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1Contents Preface Chapter 1 - Introduction
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3Chapter 2 - Suicide & the Law Chapter 3 - The Peaceful Pill
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518 34 42
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7Chapter 4 - The Exit ‘Reliability-Peacefulness’ Test 50 Chapter 5 - Hypoxic Death & the Exit Bag Chapter 6 - Carbon Monoxide Chapter 7 - Cyanide
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958 Chapter 8 - Detergent Death
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11Chapter 9 - Introduction to Drugs Chapter 10 - Drug Options - Morphine Chapter 11 - Drug Options - Propoxyphene Chapter 12 - Drug Options - Amytriptyline Chapter 13 - Drug Options - Chloroquine Chapter 14 - Drug Options - Insulin
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13Chapter 15 - Drug Options - Chloral Hydrate Chapter 16 - Drug Options - Nembutal Chapter 17A - Availability of Nembutal Chapter 17B - Nembutal Scams
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15Chapter 18 - Testing & Storage of Nembutal Chapter 19 - Administration of Nembutal Chapter 20 - The Peaceful Pill Project Chapter 21 - The Swiss Options Chapter 22 - Final Considerations Exit RP Table
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17About the Authors References
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19Support Exit International
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21106 128 144 150 166 178 190 198 204 208 212 230 286 310 330 344 364 396 418 419 420 422
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23About The Peaceful Pill Handbook Series
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25The print edition of The Peaceful Pill Handbook on euthanasia and assisted suicide was first published in 2006. The online Peaceful Pill eHandbook (subscription) was first published in 2008.
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27The online edition is updated up to 6 times each year, ensuring that readers have access to the most up-to-date important information on euthanasia and assisted suicide developments globally.
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29The Peaceful Pill Handbook information book series is published to provide research and information on euthanasia and assisted suicide for the elderly, those who are seriously ill (for example with cancer or ALS) & their family/ friends.
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31For more information about The Peaceful Pill Handbook series, please visit:
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33http://www.peacefulpill.com
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35or email: sales@peacefulpill.com Phone:
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37+31 (0)6 30 966 992 (NL) +1 360 961 1333 (USA) +61 (0)407 189 339 (Australia)
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39Media inquiries: +31 (0) 630 966 992
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41Content Revised: 20 October 2016
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43For Derek Humphry for his courage and compassion in showing the way
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45‘Freedom takes a lot of effort’ Anna Stepanovna Politkovskaya
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47The
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49Peaceful Pill eHandbook
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51Dr Philip Nitschke &
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53Dr Fiona Stewart EXIT INTERNATIONAL
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55Published by Exit International USA Postbus 283 2000 AG Haarlem NL
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57sales@peacefulpill.com (+1) 360 961 1333 (USA) +31 (0)6 30 966 992 (NL)
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59THE PEACEFUL PILL EHANDBOOK, 2016 Copyright © Dr Philip Nitschke and Dr Fiona Stewart 2016
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61The moral right of the authors has been asserted.
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63All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or intro- duced to a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of the copyright owner and publisher of this book.
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65First published by Exit International USA, 2006 Cover design by Branden Barber, Twin Lizards
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67The Peaceful Pill eHandbook
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69First published by Exit International US Ltd, 2008 Technology supplied by www.Yudu.com
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71Nitschke, Philip Haig Stewart, Fiona Joy
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73The peaceful pill handbook.
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75ISBN 978-0-9788788-4-9 www.peacefulpill.com
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77Disclaimer
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79While 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.
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81The Peaceful Pill Forums
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83Members of Exit & Subscribers to the Peaceful Pill eHandbook have free access, on approval,* to the Peaceful Pill online forums.**
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85http://www.peacefulpillforums.com
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87To apply for membership of the Forums, you will first need to be aged 50 years or over and of sound mind. To apply, send an email to: forums@exitinternational.net
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89* Photo ID is required.
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91** A wait time of 3 months applies to new subscribers.
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93Video: The Peaceful Pill eHandbook
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95Preface
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97The Peaceful Pill eHandbook has been created at a time when there are very few places where Seniors and those who are seriously ill can get information about their end-of-life choices.
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99In 1996, Australia passed the world’s first right to die law; the Rights of the Terminally Ill Act (ROTI). Under ROTI, four of my seriously ill patients self-administered a legal, lethal overdose of drugs; a Peaceful Pill if you like. All died peacefully in their sleep, surrounded by people they loved.
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101I know this, because back then I was their treating physician. I was the one who put the needle into their veins. And I was the one who built the ‘Deliverance Machine’ that they used to die. The Deliverance Machine was a laptop computer and program that gave these individuals the ultimate control over their deaths. Their deaths taught me much, but mostly how important it is for peole to be allowed to have control at the end.
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103On each separate occasion, the computer presented a short series of questions:
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1051. Are you aware that if you go ahead to the last screen and press the ‘yes’ button you will be given a lethal dose of medications and die?
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1072. Are you certain you understand that if you proceed and press the ‘yes’ button on the next screen you will die?
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1093. In 15 seconds you will be given a lethal injection … press ‘yes’ to proceed.
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111Preface
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113The Deliverance Machine is now display at the British Science Museum
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115The Peaceful Pill eHandbook
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117After pressing the button for a third time, the Machine would deliver a lethal dose of the barbiturate, Nembutal. The Deliverance Machine enabled these four people to die peacefully and with dignity under a new law.
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119My experience in those days of legal, assisted suicide taught me that the drug sodium pentobarbital - commonly known as Nembutal - provides one of the most peaceful death imaginable. And it almost never fails. That is why it is used in countries like the Netherlands, Belgium and Switzerland and the US States of Oregon and Washington where assisted suicide is lawful.
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121In western countries where there are no end-of-life laws, the means of achieving a peaceful death is next to impossible. In Australia - my birthplace - for the past decade the Government has made it increasingly difficult for Seniors and people who are seriously ill to access information about their end-of-life choices. The Australian Government seems more concerned to keep people in the dark. Their rationale is that if people are kept in a state of complete ignorance they will live longer, happier lives. NOT True!
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123In my experience, once people have access to information that empowers and enables informed decisions to be made, they tend to stop worrying. Knowing one’s options enables a person to make considered decisions as a matter of course. Knowledge about one’s end-of-life choices is empowering. It is this empowerment that promotes a longer, happier life. NOT Ignorance.
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125The Peaceful Pill eHandbook has been created to provide the most accurate, up-to-date information about end-of-life choices possible. The online medium has proven the perfect format for disseminating information in this fast-changing field. The Peaceful Pill eHandbook is deliberately published in the US
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127Preface
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129where freedom of speech is enshrined in the United States Bill of Rights. Of course, the eHandbook covers some grey areas of the law.
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131Finally, the Peaceful Pill eHandbook draws on more than a decade’s scientific research and political advocacy in the fields of Assisted Suicide and Voluntary Euthanasia. Since its publication in October 2008, it has become the leading Internet resource on end-of-life choices.
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133Acknowledgements
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135The Peaceful Pill eHandbook could not have been written without the support of many people. First to thank are the many Exit members who have contributed their expertise, ideas and travel stories. This is truly a joint effort.
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137Secondly, our staff at Exit International we thank very sincerely for all they do day in, day out.
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139Outside of Exit, special thanks to Steve Hopes of iKandy Films in Sydney, Branden Barber in San Franciso and the technical staff at Yudu in the UK.
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141Finally, we’d like to thank our publisher, Richard West, for his continued support and without whom none of this would have been possible.
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143Dr Philip Nitschke & Dr Fiona Stewart
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145It is the Constitutional protections offered by the Bill of Rights that allows these issues to be canvassed at all.
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147The Peaceful Pill eHandbook A Word of Caution
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149This book is intended for Seniors and people who are seriously ill (and their families). This book is not intended for young people or anyone suffering from psychiatric illness or depression. As authors we acknowledge that there is a small risk that this book may be misused by people for whom this information is clearly not appropriate.
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151The risk that information of this nature may be misused was a fact acknowledged by the ‘godfather’ of the right-to-die movement, former British journalist, Derek Humphry. When Derek first published Final Exit in 1991 he was criticised for endangering suicidal teens the world over. However, as he would later point out, the suicide statistics failed to show the much talked about ‘blip’. There has been no rise in the suicide rate. Providing people with information does not incite or encourage people to die. And this is a critical point.
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153Rather, reliable, accurate information empowers people to make make informed decisions about their own end-of-life circumstances. Good information should not only prevent grim, horrible deaths of gunshot and hanging (the most common causes of suicide in the US, UK and Australia respectively) but it should allay fears. It is paradox, perhaps. By equipping Seniors and those who are seriously ill with knowledge that empowers and returns control, these same people are more likely to stop worrying and get on with living. Anecdotal evidence to this effect can be seen at each and every Exit meeting. Fears are addressed and participants feel back in control.
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155Preface
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157As authors, we ask that users of this eBook respect its integrity and intended audience. Seniors, the elderly and people who are seriously ill deserve to be able to make informed decisions about their futures. Ignorance is not an acceptable state of affairs.
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159It is a basic human right to live and die with one’s dignity in tact. The Peaceful Pill eHandbook is one way of helping ensure that one’s passing might be as proud and strong as one’s living.
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161If you feel you need counselling, please contact the following organisations:
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163USA: UK
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165Australia
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167Suicide Prevention Hotline - 1 800 273 8255 The Samaritans on - 08457 90 90 90 Lifeline on - 13 11 14
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169New Zealand Lifeline on - 0508 828 865 Canada
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171The Life Line on - 1-800-668-6868
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173Other countries hotlines can be found at: http://www.suicide.org/international-suicide-hotlines.html
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175The Peaceful Pill eHandbook Tips for Use
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177Navigation The Peaceful Pill eHandbook breaks new ground in online publishing. Part-book & part-video, the Yudu technology platform of the Peaceful Pill eHandbook allows users to Turn the Page with a swoosh or by the arrows at either side of the page.
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179Notepad A notepad function is located in top menu bar, allowing users can make notes as you go. The notes are stored as yellow page icons at various places in the text.
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181Bookmarks A bookmark feature can also be found in the top menu bar. This allows pages to be marked for future reference.
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183Index
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185The traditional Index has been replaced by a search box function in the top menu bar. This does away with the need for page numbers. When page numbers are quoted, they refer to the page counter at the center top of the digital display.
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187Magnification
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189If your eyesight is failing, you can click on the eHandbook’s built-in magnifying glass that allows the user to zoom and reposition text on the screen with amazing customability. Or use your mouse or touchpad for the same effect.
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191Multimedia
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193Because this is an online eBook, by its nature users can enjoy a full multi-media experience via hyperlinks and videos.
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195Preface Access for all Devices
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197The eHandbook can be accessed across all platforms, including PCs and Mac, laptops as well as Android tablets, iPads and iPhones. No special software is required.
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199Printing The eHandbook can be printed page by page or as groups of pages.
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201As they now say in the world of online books - READ IT, WATCH IT!
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203Cashback Offer
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205Purchasers of the print edition Peaceful Pill Handbook are entitled to a $10 cashback should they elect to upgrade to a subscription to the online Peaceful Pill eHandbook.
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207Once a reader upgrades at www.peacefulpill. com, you are welcome to email Exit with proof of purchase and we will refund you $10 by check.
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2091 Introduction Developing an End of Life Plan
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211People make end of life plans for all sorts of reasons. Some people are concerned that one day they will become so sick and frail and their quality of life will become so impaired that death will become the preferred option. Others worry that because current generations are living longer than their parents’ and grandparents’ generations, they will have to face that new set of worries that come from longevity itself. Some elderly people are simply ‘tired of life.’
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213The reasons that lead an elderly person or someone who is seriously ill to seek information about their end-of-life choices are many and varied. All are intensely personal. Rewriting the ways in which society can plan for and experience death and dying is the challenge of our time.
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215The development of an end of life plan is one small step that all of us can take to protect those we love from the ravages of the law. While most of us will never use our plan, we can all draw comfort in knowing that if things ever become too painful or undignified (especially in the context of serious illness and age), we will have a plan in place that will allow us to maintain our dignity and our independence.
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217Introduction The Wonders of Modern Medicine
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219In any discussion of end of life issues the role of modern medicine is paramount. While no one can be critical of the huge advances in medical science over recent decades - improving beyond measure the length and quality of our lives – there is also a flip side. In contrast to previous generations, we are now far more likely to die of slower, debilitating conditions that are associated with old age and illness. Yet we are also more likely to be kept alive through an increasingly sophisticated array of medical technologies.
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221A longer life can be a wonderful thing, but should we be forced to live on, if we come to a point where we have simply had enough? Surely the act of balancing one’s quality of life against the struggle of daily living in our later years or in illness, should be each individual to arbitrate.
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223Our Ageing Population
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225A century ago when life expectancy was approximately 25 years less than it is today, few people had the opportunity to reflect on how they might die. Then people were much more likely to die quickly with little warning. For example, one hundred years ago infectious disease was common. People considered themselves lucky if they were still alive in their mid 50s. The widespread introduction of public health measures such as sewerage, water reticulation, good housing, and of course the introduction of modern antibiotics have all played a part in greatly reducing the toll of infectious disease.
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227The Peaceful Pill eHandbook
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229In modern times, those living in the developed west have a life expectancy of 75 to 80 years. Now in industrialised countries, we will be more likely to experience diseases and disabilities that were rare in earlier times. While old age is not in itself predictive of serious physical illness, the gradual deterioration of one’s body with age leads to an almost inevitable decline in a person’s quality of life.
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231This is why we see the issue of control in dying as being an increasingly common concern for many elderly people. Exit’s workshop program is often booked out months ahead as elderly folk seek answers to their practical questions about their end of life options. Although few who attend these workshops have any intention of dying in the near future, most see a need to organise and plan for this inevitable event.
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233Just as many of us plan for other aspects associated with dying (eg. we all write a will, appoint executors, and some of us prepay for funerals), so it is common sense to ensure that we have a plan about how we might wish to die. Yet to be in a position to plan for one’s death, one must first know one’s options. And that means information.
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235The Question of Suicide
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237Anyone who makes plans for their own death can be said to be planning their own suicide. While for some people suicide is a tainted concept, for a growing number of older people it is an issue of great interest and discussion. In this context, suicide is a way out of a life that an individual might consider is not worth living.
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239Introduction
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241People who come to Exit workshops are well aware of the importance of making that ultimate of decisions, the decision to die. They are all acutely aware of the need to get it right. In this Chapter, we examine the phenomenon of suicide in the context of the modern life course, and why access to the best in end of life information is so important.
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243A Brief History of Suicide
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245Over the years, the way in which society views the taking of one’s own life has varied enormously. Suicide has not always been seen as the act of a sick and depressed person. In ancient Greece, Athenian magistrates kept a supply of poison for anyone who wanted to die. You just needed official permission. For the Stoics of ancient times, suicide was considered an appropriate response, if the problems of pain, grave illness or physical abnormalities became too great.
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247With the rise of Christianity, however, suicide came to be viewed as a sin (a violation of the sixth commandment). As Lisa Lieberman writes in her book Leaving You, all of a sudden ‘the Roman ideal of heroic individualism’ was replaced ‘with a platonic concept of submission to divine authority’.
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249It was Christianity that changed society’s view of suicide from the act of a responsible person, to an infringement upon the rights of God. One’s death became a matter of God’s will, not one’s own and it was at this point that penalties were first established for those who attempted suicide. If the suicide was successful, it was the family of the offender who were punished with fines and social disgrace.
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251The Peaceful Pill eHandbook
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253With the emergence of modern medicine in the 19th Century, the meaning of suicide changed again and it is this understanding that prevails today. Suicide is now generally thought of as an illness. If a person wants to end their life, then they must be sick (psychiatric illness, with depression the usual diagnosis). The appropriate response, therefore, is medical treatment (in the form of psychiatric counselling and/or anti-depressant medications).
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255At Exit International, we question the view of suicide that automatically links a person’s decision to die to depression and mental illness. Are we seriously postulating that the suicide bombers of the Middle East are depressed? Rather, the act of suicide must be seen as context dependent.
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257For example, a person who is very elderly and who is seeing friends die around them on a weekly basis and who must be wondering ‘am I next?’ is going to have a very different outlook on dying than the young person who has their whole life in front of them. Likewise, when serious illness is present. A person’s attitude towards death must be understood in the context of that person’s situation.
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259In Oregon, where physician-assisted suicide (PAS) is legal, symptoms of depression have been found in 20 per cent of patients who request PAS (Battle, 2003). A 1998 Australian study reported 15 per cent of men and 18 per cent of women who suicided had ‘an associated or contributory diagnosis of a mental disorder’ (ABS, 2000). At Exit we argue that feelings of sadness (as opposed to clinical depression) are a normal response to a diagnosis of a serious illness.
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261This is why some studies continue to find a sadness associated with a serious illness. You don’t need to be a psychiatrist
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263Introduction
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265to understand that this might be a normal response to an extraordinary situation (Ryan, 1996). To assume that suicide amongst the elderly or people who are seriously ill is the result of depression or other psychiatric illness, is to adopt uncritically a biomedical way of seeing the world. We can do better.
