December 6, 2021

‘Quick and painless death’: easier said than done

The central goal of right-to-die organisations has not changed much over the past 150 years. In 1872 a British writer, Samuel D. Williams, wrote a book advocating the use of the novel anaesthetic chloroform to give patients “a quick and painless death”. In 1931 the British eugenicist Dr Killick Millard proposed legalisation of euthanasia “to substitute for the slow and painful death a quick and painless one”.

Now that legalisation has arrived, however, doctors have realised that a Q&P death is easier said than done.

Writing in a recent issue of The Spectator (UK) Dr Joel Zivot, a Georgia physician, expresses his doubts about whether lethal medications are the way forward. He studied the autopsy reports of more than 200 prisoners executed with lethal injections and found that many may have died in great pain.

“The death penalty is not the same as assisted dying, of course. Executions are meant to be punishment; euthanasia is about relief from suffering. Yet for both euthanasia and executions, paralytic drugs are used. These drugs, given in high enough doses, mean that a patient cannot move a muscle, cannot express any outward or visible sign of pain. But that doesn’t mean that he or she is free from suffering.”

Dr Zivot believes that pentobarbital, which, it seems, is used in Oregon in 4 out of 5 assisted suicides, caused pulmonary oedema – the lungs fill with liquid secretions and the person can die in agony. “Advocates of assisted dying owe a duty to the public to be truthful about the details of killing and dying. People who want to die deserve to know that they may end up drowning, not just falling asleep,” he writes.

Nor is death necessarily quick.

In Oregon, where statistics are gathered about the mode of death, the median time to death throughout the 23 years of the Act is 30 minutes but the maximum time is 4 days and 8 hours. The median time for people to fall unconscious is 5 minutes, the maximum is 6 hours.

At least in the United States, doctors who participate in assisted suicides are aware of these issues. Dr Lonny Shavelson, a California physician who specialises in this novel field, has helped to organise the American Clinicians Academy on Medical Aid in Dying. This provides a forum for doctors to establish a best-practice for helping people to die.

It turns out that the very diseases from which the patients suffer can make the drugs less effective. Dr Shavelson spoke with Medical Xpress last year about some of the difficulties:

“Shavelson and [his colleague retired anesthesiologist Dr Carol] Parrot have identified which patients are more likely to linger, and can recommend adjustments. People with gastrointestinal cancer, for example, don’t absorb the drugs as well. Former opiate users often have resistance to some of the drugs. Young people and athletes tend to have stronger hearts and can survive longer with low respiration rates.

“We’re learning. Hypothesis, data and confirmation. This is what science is,” he said. “Our job is to stop the heart; that’s what they want us to do.”

7 thoughts on “‘Quick and painless death’: easier said than done

  1. Oh my goodness … killing animals & human beings seems to be of equal footing in this discussions ! So casual , so deprived ! Heartbreaking!

  2. Thanks, MIchael Cook, for this article. You are of course entitled to your opinions, and I appreciate them. But you are not entitled to your own facts. So allow me to provide you with the facts:

    1) You state: “… pentobarbital… is used in Oregon in 4 out of 5 assisted suicides…” That hasn’t been true for many years. As the Oregon State Department of Health’s 2020 ( https://tinyurl.com/33acfdsw ) report clearly states, pentobarbital was rarely used for aid in dying, its brother secobarbital was. And since 2015, secobarbital use has declined to zero and newer and better medication protocols are used. You are writing in 2021, not 2015. So while citing old data and ignoring anything more recent is certainly useful to your argument, it is terrible and inaccurate journalism. Your readers deserve better.
    2) You state: “for both euthanasia and executions, paralytic drugs are used. …a patient cannot move a muscle, cannot express any outward or visible sign of pain. Doesn’t mean that he or she is free from suffering.” Again, your facts are simply wrong. Aid in dying (what you call euthanasia) protocols do not use any paralytic agents. Zero. None. And they never have. Secobarbital/pentobarbital are sedatives, not paralytic agents. And among the newer medication protocols that have followed since secobarbital use ended, none use paralytic agents. Again, none, zero. They all create deep sedation and coma, not paralysis. Patients are in a medically-induced coma, insensate (no feelings), and not, as you claim, paralyzed while still feeling but unable to move a muscle to show they are suffering. So that part of your opinion is entirely free of fact.
    3) “…the maximum time to death is 4 days 8 hours.” Yes, one case, in Oregon, many years ago. Again, see the 2020 Oregon report: Maximum time to death with the newer protocols: 8 hours. And that is quite unusually long. The vast majority of patients die within 1 to 2 hours after ingesting the medications.
    4) And here’s where I, Dr. Shavelson, who you cite in your “article,” agree with what you wrote: “Shavelson and [his colleague retired anesthesiologist Dr Carol Parrot] have identified which patients are more likely to linger, and can recommend adjustments.” That’s exactly correct. We have advanced the science and pharmacology by knowing which patients might “linger” — so that they DON’T linger, they have reasonably-timed painless deaths, as they have requested. You somehow see our work on understanding prolonged deaths as a criticism of aid in dying. But it is actually about our ability to now avoid prolonged deaths. This is nothing other than the advancement of medicine, so that the desires of our patients are met.

