn ess, p erh ap s so m e pain on d e e p inspiration.


W h e n th e d o c to r is th en called b ack s o m e d a y s later, it w ou ld r e a s o n a b l e f o r t h e m to a s s u m e a n a tu ra l d e a th in v o lv in g p neu m on ia. S o m e p eo p le w o r r y a g reat d eal a b o u t the w a y th eir d e a th will be recorded on th eir death certificate. T h e y fe a r being kn o w n as so m e o n e w h o ‘c o m m itte d su ic id e .ʼ O th e rs h av e n o preference, say in g ‘w h o cares w h a t th ey w r ite , I ʼll be d e a d a n y w a y ? ʼ I f a person w h o is about to d ie from a term inal disease takes their o w n life, th e d e a th w ill b e recorded a s ‘su ic id e .’ I f th a t person d o e s n o t w a n t ‘s u ic id e ʼ re co rd ed on th e death certificate, they will n eed to take steps to d isg u ise the truth. A m eth o d o f death that leaves no o b v iou s signs is o f course the o n ly logical course.

D y in g w ith o u t Trace M o st d ru g s u s e d to en d life leave n o o b v io u s id entifying signs. D eath fro m sterile veterin ary N e m b u ta l is o n e ex am p le. The p erso n w ill a p p e a r a s i f th e y s u c c u m b e d to th eir c a n c e r o r heart disease. H o w ever, there is also a d y e d form o f the drug, P entobarbital (see C h a p te r 13). I f Le tho barb (the d y e d form ) is c o n su m e d , th e p e r s o n 's lips will be s ta in e d g reen ; h ence th e n am e th e ‘green d r e a m ’. G reen lips are a d ead giv eaw ay (p ard o n th e p un ) to a death that is n o t natural. A n d rem em ber, i f an au to p sy is perform ed, the pentobarbital will b e discovered. Q u estio n s a b o u t its so u rce w ill inevitably be asked. T h is is true o f an y death b ro ug ht a b o u t by a c o n s u m e d d ru g , o r an inhaled p o iso n like c arb o n m o n o x id e.

A fter it's O ver

T h e o n ly m e th o d that leav es no trace, ev en a t autopsy, is the Exit B ag w ith n itrogen (a h y p o x ic death with helium will be detectable a t au to psy). F o r th e death to be re co rd ed as natural, how ever, the bag, flo w control fitting, tu b in g an d the helium can iste r w o u ld n e e d to be rem o v ed . It can be useful i f a fam ily m e m b e r o r friend can ‘d is c o v e r ʼ the bo d y in th e m o rn in g . This p erso n w ill then be in a position to call th e fam ily d o c to r and r e m in d the d o c to r o f th e u n d e rly in g illness. O n e can also claim that e v e ry o n e in th e h ouse w a s asleep d u rin g the ev en in g w h en th e death took place.

A u to p sies I f th ere is an y d oubt a b o u t the c a u se o f death, th e d o c to r will contact the co ron er an d an autopsy m a y be arranged. An autopsy in v o lv es the dissectio n o f th e b o d y b y a path olo gist, the visual a n d m ic ro s c o p ic in sp ec tio n o f o rg an s, an d th e b io ch em ical testing o f b o d y fluids, sto m ach co n ten ts etc. At autopsy, the ex isten c e o f an y d ru g s (a n d alco h o l) in th e body will be d isco v ered . I f the d rug is u n c o m m o n o r difficult to obtain, q u estio n s w ill be a sk e d a b o u t w h e th e r o r n o t assistance w a s p r o v id e d in o b ta in in g , p r e p a r in g o r a d m in is te r in g the substance. A lth o u g h perm ission f o r an au to p sy will b e sought, an d nex t o f kin h av e the right to refuse, it is as well to re m e m b e r that refusal can g en erally be o v errid d en (d e p e n d in g u p o n th e ju risdiction ). A utopsies are generally only so u g h t i f there is a legal o r m edical m y ste ry asso ciated w ith the d eath ; that is, i f there is uncertainty a b o u t h o w o r w h y th e p erso n died. In these situations, especially i f there is th e p ossib ility o f a crim inal act (eg. assistance), the d ecision w ill be m a d e irrespective o f fa m ily w ishes.