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267Suicide & Depression
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269The link between suicide and depression remains a vexed issue with millions of dollars in government funding devoted to raising the community’s awareness of suicide, especially amongst the young and some minority groups (eg. farmers). And there can be no doubt. People who suffer from clinical depression are clearly at risk of suicide. Severe depressive states can rob a person of the ability to make rational decisions and these people need care and treatment until they are once again able to resume control. Yet illness of this severity is not common and needs to be distinguished from a larger group of people who show occasional signs of depression but who are in full control of their actions.
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271There is a significant difference between a person having moments of feeling down or having a transitory feeling that their life has lost purpose and the person who has severe clinical depression, where even the most basic daily decisions of life become problematic.
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273This is quite different from an elderly or seriously ill person’s desire to formulate an end of life plan; a plan whose sole aim is to maintain control over their final days. People who like to be prepared and who are not depressed should not be viewed in psychiatric terms.
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275The Peaceful Pill eHandbook End of Life Decisions & the Role of Palliative Care
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277Critics of Assisted Suicide often argue that if palliative care is available and of good enough standard, patients will never need ask for assistance to die. This is untrue, but to understand the claim, one needs to look at the background of the palliative care speciality.
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279Palliative care was the first branch of medicine to shift the focus away from ‘cure at all costs’ and to focus instead upon the treatment and management of symptoms (for people who have a life-threatening illness). In this sense, palliative care’s aim has never been ‘cure’. Rather, palliative medicine is about symptom control. It is about improving the quality of life of those who are seriously ill and dying.
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281To date, palliative care has been most successful in the treatment of pain. Indeed, it is often claimed - perhaps exaggeratedly - that palliative care can successfully address pain in 95 per cent of all cases. What is much less spoken about is the speciality’s limited ability to alleviate some other common symptoms of serious disease; symptoms such as weakness, breathlessness or nausea. Or, quite simply to guarantee a good death.
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283No where can the shortcomings of palliative care be more obvious than in the tragic death in August 2008 of 31 year old writer, Angelique Flowers. At the age of 15 years, Angelique was diagnosed with painful Crohn’s Disease. On 9 May 2008, shortly before her 31st birthday she was diagnosed with Stage 4 colon cancer.
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285As Angelique said, in one of the several videos she made in the weeks leading up to her death, there is no Stage 5. At Stage 4 and upon diagnosis, the cancer had already spread to her liver and
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287Introduction
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289Angelique Flowers at Oscar Wilde’s grave at Pere Lachaise cemetery in Paris in 2006.
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291ovaries. Angie’s doctors told her then, her days were numbered. They also told her that there would be very little they could do to ensure that her death was pain-free and dignified.
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293As history now tells Angelique’s story, this courageous, clever, beautiful young woman died in the most difficult and unpleasant way. As a young palliative care patient she received the best that modern medicine can provide, and that money can buy. Despite some hiccups, Angelique’s pain control was described as reasonable. What was not so good and what the law prevents medicine from addressing, was her death.
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295Angelique Flowers wanted control over her death. Because she knew her death could come fast and it was unlikely to be peaceful. As it happened, Angelique died vomiting up faecal matter after experiencing an acute bowel blockage. Just as her doctors had warned, her death was simply awful. They had told her that it could be shocking, and it was. Her brother Damian held her in his arms through this awful ordeal.
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297The Peaceful Pill eHandbook
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299Video: Angelique’s Letter to the Prime Minister
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301Video: Angelique’s Plea for Nembutal on YouTube
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303Introduction
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305This young woman had been terrified of this possibility which is why she put out a call for Nembutal, on the Internet. Successful at obtaining Nembutal, because of the law she kept the drug hidden at her parents’ home. When the bowel blockage occurred, Angelique was in the hospice yet her Nembutal was at home. She lost her chance to take control.
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307Shortly before she died, Angie made a video diary. In it she pleaded with Australia’s Prime Minister, Kevin Rudd, to once again, legalise voluntary euthanasia in Australia. Angelique’s tragic story shows many things, including why a modern, civilised society needs the best palliative care and voluntary euthanasia/ assisted suicide. Her story is told in the feature documentary ‘35 Letters’ which won the 2015 Sydney Film Festival.
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309See: https://www.youtube.com/watch?v=5DqXGLwmJsc
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311At Exit, we are frequently approached by people who tell us that their palliative care is the best. But, like Angelique, they still wish to be in control of their death. They say that while they might not be in pain right now, the quality of their life is nonetheless seriously affected by their illness. They know that there is often nothing that modern palliative medicine can do about it.
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313Some of these people are so weak that they cannot move unassisted. Others have shortness of breath which makes independent living impossible. For a significant number of people, it is non-medical issues that have most impact upon the quality of their life.
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315The Peaceful Pill eHandbook
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317One memorable case concerned a middle aged man called Bob. Bob was suffering from lung cancer. He was incredibly sad that his favourite past time - a round of gold with his mates - was no longer possible. This person was clear. It was his frustration at being house-bound and dependent on visits from friends and family, rather than the physical symptoms of the cancer, that made him choose an elective death.
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319Palliative care is not a universal panacea. While this branch of medicine does have a valuable contribution to make, especially in the field of pain control, it is unhelpful to use symptom management as the benchmark against which a person’s quality of life is measured.
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321Rather, people rate their quality of life in different ways with no two individuals’ assessment the same. While a life without pain is clearly better than a life with pain, this is not always the most important issue. Instead it is that person’s own complex assessment of their life’s worth that is the key. The physical symptoms of an illness are often only one of many considerations. Just ask Angelique.
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323The Tired of Life Phenomenon
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325In recent years, a new trend has begun to emerge; one that has caused Exit to rethink our approach to death and dying. Increasingly at our workshops, we meet elderly people who are fit and healthy (for their age), but for whom life has become increasingly burdensome. Such people are not depressed. Rather, the sentiment expressed is that ‘I have lived enough of the good life and now it’s time to go.’ The actions of Australian couple, Sidney and Marjorie Croft, explain this phenomenon well.
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327Introduction
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329In 2002, the Crofts sent Exit International their suicide note explaining why they had decided to go together. Exit had no prior knowledge of the couple’s plans. We knew only that they had attended several Exit workshops where they sat at the back, holding hands and asking questions.
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331The Crofts did not need to write this note yet they wanted us to understand. And in return they asked for our respect.
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333To Whom it May Concern Please don’t condemn us, or feel badly of us for what we have done.
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335We have thought clearly of this for a long time and it has taken a long time to get the drugs needed.
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337We are in our late 80s and 90 is on the horizon. At this stage, would it be wrong to expect no deterioration in our health? More importantly, would our mental state be bright and alert?
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339In 1974 we both lost our partners whom we loved very dearly. For two and a half years Marjorie became a recluse with her grief, and Sid became an alcoholic. We would not like to go through that traumatic experience again. Hence we decided we wanted to go together.
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341We have no children and no one to consider.
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343We have left instructions that we be cremated and that our ashes be mixed together. We feel that way, we will be together forever.
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345Please don’t feel sad, or grieve for us. But feel glad in your heart as we do.
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347Sidney and Marjorie Croft
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349The Peaceful Pill eHandbook
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351The Crofts are the private face of an increasingly common sentiment among a minority of older people; that is that a good life should be able to be brought to an end with a good death, when and if a person so wishes. To suggest, as many in the medical profession have done, that the Crofts were ‘depressed’ is to trivialise and patronise them for their actions.
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353Another person who evoked this ‘tired of life’ phenomenon was retired French academic, Lisette Nigot. In 2002, Lisette Nigot also took her own life, consuming lethal drugs she had stockpiled over the years. Lisette’s reason for dying? She said she did not want to turn 80.
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355Lisette Nigot insisted that she had led a good and full life. She said she had always known that she would not want to become ‘too old.’ ‘I do not take to old age very well’ she told film-maker Janine Hosking whose feature documentary Mademoiselle and the Doctor traced the last months of her life.
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357In late 2002, shortly before her 80th birthday, Lisette Nigot ended her life. Intelligent and lucid to the end, Lisette knew her own mind. A fiercely independent woman, it is not surprising that she expected control in her dying, just as she had in her own life. In Mademoiselle and the Doctor she explained:
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359‘I don’t like the deterioration of my body ... I don’t like not being able to do the things I used to be able to do ... and I don’t like the discrepancy there is between the mind which remains what it always was, and the body which is sort of physically deteriorating.
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361Perhaps my mind will go and I would hate that. And certainly my body will go and I wouldn’t be very happy with that either. So I might as well go while the going is good’.
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363Introduction
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365When details of the Croft’s and Lisette Nigot’s death were made public, many tried to medicalize their situations. An assortment of diseases and conditions were suggested as reasons for their decision to end their lives. Underpinning all of this was the belief that ‘well’ people do not take their own life.
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367At Exit we do not encourage anyone, sick or well, to take their own life. We do, however, believe that a decision to end one’s life can be rational. Such a decision can occur just as much in the context of age as in the context of serious suffering and disease. This is why all elderly people should have access to reliable end of life information; information which is critical if mistakes are to be prevented.
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369Mademoiselle Lisette Nigot Conclusion
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371If one is to suggest that the elderly and seriously ill have the right - for good and sound reasons - to end their lives earlier than nature would have it, then the provision of accurate, up- to-date information is an important first step.
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373People want to know how to end their lives peacefully, reliably and with dignity. Most people know that they may never use this information. All are comforted, however, in knowing that if things ‘turn bad’ as they put it, they have a plan in place. Remember, suicide is legal, yet assisting a suicide is illegal. This is why everyone should develop an end of life plan. An end of life plan will keep one’s family and loved ones safe from the law. An end of life plan is the responsible thing to do.
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375The Peaceful Pill eHandbook Video: Introduction
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377Video: The role of providing information
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379Introduction Video: ‘Going Together’ The suicide note of Syd & Margorie Croft
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381Video: ‘Mademoiselle and the Doctor’ Film Trailer
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385Voluntary Euthanasia, Assisted Suicide, Suicide & the Law
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387In most western countries, suicide is legal, yet assisted suicide is a crime, attracting harsh legal penalties. While a person who takes their own life commits no crime, a person found guilty of assisting another can face a long jail term.
388
389Think about it. The law makes it a crime for a person to assist another person to do something that is lawful. There is no other example of this in modern western legal systems. This is why any person who chooses to be involved in the death of another - however tangentially and for whatever reasons – needs to be very careful indeed. This is especially true when friends and family are involved and emotions may cloud one’s judgement.
390
391Legal Definitions & Penalties
392
393Technically speaking Voluntary Euthanasia is the term used to describe the situation when a medical professional might administer to a patient a lethal injection. Voluntary euthanasia is legal in countries such as the Netherlands, Belgium and Luxembourg.
394
395By contrast, Physician Assisted Suicide (PAS) is the term that describes when a medical professional might prescribe, but not administer, a lethal drug to a patient. An example of this is the US states of Oregon,Washington and Vermont.
396
397Suicide and the Law The Law of Suicide & Assisted Suicide
398
399The Anomaly of Suicide and Assisting
400
401The Peaceful Pill Handbook
402
403Finally, the term Assisted Suicide describes the situation in Switzerland where the provision of lethal drugs to people who are suffering has long been decriminalized.
404
405Generally speaking, assisting a suicide is legally defined as ‘advising,’ ‘counselling’ or ‘assisting’ a person to end their life. Sometimes the words ‘aid and abet’ are also used. most countries assisting a suicide carries severe legal penalties.
406
407In
408
409The penalties generally range from 5 years to life imprisonment, depending upon the jurisdiction (eg. Australia). In Britain (and Canada) the penalty is up to 14 years. In 2009, the UK Director of Public Prosecutions, Keir Starmer, issued new guidelines on assisted suicide following a successful campaign by MS sufferer Debbie Purdy to seek clarification of the law.
410
411See:http://www.cps.gov.uk/news/press_releases/144_09/
412
413In the US, assisting a suicide is illegal in just over half of all states, with the remainder treating it in the same way as they treat murder or manslaughter. In the US, the penalties for assisted suicide vary from state to state.
414
415In Michigan, the late Dr Jack Kevorkian was incarcerated for almost a decade for the assisted suicide of his terminally ill patient, Thomas Youk. In March 1999, Kevorkian was convicted of second degree murder and sentenced to 10 to 25 years jail.
416
417The only States where Physician Assisted Suicide (PAS) is lawful in some circumstances are Oregon, Washington, Vermont and California. While the Supreme Court of Montana has held that assisted suicide is lawful, this is yet to be confirmed in statute.
418
419Suicide and the Law
420
421Defining Assisted Suicide So what is assisted suicide?
422
423At the current time, argument about what actually constitutes ‘assisted suicide’ shows no sign of easing. A significant grey area exists at the boundaries, with lawyers unable to give clear and concise answers to many questions about this issue.
424
425The dearth of case law leaves it unclear about whether, for example, giving a person the information they need is assisting with their suicide. Is buying your friend a one-way air ticket to Zurich assisting in their suicide?
426
427When the Irish authorities in 2015 prosecuted 43-year old Dublin woman, Gail O’Rorke, with doing just this - attempting to buy her friend, MS sufferer Bernadette Forde, a flight to Switzerland - the jury disagreed, and found Gail not guilty. But the Director of Public Prosecutions had made their point.
428
429See: http://www.bbc.com/news/world-europe-32499331
430
431And then there is the question of whether one would be guilty of assisting in a suicide if they are merely present when one’s loved ones drinks the Nembutal that they themselves have acquired?
432
433On the one hand there is the argument that the mere act of sitting with someone who is about to suicide provides psychological encouragement? Or does it? Do those present have a duty of care to prevent that person from harming themselves? Perhaps one should leap from one’s chair and grab the glass of lethal drugs from the person’s lips? But wouldn’t that be an assault? The law regarding assisted suicide is ill defined and murky.
434
435The Peaceful Pill eHandbook Legislation: What Type of Law is Needed?
436
437Over the years, legislation has attempted to bring clarity and order to the Assisted Suicide debate. By defining the class of person who can be helped to die and by stipulating the manner in which this help can be provided, laws such as the Rights of the Terminally Ill Act (Northern Territory) - the world’s first right- to-die law - went a long way towards establishing uniformity and equity.
438
439To make use of the Australian law a person had to be ‘terminally ill’. This was defined in the Act. The person also had to satisfy a number of other strict criteria. If they satisfied these conditions, then they would have the right to request lawful assistance from a doctor to die.
440
441Laws in places such as the Netherlands and Oregon and Washington also define exactly which group of people can have help to die. In all places, eligibility is tightly controlled.
442
443However, even where end of life laws work well, there is one significant drawback. The very strict set of conditions means that the process of establishing eligibility is demanding and can be humiliating to those involved.
444
445Besides, there are some people (those who fit the ‘tired of life’ description) who will simply never qualify. Frailty from old age is very different to having terminal cancer. Unless the law stipulates the criteria of unrelievable suffering, the person in question may find themselves wedged.
446
447In Australia in 1996, a terminally ill person had to obtain two medical opinions, a palliative care review and a psychiatric
448
449Suicide and the Law
450
451consultation before they could qualify to use the law to die. In practice, this meant that some very sick people had to beg the medical profession if they wanted to qualify to use the law to die.
452
453In the course of my involvement with this law, it quickly became apparent that none of my four patients who used the Rights of the Terminally Ill Act would have bothered with the exhaustive assessment process if they had access to a Peaceful Pill at home in the cupboard.
454
455Why would a person subject themselves to a compulsory psychiatric examination, if they already had the means to a peaceful, dignified death? They would simply have waited till the time was right and then taken the Pill from the locked medicine cabinet. The very laws that are supposed to empower these sick people can do the exact opposite, denying the individual control when it counts most.
456
457While some people may wish to involve the medical profession in their deaths, others do not. Our point at Exit is that death need not be a medical event. It is indeed arguable whether the medical profession is best placed to be given the role of arbiter: deciding who gets the right to die with dignity, and who does not.
458
459(An extensive discussion of Exit’s philosophy of death and dying can be found in Killing Me Softly: Voluntary Euthanasia and the Road to the Peaceful Pill (Penguin, 2005)
460
461Now available at: http://bit.ly/1eVogzs
462
463This medical model of death and dying hangs over us and needs to be challenged. This is, in part, why this book has been produced. The Internet Age has proven perfect for the democratisation of information.
464
465The Peaceful Pill eHandbook
466
467Laws Around the World
468
469Suicide and the Law
470
471Conclusion
472
473There are many understandable reasons why a seriously ill person (or an elderly person) should be encouraged to make an end of life plan. Exit does not accept the proposition that seriously ill people who plan for the end of their life are either depressed or mentally ill.
474
475Rather, a person’s right to end-of-life information is better understood as critical to empowering that person to make their own carefully considered decisions and choices. Just as they have done all their life.
476
477By implementing laws that restrict and withhold this information, the State is behaving in a way that is not only cruel, but inequitable and unjust. Those with money and connections will always be better resourced, better able to get the necessary information and better able to access the restricted drugs, than those who are less well off. the balance.