    So if you’re going to write about this, Mr. Cook, and I hope you will continue to do so, please educate yourself and keep up to date on the information — so that your opinions are based on truth and fact. With that, I believe your opinions will be valuable.

    Lonny Shavelson, MD
    Chair
    American Clinicians Academy on Medical Aid in Dying

    1. Hi Dr Shavelson,
      Thanks for your very useful remarks.
      You will note, however, that your remarks about pentobarbital relate to a quote from Dr Joel Zivot. We probably should have cross-checked his description of the deaths. However, further down the page you will see a comment from Dr Rob Jonquiere. He says that in the Netherlands pentobarbital is the drug of choice.
      As for the duration of the dying process: yes, the maximum time in 2020 was 8 hours. But in 2019, the maximum time was 47 hours. That’s a long, long time.
      You will also note that for nearly half of the patients in 2020 the time to unconsciousness and the time to death are *unknown*. One would be inclined to suspect that blunders and errors and mishaps are hiding behind that word. But we will never know.
      Information on duration does not appear in California’s 2020 report. The best we can do, then, is extrapolate from Oregon’s experience, which is that after more than 20 years of experience with assisted dying, it can still take 2 days to die. I am sure that you are doing your best to give patients reasonably-timed painless deaths. But it still seems like a game of roulette.
      Michael Cook
      Editor

  3. how absolutely ridiculous. The Dr “believes”! No we do not have “belief” in science and medicine, we have peer reviewed studies. In Belgium Pentobarbital is given after first an injection of midazolam, which induces deep sleep. In Oregon people are taking a liquid dose without a doctor, which will be fraught with difficulty. This is an argument for doctor assisted death, not an argument against assisted dying!.

    In the last 100 years “conscience” and “morality” has been used to prevent, gay rights, abortion, family planning, women’s vote, women’s rights, workers’ rights and now the right to die. Why must we suffer in death for someone else’s conscience? Just as for all the other rights that would have been denied but for progress and compassion the answer is easy. If you don’t agree with homosexuality, abortion, family planning or right to die, don’t do it. I have seen many animals die peacefully and in a minute from barbiturate. It is the standard of care for dying pets, but humans – let them suffer!

  4. I live in Canada where euthansia (the government calls it MAID: medical aid in dying) has been in use since 2016. I recently wrote an article for the (Toronto) Catholic Register about some people I’ve met whose parents were euthanasized. The problem is that for the most part those who witness euthanasia describe it as a beautiful experience in which the patient goes to sleep quickly and dies. For the record, I am an opponent of euthanasia and have spoken out against for many years and have written extensively on the subject. I oppose as a Catholic but also a concerned citizen. In Canada only a third of those who want palliative or hospice care can find it. Worse the government of Justin Trudeau promised C$6-billion to improve such care but more than four years later only C$2-million has been spent – on studies. I write this as a warning to those who are still fighting of euthanasia that you need to find great arguments against it.

  5. There are many painless lethal drugs used in veterinary medicine that could also be used to achieve a rapid death in humans, as well as the usual anaesthetic drugs. The drawback is that there are serious health and safety risks if not handled properly, as well as the risk being misused, eg M99 – a powerful opiate – used in dart guns (and by injection) for very large animals. Secondly, introducing an intravenous line allows for increasing doses to be given to ensure a rapid loss of consciousness in a humane order ie sedation, excess anaesthetic inducing death, followed by neuromuscular blockade and a potassium salt. A third problem, that seems to be getting to be less of an issue, is the autonomy of the nurse/doctor/phlebotomist/technician carrying out the procedures and the ethical objections in regard to seeing it as an act of beneficence or an act of maleficence.

  6. I appreciate you mentioning research into effects – or rather undesired side effects – of pentobarbital, the drug that is used in the Netherlands for decades already when applying euthanasia (or assisted suicide). But I am surprised that contrary to NL the pentobarbital causes these problems as observed. I miss in the reports mentions of doses: a “high enough dose” as mentioned by Joel Zivot is possibly much different from the Dutch “overdose”, with which we have so few side effects, it is still used in NL and is considered the Golden Standard – in both euthanasia (where it is followed by a muscle relaxant – again in overdose) as injection and in assisted suicide (15 grams).

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