In c ases w h e re th e death is cle a rly a suicid e, a n a u to p sy w ill n o t n ecessarily be p erfo rm ed . A u to p sies are e x p en siv e and o nly u n d ertak en i f a benefit can be estab lish ed . T h e y are also un d ertak en for political reasons. W hen C aren J e n n in g to o k her o w n life in S e p te m b e r 2 0 0 8 , a m on th befo re sh e w a s due to be s e n te n c e d for the m a n s la u g h te r o f G ra e m e W ylie, sh e left a suicide no te and the bottle o f N em butal b y her bed. N evertheless an a u to p sy w a s still p erfo rm ed . H er rep utation p re c e d e d her, even in death. E v e n th o u g h a u to p s ie s a re b y no m e a n s ro u tin e , a n d their u se is b e c o m in g less frequent, th ey can n e v e r be ru le d out ( O ʼC on n or, 2004). Still, in th e case o f a serio u sly ill person w h o tak es an o v e rd o se o f prescription p ro p o x y p h e n e th ey have had prescribed, a n d leaves the e m p ty p a c k e ts b y the bed, a n d a su icide note, there is little likelihood o f an a u to p sy being perform ed.

A fter it's O ver

G r ie f C ou n sellin g T h e su icid e o f a serio u sly ill p erso n w ill e v o k e m ix ed reactions in th o se close to that person. T h e b ro a d e r c o m m u n ity ʼs reaction m a y also be m ixed . W h ile m o s t p eo p le su pp ort th e co n cep t o f rational su icid e there is still a significant m ino rity w h o do not. It c an n o t be a s su m e d that th ere will alw ay s be sy m p a th y for th o se left b eh in d so b e careful. In m an y c ircu m stan ces w h e re a p erso n h as d ied o f their own hand, c o u n sellin g m a y be o f assistan c e for those left behind. T h e ability to talk thin gs th ro u g h can be therapeutic an d can g o a long w a y to w ards easin g the in evitable g r ie f an d despair. P r iv a te c o u n s e l l o r s list t h e i r s e r v i c e s in m o s t c o u n t r i e s ' telep h o n e directories an d o f c o u rs e online. C o m m u n ity health centres a lso c o m m o n ly o ffer c o u n sellin g a s p a rt o f th eir range o f health s e rv ic e s . T h e re are also often c o m m u n ity telephone h elp lines.


Telling Your S to r y Publicly M an y su fferin g people w h o c h o o se to en d th eir life, resen t the fact that th ey have to act like crim in als in o rd er to d ie w ith dignity. S o m e c h o o se to travel o v erseas to acq u ire p roh ibited drugs. O th ers lie to th eir d o c to rs an d d eceiv e those they love. M an y are a c u te ly c o n s c io u s that in m o s t w estern ju risd ictio n s, this is an u n satisfa cto ry situation. All o f u s w a n t ch an g e for the better. F o r all th e se reasons, so m e p eo p le w a n t th eir d eath s to m ean so m ethin g. T ellin g th eir sto ry in th e m e d ia is o n e w a y they believ e (an d Exit agrees) to p ush th e d eb ate forw ard. If y o u are a p erso n w h o w a n ts to con tribu te to p u b lic debate and e n co u rag e o u r legislators to act, there are several option s available. A s a rule o f thu m b, m o s t m e d ia a re k een on personal stories that involve su fferin g an d h ero ism . T h e re are h o w ev er d raw b ack s to su ch actio ns an d th ey can be significant. If the perso nal sto ry o f a fo rth co m in g death is m a d e public, there can be considerable scrutiny o f the individual an d possible frustration o f th eir plans. T h e death o f A u stralian grandm other, N a n c y C rick, w a s an e x a m p le o f this. N a n c y w en t p u b lic with h e r plans to d ie w ell before the night sh e e v en tu ally drank h er N e m b u ta l w ith 21 friends an d fam ily present. W h ile telling h er sto ry forced key esta b lish m en t figures to en g ag e w ith the issue o f a p e rso n 's right to c h o o se w h e n an d h o w they die, the exact tim e an d place o f h e r suicide tu rn e d into a b it o f a m ed ia circus. N e v e rth e le ss she died peacefully, sipp ing on Baileys an d s m o k in g h e r last cig arette .