478
479This book is intended to restore
480
4813 What is a Peaceful Pill? Introduction
482
483The Peaceful Pill is a pill or drink that provides a peaceful, pain-free death at a time of a person’s individual choosing; a pill that is orally ingested and available to ‘most’ people.
484
485Dr Philip Nitschke
486
487It was the late Dutch Supreme Court Judge Huib Drion who first called for the introduction of a Pill. In a letter to the editor of the Dutch newspaper NRC/Handelsblad, Drion openly bemoaned the fact that while his doctor friends knew what to do and how to access the right drugs for a peaceful death, as a lawyer he did not.
488
489Drion questioned the logic of why he, a retired judge, should not have the same ready access to a dignified death as his doctor friends. According to Drion, all people over a certain age should have the right to die at a time of their choosing. A pill, he argued, would confer this right.
490
491Fig 3.1: Professor Huib Drion
492
493What is a ‘Peaceful Pill’?
494
495Elderly and ailing people often realize that, at some time in the future, they could well find themselves in an unacceptable and unbearable situation, one that is worsening. A pill to end life at one’s own discretion could alleviate some of their anxiety. Not a pill for now, but for the unforeseeable future so that the end can be humane (Huib Drion, Dikkers cited in Nitschke and Stewart, 2005)
496
497Following Drion, Exit research has confirmed that a Peaceful Pill provides peace of mind for its seriously ill or elderly owner, giving that person a sense of control over their life and death. Unlike end of life laws that depend solely upon a person’s state of health (or illness), Drion’s ‘universal model’ has only one criteria, that of age.
498
499Drion suggested that all people over the age of 65 years should have access to a Pill. While the age is arguable, the point remains the same. The ‘Drion Pill’ or ‘Peaceful Pill’ should be accessible to the seriously ill as well as the elderly.
500
501The History of the Suicide Pill
502
503The idea of a Peaceful Pill – that is, a lethal substance or liquid that can be orally ingested – is not new. In Athenian times, the herb Hemlock was the drug of choice for suicide and it was taken as a drink. The most famous Hemlock suicide was that of the Greek critical scholar, Socrates.
504
505In more modern times, the chemical compound Cyanide has been widely employed as a suicide pill. One recent well known death from Cyanide was that of Spanish quadriplegic Ramon Sampedro.
506
507The Peaceful Pill eHandbook
508
509In 1998, Sampedro ended his life by drinking cyanide that had been provided and prepared by his friends. The award-winning 2004 film The Sea Inside provides a remarkable account of his life and death.
510
511For much of the 20th Century, cyanide was routinely issued to intelligence agents as part of their job. Hitler’s head man in the SS and the Gestapo, Heinrich Himmler, escaped interrogation upon arrest by the British, by swallowing a capsule of cyanide.
512
513Hermann Goering, head of the Luftwaffe, avoided the hangman by taking potassium cyanide the night before the planned execution. Where the purpose is to avoid interrogation and torture, speed of action is essential and cyanide fitted the bill.
514
515The Best Peaceful Pill
516
517Half a century on and it is pentobarbital (Nembutal) that is favoured as an ideal Peaceful Pill. Nembutal is a member of the barbiturate family of drugs that are made from the salts of barbituric acid. These active barbiturate salts have been used medically for many years, mainly as sedatives or sleeping tablets.
518
519In the 1950s, for example, there were more than 20 marketed forms of barbiturate sleeping tablets. Early examples included Veronal, Amytal, Seconal, Soneryl, and, of course, Nembutal. Fifty years ago, Nembutal was a widely prescribed drug, recommended even to help babies sleep, and to calm aching teeth.
520
521What is a ‘Peaceful Pill’?
522
523Over the last 30 years the barbiturates have slowly disappeared from the market. The fact that in overdose they caused death, either accidentally or deliberately, and the availability of newer, safer sleeping drugs has led to their decline. Nembutal was removed from most countries’ prescribing schedules in the late 1990s.
524
525Perceived Benefits of a Peaceful Pill
526
527While there are any number of ways by which a seriously ill person can end their life, few of these methods meet our criteria of:
528
529• reliable
530
531• peaceful •
532
533dignified.
534
535In most western countries, hanging and gun shot remain the most common methods of suicide.
536
537Yet few people would choose such means if they had any real choice. Most seriously ill or elderly people who are considering death, seek a method that is peaceful, dignified and pain free. Most commonly, this is expressed as, ‘I simply want to go to sleep and die in my sleep.’
538
539Fig 3.2: Survey of Exit Members Methods of Self Deliverance
540
541The Peaceful Pill eHandbook
542
543In 2004, Exit International undertook a major study of our supporters’ attitudes to various methods of dignified dying (n=1163). What we found was a strong and significant preference for a Pill over all other methods. Indeed, 89% of respondents (average age 72 years) said that they would prefer to take a Pill than use a plastic Exit bag, a carbon monoxide generator (COGenie) or seek help from a doctor to provide them with ‘slow euthanasia.’
544
545A ‘Pill’ was defined as something that could be taken as a single oral dose (by mouth) in either tablet form or as a small drink.
546
547The reasons behind the respondents’ preferences became clear as more of the data set was examined. Most of those surveyed saw the Peaceful Pill as an important way of providing independence (91%). It was seen as an advantage if one did not have to depend on friends and family for assistance when the time came.
548
549A Peaceful Pill was also seen to provide ‘peace of mind’ (90%), was reliable (88%) and, unlike the Exit Bag or the Carbon Monoxide Generator, the Pill was easy-to-administer (87%) since it required no equipment and no technical know-how.
550
551In this way, the Peaceful Pill was seen as a method that was accessible and usable, even by the most frail.
552
553What is a ‘Peaceful Pill’? Conclusion
554
555Exit’s survey revealed a strong preference for a reliable and effective Peaceful Pill.
556
557This was seen as the best means of providing the option of a peaceful death at the time of one’s choosing.
558
559The remainder of this book focuses on the various forms a Peaceful Pill might take.
560
561In providing this information we are following the agenda set by long-standing members of Exit International.
562
563The Peaceful Pill eHandbook
564
565The Single Shot Peaceful Pill Project: Background
566
567What is a ‘Peaceful Pill’?
568
5694 The Exit RP Test
570
571Many end of life options are discussed in this book and it can be a daunting project trying to distinguish or compare the relative advantages or shortcomings of one over the other. To simplify the process, we have developed a simple rating system that can be applied to all end of life methods. We call this the Reliability & Peacefulness Test – the ‘Exit RP Test’.
572
573Primary Criteria
574
575The ‘Exit RP Test’ provides a benchmark against which all end of life options can be considered. The values addressed by the test came to Exit’s attention through specific research on the notion of a Peaceful Pill and also through personal accounts and anecdotes over the past decade. This feedback continues to identify two principal factors in people’s preferences for end of life methods. These factors are ‘Reliability’ and ‘Peacefulness.’
576
577In the RP Test, Reliability and Peacefulness are each given a score of 1 to 10. The higher the number, the more reliable and peaceful the method in question. For example, Nembutal achieves a high overall score, hanging a very low score.
578
579The Exit RP Test
580
581Video: The RP Test What it is and How does it Work?
582
583Video: RP Test: Hanging
584
585The Peaceful Pill eHandbook Reliability (R - 10)
586
587Reliability has been consistently identified as a major important factor in assessing end of life methods. A seriously ill person wanting to end their life needs to know the method will work. No one wants to take chances with a method that might work. Reliability is essential.
588
589Peacefulness (P - 10)
590
591Peacefulness is the second major criteria identified by Exit. There is almost no interest in methods that are violent, irrespective of how reliable they might be.
592
593The most commonly expressed wish by seriously ill and elderly people is that they be able to die in their sleep.
594
595Secondary Criteria
596
597There are a number of lesser, but nevertheless highly-desired, characteristics for a method of dying. Six additional secondary factors are listed below:
598
599Availability (A) Preparation and Administration (Pr) Undetectability (U) Speed of Effect (Sp) Safety to Others (Sa) Storage - Shelf Life (St)
600
601In the RP test, a score of 1-5 is given for each of these secondary characteristics.
602
603The Exit RP Test Availability (A - 5)
604
605To be of any use the method must be available. The most peaceful and reliable drug is of no use if it is unavailable. Preparation and Administration (Pr - 5)
606
607Simplicity of preparation and administration is an important factor. No one wants to use complicated equipment that is difficult to assemble or drugs that are hard to use.
608
609Undetectability (U - 5)
610
611Methods that leave no obvious trace are strongly preferred. In reality, this might mean that an attending physician will be more likely to assume that the death has been caused by a known underlying disease. does not arise.
612
613In this situation, the question of suicide Speed of Effect (Sp - 5)
614
615Speed of death is a further significant factor. Speed limits the likelihood of discovery and any possible interference (resuscitation).
616
617Safety to Others (Sa - 5)
618
619Most seriously ill people do not want to die alone. Methods that present a danger to others are unpopular for this reason.
620
621Storage - Shelf life (St - 5)
622
623There is a strong preference for methods that use substances, drugs or items that do not deteriorate with time. This means the person should be able to assemble the required items or obtain
624
625The Peaceful Pill eHandbook
626
627the required drugs in advance, and not have to worry about linking the possible timing of one’s passing to the acquisition of the items. All of the methods described in this book have been given an Exit RP Test score. The maximum possible is 50 points, the higher the score the ‘better’ the method. Some criteria will vary of course depending on an individual’s particular circumstances. The RP Test rating should only ever be used as a general guide.
628
629Take the example of the Exit Bag when used in conjunction with Helium (see Chapter 5).
630
631Test Factor Reliability:
632
633This is good, but technique is important Peacefulness:
634
635There is some short term awareness and alarm Availability:
636
637Necessary items are readily available Preparation:
638
639Items require assembly and coordination Undetectability:
640
641If items removed, totally undetectable, even in the event of an autopsy
642
643Speed:
644
645Unconsciousness and death occur quickly Safety:
646
647The method presents no risk to others present Sp=5/5 Sa=5/5 Score R=8/10 P=7/10 A=5/5 Pr=1/5 U=5/5
648
649The Exit RP Test Storage: Equipment does not deteriorate and testing
650
651readily available Total for Helium and an Exit Bag
652
653St=5/5 is 41 (82%)
654
655Now compare the RP Test result for the Exit Bag + Helium with the Use of Sodium Cyanide (see Chapter 7).
656
657Test Factor Reliability: This is very high
658
659Peacefulness: Patchy reports, hard to assess Availability: Difficult to obtain or manufacture Preparation: This is straightforward Undetectability: Some clinical changes
660
661may be noted, certainly noted on autopsy Speed: Produces a rapid death
662
663Safety: There may be some slight risk to
664
665those present from possible HCN gas production Storage: Well packaged, shelf life indefinite
666
667Total for Sodium Cyanide Score
668
669R=10/10 P=5/10 A=2/5 Pr=5/5 U=3/5
670
671Sp=5/5 Sa=3/5
672
673St=5/5 38 (76%)
674
675The Peaceful Pill eHandbook
676
677A Note of Caution The RP Test score serves only as a guide.
678
679Individual
680
681circumstances and preferences will always influence a person’s decision. There are people for whom a plastic Exit bag over their head will never be a viable option, no matter how peaceful and reliable the method.
682
683This may be because of an individual’s particular aesthetic concern and have nothing to do with the method’s high reliability physiologically. Nevertheless, if this is a real concern, the method will not be considered, irrespective of the high RP Test score.
684
685Similarly, the ‘availability’ of a particular method can differ from individual to individual. The comparison above suggests that helium would be preferred above cyanide.
686
687However, if an individual has recently become so disabled through illness that the use of an Exit Bag is physically impossible, and yet that same person has access to cyanide powder, the final choice will clearly not be determined by the highest RP Test score.
688
689See the Table towards the end of the eHandbook which provides the overall RP Test scores for the six approaches described in this book.
690
691The Exit RP Test
692
693Video: RP Test : Nembutal
694
6955 Hypoxic Death & the Exit Bag
696
697• The Hypoxic Death • Role of Carbon Dioxide • Hyperventilating to minimise the Alarm Response • Aesthetic & other considerations • A Peaceful Death using Inert Gas • Optimal Gas Flow Rate • Gas Source (Nitrogen or Helium) • Max Dog Nitrogen in the USA • Testing Gas Purity • The Exit Bag • Connecting the cylinder to the Exit Bag • The Procedure • Using Spirometry to screen those with lung disease • After a death • Summary of the Max Dog Method (in pictures) • Concluding Comments
698
699Introduction
700
701The plastic Exit Bag provides people with the means to obtain a simple, effective, peaceful and entirely lawful death. While Exit research has found that relatively few people would prefer to use a Plastic Bag over the simple ingestion of a Peaceful Pill, it remains one of the most accessible methods available.
702
703There is much misinformation, however, about how a plastic Exit Bag works and why it is so effective. The common assumption is that the bag causes death by ‘suffocation.’ This is not the case.
704
705Hypoxic Death & the Exit Bag
706
707Suffocation occurs when a person cannot easily take a breath. Examples of suffocation include tying a rope around the neck, or pushing a pillow into one’s face. The act of mechanically blocking one’s breathing is terrifying, and people will struggle with the last of their strength to clear the obstruction.
708
709When used properly, the plastic Exit Bag brings about a peaceful death; there is no obstruction. The death comes from (freely) breathing in an atmosphere where there is no oxygen (hypoxia). With an Exit Bag, a person breathes easily and peacefully; and the bag expands and contracts with each breath. The bag is not next to, or touching the face or mouth. This is in stark contrast to suffocation. This is why it is important not to confuse a peaceful hypoxic death that is possible when an Exit bag is used properly, with the grim death that results from an obstruction to the airways.
710
711And this is why we should be wary of media reports that reinforce this confusion. For example, when referring in 2001 to the importation of Canadian Exit bags, Rupert Murdoch’s News Limited (The Australian newspaper) reported these bags as ‘reminiscent of the Khmer Rouge’s shopping bag executions of Cambodia’s killing fields.’ Such reports show a total lack of understanding of the process and have damaged the image of the Exit Bag.
712
713The Hypoxic Death
714
715Hypoxia is a term meaning ‘low oxygen’. A death that results from inhaling insufficient oxygen is a hypoxic death. While there are several ways that this might occur, the common method
716
717The Peaceful Pill eHandbook
718
719used by those seeking a peaceful death is to suddenly immerse oneself in a non-oxygen environment.
720
721The simplest way to achieve this is by filling a plastic bag with an inert gas and then to quickly place this bag over one’s head. To understand why the plastic Exit bag provides an easy and reliable way to die, a basic understanding of human physiology is helpful.
722
723In normal everyday life, we live in an atmosphere that is 21% oxygen. Interestingly, when there is a decline in the level of oxygen in the air we are breathing, we do not experience alarm or concern. As long as one can breathe easily, the sensation one experiences as the oxygen level drops is that of disorientation, confusion, lack of coordination and eventual loss of consciousness.
724
725This experience is sometimes likened to being drunk (alcohol intoxication). When the oxygen level becomes too low, death will result. Accidental hypoxic deaths are not uncommon and there is a number of scenarios that can bring them about. One example is the sudden drop in oxygen level that occurs when an aeroplane depressurizes at high altitude. This can lead to a rapid loss of consciousness and the death of all those on board.
726
727When the plane de-pressurizes, passengers still breath easily. The problem is that there will be little oxygen in the inhaled air. This lack of oxygen will cause a sudden drop in the dissolved oxygen in the blood reaching the brain. This will lead to loss of consciousness and death.
728
729It is not uncommon for planes that have suddenly de-pressurized to travel on autopilot until they run out of fuel, well after everyone aboard has died. Witnesses (from planes sent to
730
731Hypoxic Death & the Exit Bag Video: Introduction to the Exit Bag
732
733Video: The Problem of Carbon Dioxide
734
735The Peaceful Pill eHandbook
736
737investigate) say that it often appears as though everyone on board has just gone to sleep.
738
739Pneumonia is a more common cause of a hypoxic death. Its peaceful reputation has led to its common description as the ‘old person’s friend’. While the air inhaled may contain the full 21% of oxygen, the inflammation of the lungs (caused by the pneumonic infection) makes it impossible for the necessary oxygen to be extracted. The blood reaching the brain will have less oxygen than that required for life, and a peaceful death often results.
740
741The presence of an inert gas like Nitrogen or Helium in the Exit Bag will dramatically speed the hypoxic process. When
742
743Fig 5.1: 380 litre ‘Max Dog’ Nitrogen cylinder
744
745Hypoxic Death & the Exit Bag
746
747a person exhales fully, pulls down the Exit bag that is pre-filled with Nitrogen and then takes a deep breath, the person’s lungs will be filled with a gas in which there is very little oxygen. This means that blood passing the lungs on the way to the brain will find no oxygen available. When blood with a low oxygen level reaches the brain, consciousness is rapidly lost within one or two breaths. It is the lack of oxygen in the inhaled gas that causes death (not the gas itself).
748
749For the process to work, it is important that the air in the lungs (with 21% Oxygen) is quickly and fully replaced with the inert gas. For hypoxia to occur, the person empties their lungs of air (big breath out). They then replace this with a deep full inhalation of a gas such as nitrogen (which contains 0% oxygen). With good lung function (and practice) this can be achieved with a single exhale/ inhale cycle. A problem associated with using this method, however, is that lung disease (or poor technique) can prevent a full exchange of gas. If a person has lung disease and is concerned about the use of this method, it is advised that they undergo a test to measure their lung function (spirometry). A lung function test gives an indication of whether this strategy is appropriate for them. (See the section on spirometry screening, later in his Chapter.)
750
751It is important to note that the inert gas, itself, does not interact with the body. Nitrogen, argon or helium all have no taste or smell. All quickly dissipate after death. While helium can be detected at autopsy, there is no test that can reveal the use of a nitrogen-filled Exit bag. This makes nitrogen particularly useful for those who don’t wish their cause of death to be established. (Of course, this presupposes that the equipment will be removed before the body is ‘discovered’. In some jurisdictions this will be an offence so check your local laws if you think this is a strategy of interest).
752
753The Peaceful Pill eHandbook
754
755The Role of Carbon Dioxide (CO2
756
757)
758
759In normal respiration, the human body uses oxygen and produces carbon dioxide as waste. Carbon dioxide is removed from the body when we exhale. While the human body is relatively insensitive to falling levels of oxygen, it is very sensitive to any rise in the level of carbon dioxide.
760
761When the body detects an increase of carbon dioxide, a warning message from the brain alerts us. The person will be roused and reacts by gasping and experiences “air hunger”. If the person is using a plastic Exit bag, any rise in the level of carbon dioxide within the bag may result in the person pulling the bag from their head in panic. This reaction is known as a Hypercapnic (high carbon dioxide) Alarm Response.
762
763Hyperventilating to Minimise the Alarm Response
764
765reduces any liklehood of an alarm response when the bag is pulled down.
766
767To minimise the chance of experiencing panic and air hunger, it is recommended that before pulling down the bag, one spends a short time (1-2 mins) hyperventilating, ie inhaling and exhaling air into the lungs fully at an increased frequency. Put simply, deep breaths in and out quickly. This hyperventilating has the effect of pre-lowering the CO2
768
769level in the blood, and greatly
770
771Hypoxic Death & the Exit Bag Video: Application of the Exit Bag (Helium)
772
773Video: Suicide and the Death Certificate
774
775The Peaceful Pill eHandbook Aesthetic and Other Concerns
776
777The image of a bag tied tightly around one’s neck has turned many off the plastic Exit Bag approach. Even at Exit International workshops, it is common for those in the audience to voice their disgust at the Exit Bag, saying ‘I don’t like the thought of being found like that.’ Retired French academic, Lisette Nigot, spoke openly of her dislike for the method. In the film, Mademoiselle and the Doctor (discussed earlier), Lisette likened the plastic Exit Bag to being ‘wrapped like a piece of ham.’ For many readers, the main concern will be one of aesthetics. Despite such concerns, if used correctly, the Exit Bag provides a simple, reliable and peaceful end of life option.
778
779A Peaceful Death using Inert Gas
780
781Whereas once it was advocated that an Exit bag could be used with sleeping pills, this approach is now firmly discarded. The best method of using an Exit Bag, by far, involves the use of an inert gas such as Nitrogen, Helium or Argon.
782
783The use of an inert gas is advocated because of its ability to create a space that is devoid of oxygen. It is the space created by the inflated bag that makes a peaceful death from hypoxia (lack of oxygen) possible. A person using an Exit Bag will only have the bag over their head for a matter of seconds until unconsciousness occurs. With prior hyperventilation and a steady flow of inert gas to flush away any exhaled CO2, there is no risk of a person reacting badly.
784
785Let us explain. The flow of gas into the Exit Bag displaces residual or exhaled oxygen. A person does not need to wait for the residual oxygen inside the bag to be used. Rather, by allowing a steady flow of the inert gas into the bag, there will
786
787Hypoxic Death & the Exit Bag
788
789be no oxygen from the first instant. The flow of the inert gas into the bag has the second purpose of flushing away any exhaled carbon dioxide. As it is the build-up of carbon dioxide that panic reaction, this risk is also eliminated.
790
791Note: To recap, there is nothing special about the inert gas used in terms of whether it is Nitrogen, Helium, Argon or others. Indeed, any gas that does not react with the body and that is odorless and available in a compressed form, would be suitable. Most often the choice is determined by what is available.
792
793Most compressed gases are only available in high pressure cylinders which are leased from commercial gas supply companies (such as BOC or Air Liquide). The drawback with accessing a compressed gas in this way is the paper trail that it generates. There is no anonymity. An additional deterrent is that the commercial compressed gas cylinders are often large, heavy and difficult to transport. Suspicion might arise if an elderly or very sick person is seen leasing a cylinder from their local gas outlet. There is an added complication in that if a friend were to collect the cylinder for them, this other person may become legally implicated in assisting in the suicide. These issues are disincentives to using commercial, high-pressure, compressed inert gas cylinders.
794
795An exception to the above, is the advent of home brew beer supply companies that have started to market light-weight, portable, high pressure Nitrogen cylinders that can be purchased outright. One such company is Max Dog Brewing (owned by the first author who is also a keen home brewer and craft beer aficionado). Max Dog cylinders are made of steel or aluminium (depending on the country of purchase) and come complete with a custom flow regulator. Their shelf life is indefinite and they can be refilled if required.
796
797The Peaceful Pill eHandbook
798
799Low pressure disposable cylinders of Helium and Argon are also available and can be used effectively with the Exit Bag. It is the availability of inert gases in easy-to-acquire, purchase- outright, take-home cylinders that has seen the Exit Bag strategy of renewed interest. In places such as North America, Europe, Australia and New Zealand, Helium is a second gas available in disposable take-home cylinders. Known as ‘Balloon Time’ kits, these cylinders are used to fill balloons with helium so that they float up to the ceiling for birthday parties and so on (Fig 5.5 shows a range of available sizes).
800
801The Optimal Gas Flow Rate
802
803A peaceful hypoxic death with an inert gas and an Exit Bag, depends upon an optimal gas flow. The optimal flow will be sufficient to flush away exhaled carbon dioxide so that the gas does not accumulate within the bag. An optimal gas flow will also prevent the bag from becoming uncomfortable, yet is slow enough so that the flow continues for > 20 minutes.
804
805Fig 5.2: Exit Bag CO2
806
807& O2
808
809concentration lvels for the first 5 minutes
810
811Hypoxic Death & the Exit Bag
812
813To determine the optimal flow, Exit has carried out experiments where different flow rates of air were admitted to a bag over a test subject’s head. The level of carbon dioxide within the bag was monitored using an RKI sampling gas detector.
814
815The results for an 80 kg male taken over a 5 minute period for two gas flow rates (5 & 15 litres/ min) are shown in Fig 5.2
816
817For 15 litres/ min gas flow the level of carbon dioxide in the bag does not rise appreciably over the 5 minute period. With the low flow rate, the level of carbon dioxide approached 5%. This was enough to make the subject uncomfortable and alarmed. A flow rate of ~15 litres/ min was seen as optimal.
818
819For Max Dog Nitrogen cylinders, the click-flow regulator can be set to 15 litres/ min. The gas will flow at this rate until the cylinder’s contents are exhausted ( ~400/15 or ~25 minutes, more than enough for a reliable and peaceful death).
820
821For Balloon Time (or other similarly branded) cylinders which do not ship with suitable flow control regulators, it is difficult to control the flow of gas. The nylon tap provided with the cylinder is designed to fill party balloons. The tap is not designed to allow a slow, consistent gas flow rate. For use with an Exit bag, Exit recommends that the nylon fitting be discarded and replaced with a custom brass jet flow fitting available at: http://bit.ly/1ILmCMM
822
823Using the Exit flow control kit on a standard 420 litre helium cylinder gives a useful operating time of ~20 minutes.
824
825The Peaceful Pill eHandbook
826
827The Gas Source (Nitrogen or Helium) 1. Nitrogen & the Max Dog Brewing Delivery System
828
829Nitrogen is a very common gas, making up ~ 80% of the air we breath. The gas is cheap, in no danger of running out, and readily available. Nitrogen is not restricted and no questions are asked about why one would want a source of this gas. Indeed, home brewers use the gas in beer dispensing systems, when they want to achieve the fine bubbles and a creamy head similar to Guinness stout (Nitrogen is used to aerate Guinness stout).
830
831Since 2012, cylinders filled with nitrogen have been available from Max Dog Brewing. These high pressure cylinders contain ~400 litres of nitrogen, and can be refilled.
832
833Regulating the Flow of Nitrogen
834
835Max Dog Brewing nitrogen cylinders ship with a custom flow control regulator (see Fig 5.3). These regulators incorporate a pressure gauge which indicates the pressure in the cylinder. They use a click setting to adjust the flow rate. The optimum flow rate for a peaceful death (15 litres/ min). The delivery hose that takes the nitrogen from the cylinder to the Exit Bag fits directly on to the regulator outlet.
836
837Fig 5.3: Max Dog Nitrogen flow regulator showing the guage to indicate if the cylinder is full of Nitrogen and the click-flow setting (shown set to 15 litres/min)
838
839Hypoxic Death & the Exit Bag The Max Dog Brewing Beer Nitrogen System
840
841Max Dog is an international retailer of Nitrogen based in Cairns, Australia. The Max Dog Brewing beer nitrogen system varies slightly between country but generally consists of a 2.8 litre alloy or steel cylinder filled to a pressure of 13.1 MPa (1800 psi) (See Fig 5.4a).
842
843The cylinders weigh ~3 Kg (~7lb) and full they contain 390 litres of nitrogen. A full cylinder will provide 25 minutes of constant gas flow into the Exit bag, if the gas is delivered at the optimum 15 litres/ min. This is more than enough for a peaceful death. For details see Fig 5.12, or visit: http://www.maxdogbrewing.com
844
845One useful aspect of the MDB nitrogen system is the fact that the cylinders can be topped up if there is leakage of nitrogen over time, or completely refilled (unlike disposable Helium and Argon cylinders). Note: To determine if a cylinder is full, the pressure should be measured. The regulator provided incorporates the pressure gauge required.
846
847Max Dog in the USA
848
849In the US, MDB provides a unique American Kit consisting of an adjustable flow, soft-nose regulator, pressure gauge and connecting hose.
850
851Full 20 cu ft steel cylinders of nitrogen (0916-0145) can be ordered separately and can be delivered to your door from CyberWeld (Fig 5.4b).
852
853See: http://store.cyberweld.com/shielgascyl22.html
854
855The Peaceful Pill eHandbook
856
857Fig 5.4 (a) Australian 400 litre Max Dog Brewing cylinder
858
859Fig 5.4 (b) American CyberWeld 20cu ft Nitrogen cylinder
860
861Hypoxic Death & the Exit Bag 2. Helium
862
863Balloon Time kits from Worthington in Ohio have long been available around the world as a cheap, disposable source of Helium gas for party balloons. There have been two sizes: small (250 litres) and large (420 litres).
864
865In Nth America, Balloon Time canisters have been available at websites such as Walmart and Amazon.
866
867http://bit.ly/1EjGzTj http://amzn.to/1350XZi
868
869In Australia and New Zealand, Balloon Time cylinders have been available at Spotlight stores.
870
871In the UK, Balloon Time (and its equivalents) have been available on websites such as Party Delights, Argos and Tescos.
872
873http://bit.ly/1dkq8B9 http://bit.ly/1FB9KZb http://bit.ly/1ElUdYx
874
875As discussed earlier, these kits are designed to provide an instant system to fill helium party balloons. Most cylinders ship with a packet of party balloons (30 or 50 depending upon the size cylinder) and ribbon tie. The kits are purchased outright, leaving no paper trail.
876
877Note: The UK supermarket chain, Tescos, have recently changed from selling Balloon Time-branded cylinders to a BOC-branded version which contains 11.7ft3 /.33m3 of Helium gas.
878
879The Peaceful Pill eHandbook
880
881Fig 5.5: Balloon Time Disposable Helium Cylinders Top: Large size (420 litres) (14.9 cubic feet) Below: - Small size (250 litres) (8.8 cubic feet)
882
883Hypoxic Death & the Exit Bag
884
885Fig 5.6: Top: Tesco - BOC Disposable Helium Cylinders (UK) Below: - Argos-branded Balloon Cylinder (UK)
886
887The Peaceful Pill eHandbook Testing Gas Purity
888
889For the hypoxic method to work quickly and efficiently, it is absolutely essential that there be no oxygen in the gas being breathed. To recap, this is because it is the sudden reduction in oxygen level (from the 21% in air) to effectively 0% within the confines of the Exit bag, that results in the immediate loss of consciousness (LOC). If the gas filling the bag has any oxygen contamination, this will reduce the chance of an immediate LOC. If the oxygen level is too high, this can and will result in a failed attempt.
890
891For some time, authorities have argued that as an anti-suicide safety precaution, helium gas that is available in an unregu- lated manner for purchase by the public, should be adulterated to include up to 10% oxygen. The authorities realise that this would make the gas useless for those wishing to die.
892
893In the case of helium that is marketed as a disposable cylinder for inflating party balloons, contamination with oxygen would not affect the use of the gas for floating balloons. However, it would affect the use of the cylinders for a hypoxic death.
894
895Fig 5.7: Testing for oxygen contamination in a Tescos/ BOC (UK) disposable helium cylinder
896
897It is of interest that as long ago as 2011, the New Zealand Coroner, Ian Smith, in investigating the deaths of 37-year old Kyle McIntosh, and an unnamed 23-
898
899Hypoxic Death & the Exit Bag
900
901year old Wellington man, recom- mended mandatory oxygen con- tamination. Both men had died using Balloon Time helium.
902
903In April 2015, the largest manu- facturer of disposable helium cylinders, Worthingtons, finally announced that their dispos- able helium cylinders may now contain up to 20% air (ie. up to 4% oxygen). As stated earlier, the contamination of a source of 100% helium with up to 20% air (and 4% oxygen) is a game- changer as far as death from hy- poxia is concerned. This development by Worthingtons means that their disposable Balloon Time helium gas cylinders should NOT BE USED by those wishing to end their lives by hypoxia.
904
905Fig 5.8: Meter used to detect oxygen contamination
906
907Whether economic factors are driving this change is unknown. However, this could well be the case given the steep increase in the cost of helium in recent years. This trend is predicted to continue into the foreseeable future. Indeed, some are predict- ing that Helium will disappear altogether within the next 25 years.
908
909It is interesting to note that the British Tesco/ BOC equivalent of Balloon Time has not followed Worthington’s lead in oxy- gen contamination.
910
911To recap: it is critical to ensure that the gas source chosen for a hypoxic death is free of any significant contamination with oxygen. If there is any doubt, the gas should be tested.
912
913The Peaceful Pill eHandbook Testing a Disposable Helium Cylinder
914
9151. Obtain an accurate oxygen sensor eg the Detector CY-12C Oxygen Analyzer, cost ~US$100 - click HERE (see Fig 5.8)
916
9172. Calibrate the sensor by setting the gauge to 21% in air 3. Attach the flow regulator jet to the gas cylinder and con- nect the hose to run the 15 litres of gas for testing into the filtered input of the gauge. (See Fig 5.7).
918
9194. Let the gas flow until a steady reading is obtained on the most sensitive gauge setting.
920
921The reading should be < 2% (ie. <10% of the oxygen present in room air) if the gas is to be used.
922
923At the end of the test, record the cylinder pressure to ensure that there is still an adequate supply left for a hypoxic death.
924
925NOTE: The issue of oxygen contamination does not affect Max Dog Brewing Nitrogen cylinders because they contain 100% nitrogen.
926
927Fig 5.9: Flow Rate, Pressure and Volume of Helium with Time for 420 & 250 litre Cylinders using the Exit Gas Control Jet Assembly
928
929Hypoxic Death & the Exit Bag
930
931If, after testing your Helium cylinder and finding no oxygen contamination, a small Balloon Time cylinder (see Fig 5.5b below) will contain sufficient helium for a peaceful death, as long as the Exit gas flow control is used to establish the stated optimal flow rate of ~ 15 l/min.
932
933The larger 420 litre Balloon Time cylinder will give a greater margin for error as this cylinder produces a usable stream of gas for approximately 20 minutes. This is more than enough time for a peaceful death to occur. Useful flow rates are obtained from both cylinder (>5 litres/min for 15 minutes with the small cylinder, and 25 minutes with the larger - see Fig 5.9).
934
935Gas Flow Control
936
937No matter which brand of helium gas is used, a flow rate of ~ 15 l/min is needed to prevent the accumulation of CO2 in the Exit Bag. Exit has investigated several methods of controlling the gas flow.