A fter it s O ver

O v e r th e years, Exit has found an alternative ap p ro a c h is for th e person to reco rd th eir story, o r film an interview , w ith the provision that it b e published o n ly after th eir death. T h is w a s the case with 3 1-year-old A n g eliq u e F low ers. A n g e liq u e 's Internet p lea to the A ustralian P rim e M inister w a s front p ag e n ew s in the M elb o u rn e b ro a d sh e e t The A ge. A nd, a s d iscu ssed in C h a p te r 1 o f this H a n d b o o k, h er video diary rem ains available on YouTube to th is day. W h ile such s tatem en ts can b e v e ry p ow erfu l, the fact that w h e n th e y are only m ad e k n o w n after th e person has d ie d can lim it o n -g o in g m ed ia interest. It is a lso im p o rtan t to re m e m b e r that tapes an d records can be su b p o e n a e d an d p o ssib ly u s e d as evidence. It w a s the airing on 6 0 M in u tes o f a v id e o tape o f D r K ev o rk ian assistin g his p a tie n t, T h o m a s Y ouk, th a t s a w K e v o rk ia n s p e n d n e a rly a d ecad e in prison. A third possible w a y to tell y o u r story publicly is for y o u r family an d th o se closest to y o u to tell y o u r sto ry after y o u h ave gone. T h is o f co u rse is a v e ry safe option. W ith o u t th e im ag ery and direct q u o tes o f the p erso n , ho w ev er, there w ill be m u ch less m ed ia interest an d im pact. All that said, getting p e o p le ’s stories out to the b ro a d e r public do m ain is an essential part o f initiating political change.


C o n c lu d in g C o m m e n ts The P e a ce fu l P ill H a n d b o o k (P P H ) w a s first p u b lish ed in 2006. S ince this tim e the bo o k h as b een an nu ally up d ated to include n e w an d c h a n g e d inform ation. T h is is essential to keep u p w ith th e d eb ate a b o u t e n d o f life ch o ic e s . In 2008, th e fu lly-o nlin e P e a c efu l P ill e H a n d b o o k (P P eH ) w a s also published. T h e online form at o f the eH an d b o o k h as allowed u p d atin g w h en an d a s it is required. A t the c u rre n t tim e, the e H a n d b o o k is u p d a te d no less th an six tim es each year. T h e o n lin e e H a n d b o o k also co n tain s o v e r 50 p ieces o f video, p ro v id in g hand s-on instruction an d critical detail on a diverse ra n g e o f issues. F o r readers o f th e P P H , E xit is p le a s e d to co n tin u e to o ffer a c ash -b ack a rra n g e m e n t sh o u ld p urchasers u p g rad e to an online su b scrip tio n to the PP eH . Both b o o k s are m a d e av ailab le in the philosophical b e lie f that know ledge is em po w erin g . W ith the academ ic literature playing c atch -u p , E xit rem ains a c u te ly a w a re that h av in g an end -of-life plan m akes o n e live a lo n g er a n d h app ier life. Far from pushing p eo p le to w ards suicide, establishing o n e 's o p tio n s helps people stop w o rry in g , an d g et on w ith living better.

F o r those with

term inal illness, b e in g b ack in co ntrol can be p retty satisfying given the ad v ersity th a t o fte n circles about. F reedom s h o u ld n ’t take this m u ch effort. But for the tim e being it does. Exit ap p reciates re a d e r feed back on th e facts an d the feelin g s that co m e w ith readin g o u r books.

E xit R P Test H an g in g

D ete rg en t

R e lia b le (10)

10

10

8

4

9

9

10

8

10

P eac efu l ( 10 )

0

2

7

10

7

7

5

7

10

A v ailab le (5 )

5

5

3

3

3

4

2

5

2

P r e p a r a tio n (5 )

2

4

1

5

3

3

5

1

5

U n d e te c ta b le ( 5)

0

0

1

2

3

3

3

5*

4

S p eed (5 )

1

5

5

2

2

2

5

5

4

S afety (5 )

5

0

1

5

5

5

3

5

5

S to ra g e (5 )

5

4

4

3

3

3

5

5

4

T O T A L (50)