938
939• For high pressure cylinders of nitrogen (Max Dog or equivalent) or helium, regulation is essential. Flow regulators are provided with the Max Dog system or can be purchased from gas providers. The Max Dog regulator shown in Fig 5.4 gives the pressure of nitrogen in the cylinder, and allows the output flow rate to be set at 15 litres/ min. Using this regulator, flow rate is constant throughout the hypoxic death.
940
941• For ‘Balloon Time’ and similar helium cylinders at pressures of 1.7MPa, Exit has invented gas flow control fittings expressly for this purpose (Figs 5.10 & 5.11). These fittings give an initial flow rate of ~20 litres/min when the tap is opened fully. Exit helium flow fittings are available at: http://bit.ly/1ILmCMM
942
943The Peaceful Pill eHandbook Ensuring a Cylinder is Full
944
945When using a cylinder of compressed gas, it is important to establish that there is sufficient gas available for a peaceful hypoxic death. For compressed gas in cylinders, the easiest way of ensuring this is to measure the pressure. This is particularly important for cylinders that have been kept in storage for long periods.
946
947If using the Max Dog Brewing nitrogen system, the pressure will be shown by the gauge on the regulator supplied. To measure the pressure, turn the regulator flow rate to 0 litres/min and open the cylinder to read the pressure. This should be ~12MPa (1750psi) (see Fig 5.4).
948
949For Balloon Time and similar helium cylinders, the Exit pressure gauge that fits the flow control makes testing the pressure simple. A full cylinder should have a pressure of ~ 1.7MPa (250 psi). Some of these cylinders have been found to have faulty taps and to be near empty on purchase. This is why it is so important to use an Exit pressure gauge (see Fig 5.10 & 5.11).
950
951Fig 5.10: The Exit Helium flow control fitting
952
953Fig 5.11: Pressure
954
955gauge used to check if gas cylinder is full
956
957Hypoxic Death & the Exit Bag
958
959Fig 5.12 Max Dog website www.maxdogbrewing.com
960
961Fig 5.13 Helium flow fittings at the Exit Store
962
963The Peaceful Pill eHandbook
964
965Fig 5.14:
966
967(a) Checking the pressure of a full max Dog nitrogen cylinder. Flow 0 l/min, Pres- sure 13MPa
968
969(b) Helium cylinder with pressure gauge attached to flow control assembly. Full pressure 250psi or 1.7MPa
970
971Hypoxic Death & the Exit Bag Video: Why the Exit Bag will not suit all People
972
973Video: Do it Yourself with Betty
974
975The Peaceful Pill eHandbook The Exit Bag
976
977To download detailed instruc- tions on making your Exit Bag
978
979Click HERE
980
981The Exit plastic bag is the bag which is filled with the inert gas. The bag is designed to enable simple filling with no contamination with oxygen, providing a straight forward way for one to suddenly immerse oneself in inert gas.
982
9831. Making an Exit Bag
984
985While different people make slightly different bags, the standard Exit Bag involves a plastic bag of:
986
987• a reasonable size • a suitable soft plastic • a neck band of elastic that allows the bag to make a snug, but not tight, fit around a person’s neck
988
989The method used by Nurse Betty is shown in the video on the previous page. A second method is shown in the tab above. Either way, a reliable and effective bag can be assembled in a few minutes. The components are:
990
991•
992
993Plastic bag - PVC 35cm x 50cm x 50 micron PVC is a good size. Or a large polyester ‘oven bag’ see ‘A & B’
994
995• 1 metre of 10 mm wide elastic, ‘D’ • 1 toggle (or other fastener) to adjust elastic length • 1 roll of 20mm sticky tape ‘C’ (Micropore or equivalent) • 1 small roll of ~ 35 mm plastic duct tape • Pair of sharp scissors
996
997Fig 5.15 Items used to construct an Exit Bag
998
999Hypoxic Death & the Exit Bag Construction (See Fig 5.16 & Do it with Betty video)
1000
10011. Lay the bag out on a flat surface and folded back ~ 25mm (1”) around the open end (A-B)
1002
10032. Make a 25mm cut in the folded plastic 3. Lay the elastic (C) inside the fold and have the two ends exit through this cut
1004
10054. Tape completely along the folded edge of the plastic with the sticky tape
1006
10075. Place a cut in a ~ 60mm piece of duct tape and fold this over the exiting elastic to strengthen this part of the bag
1008
10096. Thread a small wire tie through two cuts in another piece (~50mm) of duct tape and stick this to the inside of the bag ~ 15cm up from the elastic (E). This can be used to secure the plastic helium hose inside the bag.
1010
10117. The toggle (D) (or other fastener) is then threaded onto the two ends of the elastic to complete the bag (Fig 5.15)
1012
1013Connecting the Cylinder to the Exit Bag
1014
1015To use the Exit Bag with an inert gas, one needs to connect the gas cylinder to the Exit bag. Plastic tubing (standard 2 metre oxygen tubing with soft connectors) is available to Exit members from their local Exit Chapter or pharmaceutical suppliers. The tubing is tightly fitted to the Max Dog regulator outlet, or the tail-end on the helium flow control fitting.
1016
1017The Peaceful Pill eHandbook Fig 5.16: Exit Bag Manufacture
1018
1019Fig 5.17: The completed Exit Bag
1020
1021Fig 5.18: Positioning, inflating & Using the Exit Bag with Nitrogen
1022
1023Hypoxic Death & the Exit Bag Video: Betty does Max Dog Nitrogen
1024
1025Video: Betty & the Exit Bag
1026
1027The Peaceful Pill eHandbook
1028
1029The use of Lung Function Screening (Spirometry) for those with respiratory disease
1030
1031For a peaceful death one must be able to fully exhale and inhale. This allows the rapid exchange of the air in the lungs with the gas in the bag. Some respiratory disease can make this difficult or impossible. The question is, when is lung disease severe enough to indicate that an alternative end of life method should be considered.
1032
1033Lung disease is usually broken into two main classifications: ‘Restrictive’ disease where there is difficulty filling the lungs with air, and ‘Obstructive’ disease where there is difficulty emptying the lungs. Emphysema, COAD, chronic bronchitis and asthma are all examples of obstructive respiratory disease. Pulmonary fibrosis, sarcoid, or conditions such as scoliosis or obesity or neuro-muscular conditions such as motor neurone disease can all cause a restrictive pattern.
1034
1035For the hypoxic method to work well and bring about a quick, peaceful and reliable death, you need to be able to fully exhale (leaving little residual air in the lungs ie not have significant obstructive disease), then fully inhale filling the lungs with
1036
1037Fig 5.19: Spirometry to assess lung function before using an Exit Bag
1038
1039Hypoxic Death & the Exit Bag
1040
1041nitrogen (ie not have significant restrictive disease). Spirometry offers a quick effective screening test to exclude significant lung pathology that may interfere with the method.
1042
1043The test involves inhaling fully, then fully exhaling hard and fast through the spirometer mouthpiece while the machine measures the rate of gas flow, and the volumes involved. The spirometer then compares results with those expected for a normal person of the same weight, sex and height. Deviations from normal are expressed as a percentage.
1044
1045Three important parameters are measured, the Forced Vital Capacity (FVC) is the volume of air in the lungs (in liters) that can be exhaled after taking a deep breath. The second is the Forced Expiratory Volume - 1 second (FEV1) which is a measure of how much air is exhaled in one second, following a deep breath. The third is the FEV1/ FVC ratio. This number represents the percentage of a full breath that can be exhaled in one second. For example, if the FVC is 5 litres, and 4 litres can be exhaled in 1 second, then the FEV1/ FVC ratio would be 4/5 or 80%.
1046
1047To ensure a peaceful and reliable death using an inert gas, it is important that the lungs can be fully emptied of air (ie no obstruction, with little residual air left), then fully expanded filling them with nitrogen (ie no restriction). The presence of significant restrictive OR obstructive respiratory disease will
1048
1049The Peaceful Pill eHandbook
1050
1051reduce the chance of a quick loss of consciousness and peaceful death. With obstruction, only a fraction of total lung volume is exhaled leaving significant air (and oxygen) in the lungs, then taking a full breath with restrictive disease, a much smaller amount of nitrogen is added to the lungs.
1052
1053The result is that the lungs now have significant residual oxygen. There is not the precipitous drop in the oxygen level in the arterial blood travelling from the lungs to the brain that causes the rapid loss of consciousness. If one persists, taking more breaths of pure nitrogen from the bag, the residual oxygen in the lungs will eventually be used by the body (or exhaled) and flushed away, and loss of consciousness will eventually occur. But this can take some time, and often leads to anxiety and panic.
1054
1055To eliminate the possibility of such failure, ask your doctor for a spirometry test to measure your lung function. If either the FVC or FEV1 measurement (usually an average of several measurements) is less that 60%, or if the FEV1/ FVC is less than 50% of the normal value for a person of your height, weight and sex, this method of obtaining a peaceful death is not the most suitable for you.
1056
1057Note: Some restrictive lung disease can be improved significantly with the use of certain drugs. The best example is asthma, where the inhalation of salbutamol prior to the test can sometimes restore FVC, FEV1 & FEV1/ FVC values to near normal. If this is the case, the hypoxic method need not be abandoned, but salbutamol should be used immediately before inhaling the nitrogen to die.
1058
1059Hypoxic Death & the Exit Bag After the Death - The Affect of Inert Gas on the Body
1060
1061The use of an inert gas with an Exit Bag produces no changes in the body that can be seen or found on initial inspection. However, in 2007 forensic laboratory tests were developed to establish the presence of gases like Helium, Argon and Neon in the lungs of the deceased.
1062
1063In 2009, the first report of the use of these tests to determine the cause of death of an Exit member was noted. Such testing at autopsy is becoming more common. Helium are Argon can both be detected showing the death is not ‘natural’.
1064
1065If, however, Nitrogen is used for a hypoxic death, and if the Exit bag and tube is removed, autopsy findings will be recorded as ‘inconclusive’. The Exit Bag with nitrogen is the only totally undetectable method of a peaceful and dignified death, even when sophisticated testing at autopsy is carried out. However, in some jurisdictions, the taking-away of the equipment may constitute an offence such as ‘interfering with a corpse’ or ‘interfering with the circumstances of a death.’ Caution and legal advice should be sought before acting in this regard.
1066
1067The Peaceful Pill eHandbook Nitrogen Method Summary Supplement
1068
1069Fig 5.17: MaxDog gas regulator (with plastic dust cap) Preparation of the Regulator and Tubing
1070
1071Identify the regulator. The regulator may have a plastic dust cap over the right hand end of the brass fitting. A black click setting with numbers from zero to 25 at the other end sets the gas flow rate (in litres/ sec), Rotate the black knob until it shows 15. This is the required gas flow. During storage, the black knob should be set to zero. (see fig 5.17)
1072
1073Fig 5.18: Connecting the hose
1074
1075Take the oxygen tube (provided in Max Dog kits outside Aus- tralia). Note, this is called an ‘oxygen tube’ but it is perfect also for use with Nitrogen.
1076
1077Hypoxic Death & the Exit Bag
1078
1079Dip one of the ends of the tube into a cup of very hot water. When pliable, shake off the water and push the end on to the barbed nipple of the regulator (see fig 5.18 )
1080
1081Make sure that the end of the tube is pushed all the way on to the barbed nipple so that the end of the plastic fitting is flush with the chrome hexagonal nut.
1082
1083Test to ensure that the tube is attached securely by pulling on it – it should be virtually impossible to pull it off the barbed nipple. If you have any doubts about the secureness of the hose, or are unable to attach it properly, then remove it. Re- peat the heating of the end and push it on to the barbed nipple again, this time more securely.
1084
1085An alternative gas connection can be made using 1.5m of clear Boston PVC food grade tubing 6mm (¼ inch). This can be bought from a local plumbing supplies store.
1086
1087An alternative connnec- tion system involes us- ing a small hose clamp. This can be placed over the tube and tightened to ensure that it cannot be dislodged. (fig 5.19).
1088
1089Note – ensure that it is impossible to pull the hose off the barbed nip- ple on the regulator.
1090
1091Fig 5.19: 6mm PVC tubing attached toMaxDog gas regulator
1092
1093The Peaceful Pill eHandbook Connecting the Exit Bag to the Cylinder
1094
1095There are a few first steps before the Exit Bag can be connected to the cylinder. Firstly, the oxygen tube should be taped to the inside of the Exit Bag. This can be done with ‘Micropore’ tape or ‘Leuko- flex’ tape show in fig 5.20. Both tapes grip well but are also easily removed for repositioning. The recommended width of the tape is one inch (~2.5cm).
1096
1097Insert the end of the tube into the open end of the bag. Push the tube up inside the bag to the end. Using the tape, place a number of strips over the tube to hold it in position (see fig 5.21). It is easiest to do this with both hands working inside the bag. Ensure the tape is placed over the tube at regular intervals, right up to the tube’s open end. This will require ap- proximately eight pieces of tape.
1098
1099Tape the hose to the inside of the mouth of the bag, close to its open end. Use two pieces of tape to fasten the hose at the bag mouth to ensure it will not dislodge.
1100
1101Fig 5.21:Taping gas hose to inside of Exit Bag
1102
1103Fig 5.20: Adhesive tape to attach tube to Exit bag
1104
1105Hypoxic Death & the Exit Bag Ensure the Cylinder is Vertical
1106
1107It is preferrable for the Nitrogen cylinder to be vertical for use. An effective way to ensure that the cylinder is stable and vertical is to secure it to a solid object. The cylinder could be strapped/ taped to a chair or table leg. See fig 5.22
1108
1109Fig 5.22:Positionin the nitrogen cylinder
1110
1111An alternative is to place the cylinder in a market cart (above centre). In order to ensure the cylinder does not flop around inside the trolley, pillows or cushions could be stuffed into the market cart as padding.
1112
1113Another alternative is to strap the cylinder to a workshop trolley (above left). The uprights of the trolley provide good support. Like the soft canvas market trolley both are move- able which may be convenient in some circumstances.
1114
1115Attaching the Regulator to the Gas Cylinder
1116
1117In some countries the cylinder ships with a dust cap. Re- move the dust cap from the cylinder. (See fig 5.23, right)
1118
1119The Peaceful Pill eHandbook
1120
1121Now look at the regulator. Inspect the small black rubber ‘O’-ring on the regulator for any damage. If damaged the ‘O’ ring should be replace (see fig 5.24a).
1122
1123To connect the regulator to the cylinder, slide the brass end of the regulator into the outlet on the cylinder (see fig 5.24b). Note this image is looking down on the vertical gas cylinder.
1124
1125To fasten the regulator to the cylinder, slide the large brass hexagonal nut onto the threaded part of the gas cylinder outlet (see fig 5.24c).
1126
1127Hold the regulator firmly with one hand and hand-tighten by screwing the hexagonal nut onto the cylinder thread. You do not need a wrench or other tool to fasten the regulator to the cylin- der.
1128
1129Fig 5.24 Atatching the regulator to the cylinder:
1130
1131If you cannot fasten the regula- tor tightly to the cylinder by hand, you can use a wrench but do not over-tighten.
1132
1133The regular should not be loose or easily rotatable on its axis. To change the angle of the display of the screen on the regulator, loosen the hexagonal nut, then rotate the regulator. Complete this process by re-tightening the hexagonal nut (see fig 5.24d).
1134
1135Hypoxic Death & the Exit Bag Turning on the Gas & Checking for Leaks
1136
11371. Set the flow control on the regulator to zero (fig 5.25a).
1138
11392. Turn on the tap on the top of the cylinder. The tap turns anti-clockwise. Turn it for 3 or 4 turns. (fig 5.25b).
1140
11413. The pressure in the cylin- der will show on the regulator gauge. If the cylinder is full, it will be in the green zone (fig 5.25c).
1142
11434. Listen for the sound of any gas leaking and watch the pres- sure gauge. If there is a leak, the pressure gauge will fall.
1144
11453 If the pressure falls, turn the tap fully off in a clockwise di- rection, and tighten the regula- tor, if the leak persists replace the ‘O’ ring.
1146
1147Fig 5.25:Checking gas pressure
1148
1149The Peaceful Pill eHandbook Checking Gas Cylinder Pressure
1150
1151Max Dog Nitrogen Cylinders vary slightly between country, but they are generally filled to a pressure 13.7 MPa (2000 psi) and contain ~400 litre (20 cuft) of compressed nitrogen. This provides a reliable flow of gas for around 25 minutes at a flow rate of 15 litres/min. This is more than enough for a peaceful, reliable hypoxic death.
1152
1153To test the pressure of the cylinder, set the regulator flow set- ting to zero, then turn on the cylinder tap. The needle on the regulator pressure gauge should move from zero to around 2000 psi. This indicates the cylinder is full (see fig 5.25c).
1154
1155If the pressure gauge points to the left of the green zone of 2000psi (or is in the red zone indicating zero pressure), the cylinder will need refilling (see fig 5.25d).
1156
1157Preparing for a Peaceful, Hypoxic Death
1158
1159There are some diseases that make a hypoxic death using an Exit Bag and an inert gas such as Nitrogen or Helium un- suitable (see section on Lung Function using Spirometry). Remember, this method is very technique dependent. Being able to breath fully out (exhale) is a key component of this technique.
1160
11611. Make sure the gas cylinder is stable and ensure that it will not roll over.
1162
11632. Ensure the tube will not be dislodged if it is pulled after the person becomes unconscious.
1164
11653. The optimum position for a hypoxic death is to be reclin- ing comfortably in an armchair, supported by pillows if necessary. Do not lie down. Finally, ensure that the bag will not be dislodged when consciousness is lost.
1166
1167Hypoxic Death & the Exit Bag Things to Remember
1168
1169Remember, there is nothing poi- sonous about a gas such as Helium or Nitrogen. The effectiveness of this method comes from the fact that an oxygen-free environment is being created within the Exit Bag.
1170
1171Fig 5.26:Gas flow @ 15l/min
1172
11731. With the regulator’s flow rate set to 15 l/min, (fig 5.26) a full cylinder will provide around 25 minutes of continu- ous gas flow.
1174
11752. The nitrogen displaces the oxygen in the Exit Bag. It is the low oxygen environment that causes death.
1176
11773. The Exit Bag should be filled with nitrogen before one exhales and pulls the bag down.
1178
11794. Once a deep breath is taken, loss of consciousness is almost immediate and death follows soon after.
1180
11815. The Exit Bag is not be tight over a person’s head. 6. The elastic collar provides a loose fit around the neck when pulled down.
1182
11837. The loose fit allows the Nitrogen to flow continuously from the Exit Bag taking any exhaled carbon dioxide with it.
1184
1185The Peaceful Pill eHandbook The Process
1186
11871. Place the Exit Bag collar around the head, above the ears and scrumple up the bag so there is no air inside.
1188
11892. Set the regulator to 15 l/min (see fig 5.26) 3. Turn on the gas from the cylinder. 4. Remove glasses or other protruding objects such as hear- ing aids.
1190
11915. Wait until the bag is fully inflated with the collar still sitting above the ears. This will take around two minutes. When full, the Bag should look like a balloon. Use a mir- ror to check. The nitrogen/ helium will begin escaping under the collar of the Bag (see fig 5.26).
1192
11936. Position oneself in a steady, comfortable position. 7. To proceed, take some rapid, deep breaths (hyperventi- late). When ready, exhale completely, grasp the Bag with both hands, one on each side, and pull the bag down over the head.
1194
11958. With the Bag fully over the head and take a deep breath (see fig 5.28).
1196
1197Fig 5.27:Filling the Exit Bag
1198
1199Fig 5.278The Exit Bag over the head
1200
1201Hypoxic Death & the Exit Bag Changing Your Mind
1202
1203Remember, it’s always OK to change your mind and this can be done up to the point where consciousness is lost. To put a stop to the process:
1204
12051. Release the elastic toggle and pull the bag off your head. 2. Turn the cylinder tap anti-clockwise until it is fully off. 3. When the pressure dial drops to zero, the system is com- pletely closed down and can be disassembled.
1206
12074. Undo the brass hexagonal nut on the regulator and dis- connect from the cylinder.
1208
12095. Put the dust caps (if available) back on the regulator and cylinder.
1210
12116. Ensure the cylinder gas tap is fully off. 7. The gas cylinder can then be re-stored (lying down) and the regulator replaced in its box to keep it clean.
1212
1213Concluding Comments
1214
1215The Exit Bag with Inert Gas is an end of life method that is reliable, simple, peaceful and quick. And it does not involve illegal drugs or equipment. If Nitrogen is the gas used, it is also a method that provides a totally undetectable death.
1216
1217Nevertheless, the method demands substantial preparation. A disposable gas cylinder needs to be purchased, along with the requisite connections. Tubing and a Bag must be made. Technique is important and a certain degree of physical dexterity is required. The need for equipment, and the unaesthetic nature of placing a bag over one’s head, prevent many people from ever considering this method.
1218
1219The Peaceful Pill eHandbook
1220
1221Is it necessary to have more than one cylinder to ensure sufficient gas is available?
1222
1223No. Using the Max Dog nitrogen system, the flow control regulator ensures that a full cylinder will provide gas at 15 litres/min for >20 min - more than enough for a peaceful death.
1224
1225Using a Balloon Time helium cylinder or similar and the Exit flow control fitting, even the smaller (250 litre) cylinder will provide sufficient gas for enough time (Fig 5.2). However, if the tube is to be connected directly to the Balloon Time cylinder with no gas flow regulation (other than the cylinder on/off tap), multiple cylinders should be employed.
1226
1227Can a face-mask be used instead of the Exit Bag?
1228
1229Common, inexpensive face masks are often used to deliver oxygen to patients. They are usually held in place by elastic which covers the nose and mouth with oxygen delivered through a plastic tube attached to the base of the mask. There is no attempt to seal the mask and face. Masks that seal preventing entry of external air are more complex, difficult to fit, and prone to leakage (eg a seal is difficult with a beard). CPAP devices used for sleep apnea are of this type.
1230
1231The Exit Bag produces rapid loss of consciousness by ensuring that NO oxygen is inhaled. To achieve this using a mask a perfect seal would need to be maintained till death. Even with a well fitting sealing mask this is difficult, as the muscles and contours of the face change as consciousness is lost. Attempting a hypoxic death using a sealing mask is risky and NOT recommended.
1232
1233Hypoxic Death & the Exit Bag
1234
1235THE RP TEST SCORE – Exit Bag + Inert gas Reliability Peacefulness
1236
1237Considered “peaceful” partly because the loss of consciousness comes quickly. There is the sensation of “air hunger” and alarm
1238
1239Availability
1240
1241All components are readily available Preparation
1242
1243(A = 5/5) (Pr = 1/5)
1244
1245Considerable assembly and “setting up” of equipment Undetectability
1246
1247Speed
1248
1249Loss of consciousness comes quickly Safety
1250
1251The method presents no danger to others Storage
1252
1253Total RP Score (U = 5/5)
1254
1255If all equipment is removed detection is rare. If Nitrogen is the gas used the method is totally undetectable.
1256
1257(Sp = 5/5) (Sa = 5/5) (St = 5/5)
1258
1259Components do not deteriorate with time. Pressure testing can readily establish that the cylinder is full
1260
126141/50 (82%) (R = 8/10)
1262
1263The method is reliable but technique is important and a degree of coordination and dexterity is required
1264
1265(P = 7/10)
1266
1267The Peaceful Pill eHandbook
1268
1269THE RP TEST SCORE – Exit Bag + Inert gas Criteria
1270
1271Reliability
1272
1273Peacefulness Availability Preparation
1274
1275Undetectability Speed
1276
1277Storage Total
1278
1279Score 8/10 7/10 5/5 1/5 5/5 5/5 5/5
1280
128141 (82%)
1282
1283Hypoxic Death & the Exit Bag
1284
12856 Carbon Monoxide (CO)
1286
1287• The importance of Concentration of Monoxide • Testing the Concentration • Sources of Carbon Monoxide • Vehicle Exhaust Gas as a Source of CO • Making Carbon Monoxide • The COGen Generator • Charcoal burning as a Source of CO • The Destiny Euthanasia Machine • The RP Test for Carbon Monoxide
1288
1289Introduction
1290
1291Carbon Monoxide (CO) is one of the most lethal gases known. Its toxicity is due to its ability to strongly bind with haemoglobin which greatly reduces the oxygen-carrying capacity of a person’s blood. Areas of the brain sensitive to ischaemia (low oxygen level) are affected severely and a rapid, peaceful death is the common result. The gas is particularly dangerous, as it is a colourless, odourless and a non-irritating gas. Without specialized monitoring equipment, there is no way of knowing that carbon monoxide is present.
1292
1293Death by poisoning from carbon monoxide can be reliable, quick and peaceful, provided the concentration of the inhaled gas is sufficiently high. In the 1990s, Dr Jack Kevorkian helped more than 50 seriously ill people to end their lives peacefully, using carbon monoxide. Those present at these deaths described the effectiveness and peacefulness of the approach.
1294
1295Carbon Monoxide
1296
1297PPM [CO]
1298
129935
1300
1301200 400
1302
1303800
1304
13051600 3200
1306
13076400 12,800 Time 8 hours
1308
13092-3 hours 1-2 hours
1310
1311Symptoms
1312
1313Maximum exposure allowed by OSHA in the workplace over an eight hour period.
1314
1315Mild headache, fatigue, nausea and dizziness.
1316
1317Serious headache-other symptoms intensify. Life threatening after 3 hours.
1318
131945 minutes Dizziness, nausea and convulsions. Unconscious within 2 hours. Death within 2-3 hours.
1320
132120 minutes 5-10
1322
1323minutes 1-2
1324
1325minutes 1-3
1326
1327minutes Table 6.1 Effect of carbon monoxide exposure
1328
1329It is important to establish that monoxide concentration is high enough as periods of time spent in sub-lethal gas levels can lead to serious irreparable damage. From the accompanying table (Table 6.1) it is clear that although death will occur at much lower levels, if one is in the environment for some time, it is strongly recommended that concentrations greater than 1% (10,000 ppm) are generated by the method chosen.
1330
1331There are often no specific clinical findings to identify this agent as the cause of death, although occasionally the red colouration of ‘venous’ blood gives a flushed pink colour to the skin of the corpse. This colouration may indicate the cause of death to an examining doctor and its presence will be detected at autopsy. If it is important that the death look ‘natural’ (and ‘suicide’ not be stated on the death certificate), then poisoning by carbon monoxide may not be the best choice.
1332
1333Headache, dizziness and nausea. Death within 1 hour. Headache, dizziness and nausea. Death within 1 hour.
1334
1335Headache, dizziness and nausea. Death within 25-30 minutes. Rapid Death
1336
1337The Peaceful Pill eHandbook Testing the Concentration of Carbon Monoxide
1338
1339To ensure that the monoxide concentration is sufficiently high for a peaceful death, it is wise to test the gas concentration. To do this one needs an appropriate meter capable of reading carbon monoxide concentration levels.
1340
1341Exit has tested several meters for this purpose. The cheapest monitors have only a warning light set to alarm when levels of 50ppm are exceeded. These are of limited use.
1342
1343Fig 6.2
1344
1345a) RKI sampling multi-gas meter b) TPI 707 high level monoxide analyser c) TPI 770 monitor with sampling probe
1346
1347Carbon Monoxide
1348
1349Gauges with a digital readout of up to to 1000 ppm (0.1%) can be easily obtained. It is advisable to have a sampling facility on the gauge so that the level produced can be sampled before using this method. Sampling gauges can be modified with a 10:1 reduction, so that levels up to and greater than 1% can be measured.
1350
1351Gauges used by Exit are shown in Fig 6.2. The multi-gas sampling meter (RKI Eagle) enables the monitoring of carbon monoxide levels, carbon dioxide levels as well as the concentration of available oxygen. This gauge retails for over US$2000 and is primarily used as a research tool. A smaller hand-held device (TPI model 701 carbon monoxide analyser) that measures aspirated gas of up to 10,000 ppm is also shown. This useful gauge costs ~ US$600. A cheaper TPI gauge used by Exit with a modified 10:1 sampling probe (TPI model 770) costs ~US$200.
1352
1353Sources of Carbon Monoxide From Commercial Gas Suppliers:
1354
1355Cylinders of compressed carbon monoxide, either as the pure gas or as a mixture (eg 5% in Nitrogen) are available from scientific gas supply companies. There are no special restrictions but an account will be needed. Table 6.1 lists some available packaging for pure compressed carbon monoxide from BOC. http://www.boc.com/
1356
1357Cylinders of special gas mixtures that contain lethal levels of monoxide are also used as source gases for some industrial lasers (eg 6% CO in gas used in the Rofin CO2
1358
1359slab laser). See: http://www.praxair.com/gases/buy-carbon-monoxide-gas
1360
1361The Peaceful Pill eHandbook
1362
1363Table 6.3. Compressed CO cylinder sizes Vehicle Exhaust Gas
1364
1365Carbon Monoxide is produced as an exhaust gas from internal combustion engines. The concentration of the monoxide in the exhaust gas varies, depending on a number of factors and establishing this is critical.
1366
1367Formic Acid
1368
1369Carbon Monoxide is produced by a chemical reaction that occurs when the formic acid (HCOOH) is broken down into water (H2
1370
1371O) and carbon monoxide (CO). The catalyst for this
1372
1373breakdown is concentrated sulphuric acid. The sulphuric acid remains chemically unchanged but is diluted by the water released.
1374
1375Monoxide generation ceases when all of the formic acid is broken down, or when the sulphuric acid becomes too dilute to catalyze the reaction. Heat is generated in the reaction and this can lead to traces of formic and sulphuric acid in the emerging carbon monoxide. One mole of formic acid (46gm) will produce ~22 litres of carbon monoxide.
1376
1377The chemical equation is: HCOOH a H2 O + CO
1378
1379Carbon Monoxide Oxalic Acid
1380
1381Concentrate sulphuric acid can be used to breakdown anhydrous oxalic acid to produce carbon monoxide (and carbon dioxide). Again the sulphuric acid remains chemically unchanged but is diluted by the water produced in the reaction. Less heat is generated in the reaction and there is less likelihood of contamination with vapour from the sulphuric acid. One mole of oxalic acid (~90gm) produces equal molar amounts of carbon dioxide and carbon dioxide.
1382
1383The chemical equation is: HO2CCO2H aH2 Carbon (charcoal)
1384
13850 + CO2 + CO
1386
1387The incomplete oxidation of carbon can produce copious amounts of carbon monoxide. As the oxygen available to a charcoal fire decreases the production of carbon dioxide decreases and carbon monoxide increases.
1388
1389The chemical equation is: 2C + O2 a 2CO
1390
1391Zinc and Calcium Carbonate Powdered zinc can be mixed with calcium carbonate and heated to produce carbon monoxide, along with calcium and zinc oxide. Heat is needed for the process and this offers the opportunity of controlling the process (using an electrical heater).
1392
1393The chemical equation is: Zn + CaCO3 → ZnO + CaO + CO Vehicle Exhaust Gas as a Source of Carbon Monoxide
1394
1395Internal combustion engines produce a small percentage of carbon monoxide in the exhaust gas. If this gas is inhaled, death will result. Piping the gas into the car, or running the car in a closed shed are common approaches. In all cases, though, the carbon monoxide will be mixed with a large amount of other foul-smelling exhaust products. One of the benefits of using this gas, peacefulness, is lost.
1396
1397The Peaceful Pill eHandbook
1398
1399Older cars tend to produce the highest levels of exhaust carbon monoxide. With the introduction of unleaded petrol in the 80s, there have been controls on the monoxide levels in exhaust gases to meet environmental standards. Since 1997 new cars can emit no more that 10% of the levels of carbon monoxide acceptable in 1976. Mandatory catalytic convertors oxidize most of the produced carbon monoxide to form carbon dioxide.
1400
1401Despite these significant changes in the emission levels of carbon monoxide, motor vehicle exhaust gas suicides continue to occur at a surprisingly high rate. Indeed, in the period from 1976 to 1995 the rate of exhaust gas suicides in some countries increased faster than the rate of motor vehicle registrations (Routley & Ozanne-Smith, 1998). Possible explanations include the fact that idling motors do not necessarily comply with international standards. Additionally, catalytic convertors do not function when cold. Rather, they require several minutes to warm from a cold start. Of significance though is the increasing number of failed suicide attempts from breathing exhaust gas reported in this period.
1402
1403This is not to say that the motor car cannot be used as a source of carbon monoxide to effect a reliable death, but there are problems associated with the method. One concern is the mechanical connection of the exhaust to the hose carrying gas to the car. Many modern vehicles have elliptical exhaust outlets. Coupling the exhaust to a round hose, often using plastic tape, can cause problems because of the heat of exhaust gas. If the tape or tube melts or is destroyed by the heat, failure is likely. Fig 6.4 shows a carefully engineered system using metal connections and clamps and heat resistant tubing.
1404
1405Carbon Monoxide
1406
1407Fig 6.4. The car as a carbon monoxide source
1408
1409This approach demands meticulous attention to detail and testing is strongly recommended. A carbon monoxide meter should be used for testing. The meter should be placed on the front seat. The car should then be run using the planned setup. The meter can be watched safely from outside the car. The meter reading will soon show if the system will work. If the meter moves quickly off-scale (>500ppm), the method is unlikely to fail. If the meter struggles to rise, even when the motor is started cold and allowed to idle, the system should be avoided.
1410
1411In addition, careful planning is required to avoid the possibility of intervention. A car running with a hose fed into the back window will almost certainly attract attention. And, even if effective, sitting in an environment of hot, foul smelling, burnt engine waste, just to make use of the tiny percentage of monoxide present, is an unpleasant way to die. In Exit’s research of our elderly members’ attitudes, only a small number showed interest in using exhaust carbon monoxide.