28

30

31

34

35

36

38

41

44

56%

60%

62%

68%

70%

72%

76%

82%

88%

9

8

7

6

5

4

3

2

1

R a tin g

M o n o x id e

M o rp h in e

E ndep

D o lo x en e

C y a n id e

I n e r t G as

N em b u tal

* N itro g e n o n ly


References A ustralian B u reau o f S tatistics (2 0 0 0 ) S u ic id e Trends, A u s tra lia , 1 9 2 1 -1 9 9 8 . Cat. N o. 33 09 .0 , C an b e rra, A B S . A ustralian V eterinary A sso ciatio n ( 2 0 0 6 ) ʻAVA rejects N itsch k e ad v ice a s u n e th ic a lʼ M e d ia R elease 24 July, 2006. B atlle, J. C. (2 0 0 3 ) ‘Legal status o f ph y sician -assisted su ic i d c ʼ, J A M A , Vol. 2 8 9 , N o . 17, p. 2279-81. C o m m o n w e a lth o f A u stralia (2 0 0 5 ) C rim in al C o d e A m e n d m en t ( S u icid e R elated M aterial O ffen ce s) Act 20 0 5 N O . 9 2 at: h ttp ://w w w .austlii.edu .au/au /leg is/cth/n um _ act/ccarm oa2005n922005479/ D ru g M isu se an d T rafficking Act 1985 (N S W ) at: http:// w w w .au stlii.e d u .au /au /le g is/n sw /co n so l_ act/d m ata1 9 8 5 2 5 6 / in d ex.html F u rniss, B., H an n afo rd , A. Sm ith, P. W. G. & A. Tatchell (1 9 8 9 ) Vogels's T extbook o f P ra c tic a l O rg a n ic C hem istry, H arlow , P rentice Hall. H an co ck , D. (2 0 0 5 ) ‘D eath s C o c k ta ilʼ, T h e B u lle tin , 8 N ov at: h ttp ://w w w .ex itin tern atio n al.n et/d o cu m en ts/ex it4 5 .p d f H u m p hry , D. (1 9 9 6 ) F in a l E xit. N e w York, Dell, p. 30. Lie be rm ann , L. (2 0 0 3 ) L e a v in g You - The C u ltu ra l M ea n in g o f S u icid e. C h icag o , Ivan R. Dee. M e nde lson, W. В. ( 198 0) T h e U se a n d M isu se o f S lee p in g P ills - a C lin ic a l G u id e, N e w York, P lenu m M edical Book C om pany.

References

N ation al P rescribing C entre (2 0 0 6 ) ‘T h e w ith d raw al o f cop ro x am o l: altern ativ e an algesics for m ild to m o d e ra te p a i n ʼ M e R e C B u lletin , Vol. 16, N o . 4. N itsch ke, P. & S tew art, F. (2 0 0 5 ) K illin g M e S o ftly: V E a n d th e R o a d to th e P e a c efu l P ill. M elb o u rn e, Penguin. O 'C o n n o r, A. (2 0 0 4 ) ‘D eath s go u n e x a m in e d a n d th e living p ay th e p r ic e ʼ, N e w York Tim es, 2 M arch. Public C itizen (2 0 0 6 ) ‘Petition to the F D A to b an all p ro p o x y p h e n e (D a rv o n ) p roducts at: h ttp://w w w .citizen.org/ p u b licatio n s/release .cfm ?ID = 7 4 2 0 Routley, V. & O zan n e-S m ith , J. (1 9 9 8 ) ‘T h e im p act o f catalytic con verters on m o to r veh icle ex haust g as su ic id e s ’, M e d ic a l J o u r n a l o f A u stra lia . Vol. 168, p. 65-67. Ryan, C. J. (1 9 9 6 ) ‘D epression, d ecisio n s an d th e d esire to d ieʼ, M e d ic a l J o u r n a l o f A u stra lia , Vol. 165, p. 411. S h an ah an , D. (2 0 0 1 ) ‘M ail o rd er su icide k itʼ. The A u s tra l ian. 20 August. S o lo m o n s, T. W. B. & F ry h le, С . B. (2 0 0 4 ) O rg a n ic C h em istry (8th cd.), N e w Jersey, Jo h n W iley & Sons. Stone, G. (2 0 0 1 ) S u ic id e a n d A tte m p te d S u ic id e : M ethods a n d C o n seq u en ces, N e w York, Carroll an d Graf. V eterinary S u rgeo ns B o ard o f th e A C T (2 0 0 3 ) N e w sle tte r J u n e 2003

A b o u t P h i l i p N its c h k e Dr Philip Nitschke PhD, MBBS, BSc (Hons) is a leading authority on Voluntary Euthanasia and Assisted Suicide. As the first doctor in the world to administer a legal, lethal, voluntary injection under Australia’s short-lived Rights o f the Terminally Ill A ct, Philip has experienced all sides o f the end-of-life choices debate. A graduate o f Sydney University Medical School, Philip is the Founder and Director o f Exit International, an organisation at the forefront o f this debate. With his co-author Fiona Stewart he is also author o f Killing M e Softly: Voluntary Euthanasia and the R oad to the Peaceful Pill (Penguin 2005, republished Exit US 2011). In 1997, Philip was awarded the Rainier Foundation Humanitarian Award in the US and w as Australian Northern Territorian o f the Year. In 1998, Philip w as Australian Humanist o f the Year and New Zealand Humanist o f the year in 2001. He has been nominated for Australian o f the Year eight times.

A b o u t F io n a S te w a rt Dr Fiona Stewart PhD, MPolLaw, GradDip PubPol, BA is a public health sociologist. As an academic, Fiona w as the recipient o f re search grants from the Australian Research Council & the National Health and Medical Research Council. Fiona has held various positions outside the academy including as a journalist, columnist, dot-com founder and media strategist. Since 2004, Fiona has been Executive Director o f Exit International.

Fiona Stewart & Philip Nitschke

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