1412
1413The Peaceful Pill eHandbook
1414
1415Fig 6.5 The early CoGen
1416
1417Fig 6.6. COGen 4 on fume cupboard test bench with acid bottles and CO monitor
1418
1419Carbon Monoxide
1420
1421Video: The Exit COGen
1422
1423The Peaceful Pill eHandbook Making Carbon Monoxide (the COGen)
1424
1425For over a decade, Exit International has investigated the use of carbon monoxide. Since the compressed gas is difficult to source, Exit has developed generators that produce the carbon monoxide gas when and as required. The first carbon monoxide generator (the COGen) made use of the chemical reaction (catalytic breakdown) that takes place when formic acid is added to sulphuric acid.
1426
1427In the original model (Fig 6.5) the formic acid was placed in an intravenous bag and allowed to drip into the reaction chamber containing the sulphuric acid. The gas produced was then fed to the mannequin using nasal prongs. Filmmaker Janine Hosking recorded this first demonstration at Exit’s laboratory in late 2002, and the sequence was shown in the film Mademoiselle and the Doctor.
1428
1429Since that time other methods of carbon monoxide generation have been investigated. Methods include the partial oxidation of carbon (charcoal), the reduction and catalytic conversion of oxalic acid, and the reaction between powdered zinc and calcium carbonate.
1430
1431How the COGen Works
1432
1433The COGen consists of two PVC chambers (‘A’ & ‘C’, Fig 6.7). The inner chamber “A’ is mounted to the screw lid of the larger outer 10cm (3.9 inch) container and has a drip exit ‘F’ in its base. The drip rate is controlled by a screw ‘E’.
1434
1435150 ml of 85% formic acid is placed in chamber (‘A’) with the control-valve shut.
1436
1437Carbon Monoxide
1438
1439Fig 6.7 The COGen & acids
1440
1441The Peaceful Pill eHandbook
1442
1443250ml of concentrated sulphuric acid (98%) is placed in the outer chamber ‘D’ and the COGen assembled.
1444
1445Opening the screw ‘E’ allows the formic acid to drip into the concentrated sulphuric acid. Copious amounts of carbon monoxide are released and exit the chamber through vent holes in the lid ‘H’.
1446
1447The Video shows the COGen being armed and placed in a small car. The carbon monoxide concentration in the car was continuously sampled with a probe positioned near the head of the mannequin. The graph (Fig 6.8) shows the measured concentration in ppm, plotted over the first 30 minutes. Lethal concentrations were reached a few minutes after switching on the generator. A peak level of ~3% CO was recorded.
1448
1449Sourcing the Acids
1450
1451Concentrated sulphuric acid (98%) can be purchased from chemical suppliers or at hardware stores where it is sold as a drain cleaner. Concentrated laboratory sulphuric acid is an oily clear liquid, whereas the drain-cleaner sulphuric acid can be dark brown in colour because of additives, but this does not effect the generator’s operation.
1452
1453Formic acid is available from chemical supply companies. Home hobbyists use formic acid in tanning or bee-keeping. Formic acid can also be purchased online through chemical supply websites.
1454
1455Oxalic acid is used as rust and stain cleaner and can be purchased from hardware stores.
1456
1457Carbon Monoxide Safety Note
1458
1459Concentrated formic and sulphuric acids are corrosive liquids. They should be kept secured in glass or polyethylene containers (plastic soft drink/ soda bottles are not suitable). When using sulphuric acid, rubber gloves should be worn along with eye- protecting goggles and a face-splash protector. Spills of acids on to the skin should be washed off immediately with copious amounts of water. If either of these acids gets in the eyes, wash the eyes continuously for several minutes and then seek medical assistance.
1460
1461Generating Carbon Monoxide using a Charcoal Burner
1462
1463This method of generation is commonly used as it is simple to set up and all necessary items are readily obtained. A charcoal burner can made from a steel container or by using a brazier or using a pre-packaged charcoal BBQ grill.
1464
1465If you make your own burner, obtain good quality charcoal to reduce the level of unwanted smoke. You will also need a car, or other small room that can be sealed.
1466
1467Table 6.8 CO concentration with time using COGen in a vehicle
1468
1469The Peaceful Pill eHandbook
1470
1471In the series of experiments carried out by Exit, a small pre- packaged charcoal burner was set alight and placed on the floor in a small car. The level of carbon monoxide inside the car was continuously monitored.
1472
1473Other tests were carried out using a sealed 20ft shipping container as the closed environment. A brazier was loaded with 1.5 Kgm of good quality charcoal which was then set alight and placed in the centre of the floor. The container doors were shut (see Fig 6.10). Again, the carbon monoxide concentration within the container was continuously sampled from outside using a sampling probe.
1474
1475Fig 6.9 Test vehicle with BBQ charcoal burner
1476
1477Carbon Monoxide
1478
1479Fig 6.10. Charcoal burner.brazier and test shipping container
1480
1481Table 6.11. CO concentration with time in test shipping container
1482
1483The Peaceful Pill eHandbook
1484
1485The Destiny Euthanasia Machine
1486
1487In early 2012 Philip Nitschke was contacted by Mr Paul Bowen QC who was for acting for British man, Tony Nicklinson. Tony suffered from ‘locked-in syndrome’ following a stroke some years earlier. See: http://bit.ly/1KIEhqz
1488
1489Tony and Paul wanted to know if it was possible to build a new Deliverance Machine; a machine that would enable Tony to blink an eye and receive a dose of a lethal gas. Dr Nitschke grasped the opportunity and set to work on a euthanasia machine that could be easily operated by a person with limited mobility. The goal was a machine that would reliably and peacefully cause death, and would require no special skill to apply. One whose operation could be initiated by a button press, or by a
1490
1491Table 6.12. Destiny CO Machine
1492
1493Carbon Monoxide
1494
1495voice or eye movement. The result was the ‘Destiny Machine’ first shown publicly as part of Philip Nitschke’s ‘Dicing with Dr Death’ show at the Edinburgh Fringe in August 2015. Media stemming from the Edinburgh Fringe is at:
1496
1497The Independent: http://ind.pn/1VRumkf The Daily Mail: http://dailym.ai/1Jf8FGz The Daily Record: http://bit.ly/1iC6cvI TV Bomb Review: http://bit.ly/1Q6hYZX
1498
1499Design Considerations
1500
1501Following discussions with Neal Nicol, a long-time associate of Dr Jack Kevorkian, features of the earlier Deliverance Machine and Dr Kevorkian’s own Mercitron Machine were integrated. The Mercitron had been used by Kevorkian and Nicol in the assisted suicides of ~ 50 patients in the US in the 1990s.
1502
1503The gas that is used in the Destiny is the same compressed carbon monoxide/ nitrogen mixture (9%/91%) that was used in the original Mercitron. Delivery of the gas at ~4 liters/min is through simple nasal prongs. Gas control is determined by a modification of the original Deliverance program where a positive response to three separate questions, either through button press or other means, activates the gas control relay.
1504
1505As a safety measure, a finger cuff provides the person’s cardiac rate and oxygen saturation input to the Rasberry Pi microprocessor. This microprocessor controls the process and presents the questions. The person’s cardiac trace, heart rate and oxygen saturation is displayed . When cardiac function ceases and oxygen saturation drops to zero, the microprocessor terminates the gas flow.
1506
1507The Peaceful Pill eHandbook Construction of Destiny
1508
1509Construction of Destiny began in 2014. Input for the first machine is a ‘Yes’ green button and a ‘No’ red button which both feed into the Raspberry Pi microprocessor case. Secondary input is from a pulse oximeter (CONTEC CMS50D+) which provides pulse waveform, heart rate and saturation via USB input of 5.2v power from a USB source. Output in the form of a visual display is via HDMI to a screen displaying the person’s cardiac trace, oxygenation and pulse, along with the sequential presentation of the three questions.
1510
1511• Are you aware that if you proceed to the last screen and press the ‘yes’ button you will be given a lethal dose of fast and die?
1512
1513• Are you certain you understand that if you proceed and press the ‘yes’ button to go to the next screen that you will die?
1514
1515• If you press this button in 15 seconds you will die
1516
1517Table 6.13. Destiny screenshot
1518
1519Carbon Monoxide
1520
1521The gas source is a compressed Nitrogen/CO mixture (91%/ 9%) at 2000psi, regulated with a Max Dog Brewing nitrogen regulator. This provides a flow rate of 4 litres per minute. The 91%/9% combination was chosen because it is quickly and effectively lethal. Importantly, this concentration of carbon monoxide is also not considered flammable. Flow is controlled by the microprocessor which activates a relay gas valve. Power is provided from a 9v battery pack.
1522
1523Testing & Use of Destiny
1524
1525At the time of publication, the Destiny Machine has not been used to end life. The machine has undergone extensive testing with volunteers. The Destiny Machine has shown itself to be 100% reliable in operation and gas control, when used with nitrogen gas.
1526
1527The sourcing of small (150 litre/ 5 cu ft) cylinders of the Nitrogen/ Carbon Monoxide mix is currently under examination and will be reported on when available.
1528
1529Warning
1530
1531It is stressed that carbon monoxide is an extremely lethal gas. A person using this gas to end their life should be aware of potential risks to other people present. Always place a warning sign in a prominent position to prevent any accidental exposure to other people. This danger is greatly reduced when administration is via the Destiny Machine because of the minimal amount of lethal gas used.
1532
1533The Peaceful Pill eHandbook
1534
1535Conclusion
1536
1537Carbon Monoxide can provide a person with a peaceful death. The gas can be obtained in a variety of ways ranging from direct purchase, simple burners, or more sophisticated generating devices. Tests should be made to ensure that concentrations of over 1% can be delivered. The Destiny machine addresses many of these issues.
1538
1539Most interest in this method has come from those who reject the taking of drugs orally (eg. for fear of vomiting) and by others who reject the use of helium because of the need for a plastic bag to be placed over one’s head. The Destiny machine and the COGen address these concerns. In particular the Destiny machine has the ability to be used by persons with significant disability (quadriplegics, people with advanced MND etc).
1540
1541Exit RP Test for Carbon Monoxide
1542
1543The method loses points in the subcategories of Preparation, Undetectability and Safety.
1544
1545Preparation is not simple (Pr=1), there is equipment present at the death, and if using a COGen preparation with concentrated acids requires care. Using compressed nitrogen/ carbon monoxide mix will greatly simplify Preparation moving from 1/5 to 3/5.
1546
1547Carbon Monoxide
1548
1549This method may be detectable on inspection of the body (U=2), and can present some risk to others (Sa=1). The action of the Destiny machine in reducing the amount of monoxide used to a minimum significantly reduces the danger to others. Safety moving from 1/5 to 3/5
1550
1551RP test result 31 (62%), for Destiny RP is 35 (70%)
1552
1553Criteria Reliability
1554
1555Peacefulness Availability Preparation
1556
1557Undetectability Speed Safety
1558
1559Storage Total
1560
1561Score 8/10 7/10 3/5 1/5 1/5 5/5 1/5 4/5
1562
156331 (62%)
1564
15657 Cyanide
1566
1567The death of Spaniard Ramon Sampedro in 1998 and the subsequent award-winning film The Sea Inside has focused attention on the use of cyanide as an effective means by which a seriously ill person can put an end to their suffering.
1568
1569Sampedro, a quadriplegic since a diving accident at age 26, ended his life by drinking a glass of water in which soluble potassium cyanide (KCN) had been dissolved. He died quickly, and peacefully. Many people who have seen The Sea Inside have asked why these cyanide salts are not more frequently used by those who are seriously ill to provide a peaceful death. In this chapter we explain some of the difficulties involved in using cyanide and provide some answers. It is not unreasonable to expect that the use of cyanide will increase in the future, and it may yet become an acceptable form of the ‘Peaceful Pill’.
1570
1571Ramon San Pedro
1572
1573Cyanide
1574
1575Background to Cyanide
1576
1577In 1814, the carbon-nitrogen (CN) ‘radical’ common to a number of chemical substances was isolated and given the name ‘cyanogen’ by the French chemist Joseph Gay Lussac. The subsequent name ‘the blue generator’ referred to the place of the CN radical in a number of chemicals that were used as blue dyes; the Prussian Blue of blueprints (iron ferro cyanide) is perhaps the best known. In many of these compounds, the CN radical is so tightly bound that the substances are relatively non-toxic.
1578
1579With the discovery of substances where the CN radical was not so tightly bound - the gas hydrogen cyanide, hydrocyanic acid, and simple salts like potassium and sodium cyanide - it was soon realised that cyanide was extremely toxic to animal cells. By destroying the mitochondria, an essential element within each cell, the CN radical caused rapid cellular death. This causes a red complexion as cells are unable to utilise oxygen in the blood, and death is by cerebral anoxia.
1580
1581In 1921, cyanide gas (hydrogen cyanide, HCN) was proposed as a humane method of execution and led to the passage of the ‘Humane Death Bill’ in Nevada. The gas was first used to execute Gee Jon in 1924. Since that time nearly 1000 people have died in the execution gas chambers in the US. All chambers used the same method to produce cyanide gas. Pellets of sodium cyanide were dropped into sulfuric acid to release the gas which then enveloped the prisoner.
1582
1583The Peaceful Pill eHandbook
1584
1585Hydrogen cyanide is a volatile liquid and can be stabilised and absorbed onto a substrate. In this form (Zyclon B), it was used by the Nazi’s during the Holocaust. Originally developed as an insecticide, the pellets were kept in sealed containers and released as HCN gas when the pellets came into contact with air.
1586
1587Today, cyanide compounds are widely used in industry. Vast quantities of the cyanide salts are produced for use in the gold mining, metallurgy, electroplating and photographic industries. Their toxicity is well known and despite the large quantities used, they remain heavily restricted and difficult to obtain.
1588
1589Can Cyanide provide a peaceful and reliable death?
1590
1591Those watching the cinematographic depiction of Sampedro’s death would have cause to believe that a death resulting from the ingestion of cyanide salts is peaceful. Unfortunately, not all reports of cyanide deaths support this view. Indeed, there is considerable variation in accounts. While reliability is not an issue, the question most raised relates to the method’s ‘peacefulness.’ Just how peaceful is it to die with cyanide?
1592
1593Most accounts of death from cyanide poisoning come from witnesses to gas chamber executions where the (unwilling) prisoner inhaled HCN. One study undertaken at San Quentin prison showed that, on average, consciousness was lost within one to three minutes, with death occurring after nine minutes. These deaths were often peaceful with the prisoner falling quickly asleep.
1594
1595On some occasions, however, a violent (and presumably painful) death was observed. This method of execution was largely abandoned in the US in 1994 when the American Civil
1596
1597Cyanide
1598
1599Liberties Union took a successful action against the California Department of Corrections. In their action, the ACLU argued successfully that the gas chamber violated the US Constitution’s ban against cruel and unusual punishment, because it inflicted needless pain and suffering.
1600
1601Eyewitness accounts of seriously ill people drinking dissolved cyanide salt are also mixed. In his book Final Exit, Derek Humphry describes deaths that are quick and painless. But he also documents one unexplained account that refers to a death that was ‘miserable and violent, marked by frequent tetanic convulsions while awake’ (Humphry, 1996: 30).
1602
1603Toxicology texts of death by cyanide commonly refer to a rapid collapse and loss of consciousness if a large enough dose is absorbed. Occasionally convulsions occur after consciousness is lost. In his book Suicide and Attempted Suicide: Methods and Consequences, Geo Stone makes the observation that while cyanide might be commonly used by suicidal chemists, it is rarely by physicians. He concludes that this may be due to their different levels of access to poisons (Stone, 1999).
1604
1605In 1995 when the guidelines for the Northern Territory Rights of the Terminally Ill Act (ROTI) were being developed the use of cyanide was not considered; better drugs (the barbiturates) were available and cyanide is not used in any country where euthanasia legislation is now in place.
1606
1607Nevertheless, cyanide salts have some very positive properties of and play a role in ensuring people have control over their lives. In particular, the small quantities needed, easy administration, long shelf life, and rapid action are often seen as deciding factors. Taking a gram of potassium cyanide as a simple single capsule to provide a reliable death is seen by many to offer the best means of ensuring control at the end of life.
1608
1609The Peaceful Pill eHandbook The Availability of Cyanide
1610
1611Soluble cyanide salts have traditionally been hard to obtain unless one has a contact in the industries where these substances are used. These salts are heavily regulated and restricted, and the public is well aware of the toxic properties of cyanide. .
1612
1613The advent of internet suppliers of sodium or potassium cyanide has increased the importance of these substances in providing a reliable end of life option. However, there may well be legal issues associated with internet ordering, so it is advised to check with a lawyer or attorney in your local area first.
1614
1615NOTE: The possession of cyanide presents the possiblity of carrying out acts of terroism against the community, and the legl risks associated with obtaining this drug may well outweigh and possible end of life benefit the substance is likely to provide.
1616
1617Cyanide over the Internet
1618
1619In 2013 Exit became aware of an internet supplier of sodium cyanide from Thailand.
1620
1621Contact: Napat Chorphantha, 4/596 Moo4 Klongkum, Bunglim, Bangkok, Thailand 10240 Email: ploychava1982@gmail.com
1622
1623However in late 2015 we received several reports that this source had become a scam: viz: Dec, 2015, Ploy Chova which has his email in your Peaceful Pill eHandbook, just sent COFFEE in sealed envelope and it was a complete scam.
1624
1625Cyanide
1626
1627Fig7.1: Quantofix quantitative cyanide test kit
1628
1629Testing Cyanide
1630
1631As with all internet purchases, testing the product obtained is important. Purity testing is relatively simple with graded immunoassay test strips. Quantofix manufacture a cyanide test kit with 100 strips, able to read between 1 - 30 mg/litre (Fig 7.1). The cost of the kit is ~ US$100. To establish purity, one dissolves 30mg of potassium cyanide powder into distilled water. A colour change on the test strip will indicate a positive reading.
1632
1633The Peaceful Pill eHandbook
1634
1635Using Cyanide for a Peaceful & Reliable Passing
1636
1637Only a small amount is required (Fig 7.2), if one has sodium or potassium cyanide dissolve 1 - 2 gm (a teaspoonful) of the salt into half a glass of water. The solution is stable in neutral or alkaline solutions, so do not use carbonated water. Drink the solution down quickly.
1638
1639Alternatively, pack the powder into ‘OO’ gelatin capsules (Fig 7.3) and take these with a glass of water. The powder density is 1.5gm/cc and a single ‘00’ capsule will contain 1.35gm of the powder, 2 capsules is more than enough for a peaceful death,
1640
1641The effect is greatest when the salt reaches the acid environment of the stomach, so ensure that your stomach is empty before taking the cyanide.
1642
1643A noted variation was used by computer pioneer Alan Turing, who injected the dissolved salt into an apple before eating it. Alan’s actual act of suicide was interestingly ommitted from the 2014 film, ‘The Imitation Game.’
1644
1645Cyanide
1646
1647Fig7.2: Lethal quantity (1gm) of KCN
1648
1649Fig7.3: ‘0’& ‘00’ gelatine capsules
1650
1651The Peaceful Pill eHandbook What about hydrogen cyanide gas?
1652
1653Potassium cyanide is not the only form of cyanide that is lethal. There is also the gas, hydrogen cyanide.
1654
1655The process of making hydrogen cyanide gas mimics that used historically in the US gas chamber in acts of capital punishment. There, the solid cyanide salt (sodium, potassium or calcium cyanide) was added to concentrate acid in order create the legal gas. The gas chamber was abandonned in the 1990s by most US states for reasons of being unconstitutionally cruel and unusual.
1656
1657Hydrogen cyanide can be made by placing 500ml of concentrated hydrochloric acid in a plastic bucket and adding a few grams of the solid salt. This will rapidly produce hydrogen cyanide. If this is done in a confined space (a vehicle,or small room with windows shut) the inhalation of this gas will lead to a rapid and inevitable death.
1658
1659Concentrated hydrochloric acid (>25%) is readily available from hardware stores where it is marketed as a bathroom cleaning agent, brick or paving cleaner, soldering flux or as an agent for reducing the pH of a swimming pool. The smell is sometimes reported as similar to that of bitter almonds, although some people, because of their genetic makeup, are unable to smell the gas.
1660
1661Warning
1662
1663Be aware that the production of the gas may continue for some time and anyone entering the area may be unaware of the presence of the lethal gas. Warning signs must be posted to protect those who may come across the site. Safety on the Exit RP Test, is therefore low for this method 1/5.
1664
1665Cyanide The Manufacture of Sodium Cyanide
1666
1667They can however be manufactured (with care) from readily available ingredients, using unsophisticated facilities and equipment. Care must be employed in the manufacture, and the substance produced should be assayed to ensure the desired result.
1668
1669Sodium cyanide can be manufactured in a number of ways. Two relatively simple methods are described in the scientific literature. The first involves the use of the readily available dye, Prussian Blue (Iron III Ferro cyanide). A second uses the common swimming pool chlorine stabiliser, cyanuric acid.
1670
1671In the first process the Prussian Blue is first converted to sodium ferrocyanide. This is done by allowing it to react with caustic soda in water. Iron oxide is precipitated and sodium ferro cyanide obtained. This sodium ferrocyanide (Yellow Prussate of Soda) is then converted to sodium cyanide by allowing it to react with concentrated sulphuric acid.
1672
1673The very toxic HCN produced is passed into caustic soda to form the desired salt. There is considerable information available on this process but it was abandoned after initial experiments, considering it too dangerous for the inexperienced home chemist - some of whom may be readers of this book.
1674
1675A more suitable method of safe, small-scale home manufacture of sodium cyanide involves the two stage conversion of the common swimming pool chemical cyanuric acid.
1676
1677The Peaceful Pill eHandbook
1678
1679Fig7.4: Forge reduces sodium cyanate with carbon
1680
1681Fig 7.5: Filtering and weighing the sodium cyanide
1682
1683Cyanide
1684
1685The first step is carried out by heating powdered cyanuric acid with sodium carbonate. Sodium carbonate is obtained directly as washing soda (or by converting sodium bicarbonate, baking soda). In the second stage, the sodium cyanate produced is reduced to sodium cyanide by heating it with powdered charcoal in a covered crucible (Fig 7.2).
1686
1687It is important that this stage is undertaken outside. In this process, carbon monoxide is given off. The resultant glassy mass is cooled, crushed and filtered with water to remove the soluble sodium cyanide from the remaining insoluble carbon (Fig 7.5). Careful drying produces solid sodium cyanide powder.
1688
1689As with all home manufacture there is a need for great care in carrying out this process. Contaminated items need to be disposed of carefully after traces of cyanide are removed. This is best achieved using chlorine bleach to oxidise any unwanted cyanide and to prevent it contaminating the equipment.
1690
1691The product also needs to be tested by analytic means to determine its concentration and purity. More detailed information that details the manufacturing process can be found in most university and public libraries.
1692
1693The Peaceful Pill eHandbook
1694
1695Cyanide - RP Test
1696
1697For a substance or drug to be useful as a Peaceful Pill two main criteria must be met. It must be ‘Reliable’, and it must be ‘Peaceful’. Applying the Exit RP test to a salt like sodium cyanide gives some encouragement.
1698
1699Reliability is high, few people will ever survive the ingestion of a sufficiently high dose of sodium cyanide. For a dose of 2gm of sodium cyanide, R=10.
1700
1701There is also a correlation between the size of the dose and the speed of death and this minimises the chance of any adverse symptoms developing.
1702
1703In terms of Peacefulness, mixed accounts make this a difficult characteristic to assess. Clearly the size of the dose matters, if one is to minimise symptoms. Preparation is also important.
1704
1705The toxic effect is produced when stomach acid acts on the salt producing HCN which is then absorbed by the gut into the blood stream. This process is facilitated by dissolving the salt in cold water and drinking on an empty stomach where the gastric acid content is high.
1706
1707An alternative is to place the cyanide salt into a treated gelatin capsule. Taking 2 x ‘00’ capsules (2.5gm) with an acidic drink (lemon juice, vinegar) creates the optimum conditions in the stomach. The delay can also usefully be employed to induce sleep with the addition of a strong soporific (sleeping tablet).
1708
1709Taken in this manner the likelihood of a peaceful cyanide death is increased significantly. (P= 5)
1710
1711Cyanide
1712
1713Looking at the Minor Criteria:
1714
1715Availability (3/5) - Soluble cyanide salts are generally hard to obtain and the salts are heavily regulated. The recent (2014) news of a reliable Thai internet source has altered this situation.
1716
1717Preparation (5/5) - Cyanide salts are consumed as a drink or in a gelatin capsule.
1718
1719Undetectability (3/5) - at autopsy the substance will be detected. Some clinicians examining the body after death, will note the pink colour and a possible smell of bitter almonds, but this is often missed..
1720
1721Speed (5/5) - a very quick death.
1722
1723Safety (3/5) - there is little risk to others, although the glass should be washed. Note - if vomiting occurs, the gastric contents may give off dangerous HCN.
1724
1725Storage (5/5). With proper storage, the sodium and potassium soluble cyanide salts have an almost indefinite shelf life.
1726
1727Exit RP Score for Sodium Cyanide: 39 (78%)
1728
1729The Peaceful Pill eHandbook
1730
1731Exit RP Test
1732
1733Criteria Reliability
1734
1735Peacefulness Availability Preparation
1736
1737Undetectability Speed Safety
1738
1739Storage Total
1740
1741Score 10/10 5/10 3/5 5/5 3/5 5/5 3/5 5/5
1742
174339 (78%)
1744
1745Cyanide
1746
1747The Peaceful Pill eHandbook
1748
1749. 8 Detergent Death
1750
1751Since 2009, Exit has received requested for information on the so-called ‘Detergent Suicide’ method of ending one’s life. While answers were provided to those asking the questions, it was not thought necessary to include details of the method in The Peaceful Pill Handbook.
1752
1753This decision has been reviewed in 2011 and this chapter included. We stress however that the method scores poorly on the Exit RP test, and has little to recommend it. It is in effect a cheap and nasty suicide strategy, and readers are advised to consider other better alternatives outlined in this book.
1754
1755Detergent Death
1756
1757The Method
1758
1759The method makes use of the toxic nature of the gas hydrogen sulfide (H2
1760
1761S) and it’s ease of generation from readily available
1762
1763(unrestricted) household chemicals. Hydrogen Sulfide (commonly known as ‘rotten egg gas’) is extremely toxic when inhaled.
1764
1765The mechanism of action is similar to that of hydrogen cyanide where the gas binds with and destroys the function of mitochondria within living cells. The gas is as toxic as hydrogen cyanide, but accidental exposure is uncommon because of the strong and unpleasant smell noted with even the smallest concentrations of the gas.
1766
1767Concentrations of over 0.1% (1000ppm) will lead to immediate loss of consciousness and rapid death. Production of the gas in a confined space (with levels in excess of 1%) will cause certain death.
1768
1769Fig 8.1 Simple ingredients used in Detergent Suicide
1770
1771The Peaceful Pill eHandbook
1772
1773Production of the Gas The gas is easily produced using readily available ingredients. The usual method employed is to add a concentrated acid to an inorganic sulfide. For example adding concentrated hydrochloric acid to calcium sulfide leads to the rapid production of the gas.
1774
17752HCl + CaS 4 H2 S + CaCl
1776
1777The sulfide used in the early spate of Japanese suicides was reported as ‘bath sulphur’ a product used as a supplement added to bath water for therapeutic use. In western countries where there is little interest in sulphur baths, the commonest source of sulfides is the readily available ‘Lime Sulphur’ used as a common fungicide and insecticide by home gardeners. The major ingredient is calcium polysulfide (CaSx
1778
1779) in aqueous solution. is used in vehicle lead acid batteries.
1780
1781The addition of a strong acid to Lime Sulphur liquid in a plastic bucket results in the copious production of hydrogen sulfide gas. Common acids that release the gas include hydrochloric acid (HCl) available from hardware stores, and used as a paving, brick or toilet bowl cleaner, or as a swimming pool chemical, where it is used to lower the pH of the pool. An alternative acid that can be used in sulphuric acid (H2
1782
1783SO4 ) (See Chapter 6) which
1784
1785Detergent Death
1786
1787Problems with the method
1788
1789While the ingredients required to make the gas are readily obtained, and unrestricted, the use of the gas to end one’s life presents a number of significant problems. Of major concern is the risk to others when large amounts of hydrogen sulfide gas are produced. Apart from the likelihood of annoying everyone in the area with the stink, there are real dangers to those who might try to enter the area or attempt resuscitation. Indeed emergency personnel are trained to be careful entering an area where this gas is suspected, and not to attempt mouth to mouth resuscitation.
1790
1791Clearly if one is planning to use this method it is essential that a site is chosen where leakage of the gas can not endanger innocent people and prominent warning signs should be displayed. The use of a car parked in an outdoor location with warning signs displayed prominently on the windows would seem to be the most responsible choice.
1792
1793While it has been reported that as the concentration of the gas rises,there is a rapid inhibition of the sense of smell, so that one does not necessarily experience the sickening stench right to the point of death, it could not be considered a particularly peaceful.
1794
1795The Peaceful Pill eHandbook
1796
1797The Exit RP Test
1798
1799The method scores poorly for Peacefulness (P=2), but high on Reliability (R=10).
1800
1801Considering the minor criteria:
1802
1803Availability & Speed score well at 5/5, Preparation & Storage at 4/5.
1804
1805However on Safety and Detectability, only the lowest score would be appropriate, giving a total score of only 30 (60%).
1806
1807The method therefore scores only slightly better than hanging which says it all (28, 56%).
1808
1809Detergent Death
1810
1811Criteria Reliability
1812
1813Peacefulness Availability Preparation
1814
1815Undetectability Speed Safety
1816
1817Storage Total
1818
1819Score 10/10 2/10 5/5 4/5 0/5 5/5 0/5 4/5
1820
182130 (60%)
1822
18239 Introduction to Drugs Introduction
1824
1825For many seriously ill people, taking drugs or substances orally (by mouth) is the preferred way to end life. Substances taken in this way (eg. Nembutal liquid) require no special equipment. It is this simplicity that explains the appeal of this version of the Peaceful Pill. The lack of any necessary bedside equipment also means that the death is more likely to be understood as one from ‘natural causes’.
1826
1827For example, if a person dying of cancer takes the final step by drinking Nembutal they will look as if they have died in their sleep. Most examining doctors would sign the death certificate indicating that this was the natural, expected death from their cancer. Of course, if an autopsy is undertaken, the causative drug will be discovered, but autopsies are increasingly rare in situations where the attending doctor believes the cause of death is clear (see the final Chapter for a discussion of this).
1828
1829However, while taking oral drugs might seem to be the simplest way of obtaining a peaceful and dignified death, the method does require planning. Knowledge of the substance to be used, its acquisition, preparation and administration are important.
1830
1831Introduction to Drugs The Role of the Drug Overdose
1832
1833Generally speaking, drugs are developed to provide a cure to an illness or to give relief from symptoms. Drugs are never developed to end life, at least not in humans. Yet some drugs do cause death, especially if they are administered in ways that were never intended. The usual way to misuse a drug is to exceed the suggested dose: ‘the overdose’.
1834
1835While most drugs have side-effects (effects other than the purpose for which they are designed), and most side-effects are more pronounced when a drug is misused or taken in overdose, a side-effect like death is always going to be a serious problem for a drug manufacturer.
1836
1837The company responsible for manufacturing a drug that will cause death in overdose will always be nervous about such a product and there will be a search to develop safer alternatives. So, while there are some drugs that do reliably cause death if misused, this number is small and decreasing. This process of replacing potentially lethal drugs with safer modern alternatives goes on all the time. The lethal barbiturates of earlier years have now been replaced by modern, safer sleeping tablets.
1838
1839The lethal tri-cyclic antidepressants have almost disappeared, replaced by much safer serotonin uptake inhibitors like Prozac. Pain-relieving drugs like propoxyphene are currently under review and have already been replaced in many countries. The number of drugs that are of practical assistance to a seriously ill person seeking a peaceful death decreases each year.
1840
1841The Peaceful Pill eHandbook Drugs, Swallowing & Taste
1842
1843A person seeking a peaceful death will need to consume a lethal quantity of their chosen drug. These drugs are often bitter to taste, and consuming a large number of tablets can also be difficult if the person is suffering from a disease that effects swallowing. Examples include some diseases of the throat and oesophagus, or a disease like Motor Neurone Disease that can effect the muscles needed for swallowing. In some cases, problems with swallowing can be so severe that oral ingestion of drugs is simply not an option.
1844
1845To avoid the bitter taste of the lethal dose, drugs are sometimes mixed with another substance to disguise the taste. Another approach is to spray the tongue and throat with a topical anaesthetic like Lignocaine. In Exit’s experience neither of these strategies is particularly rewarding. This is because the drugs are often so bitter that mixing the drug with another substance, like yogurt or jam, simply creates a much larger quantity of an equally-unpleasant substance that then needs to be consumed. Anaesthetic sprays can work, but they are prescription items and require some expertise in administration.
1846
1847The most effective method of consuming quantities of bitter- tasting drugs is to turn them into a liquid which can then be quickly drunk. This can be done by reducing tablets to powder with a mortar and pestle. Another way is to remove the gelatin covering of the capsules and dissolving the powder in a common solvent such as water. Even if a drug does not fully dissolve, a fine powder can still be made drinkable by rapid stirring with a teaspoon. A suspension of fine particles can usually be swallowed without much difficulty.
1848
1849Introduction to Drugs
1850
1851By keeping the volume of the liquid to be drunk to 100ml (approx. 1/3 cup), only a few mouthfuls are needed. The bitter after-taste is effectively dealt with by following this drink with another stronger tasting drink - usually alcohol (see Drugs & Alcohol).
1852
1853Drugs and Vomiting
1854
1855Any substance taken orally can be vomited up, and concern about this can cause considerable anxiety. A person intending to die must take the full (lethal) amount, so it is important to ensure that vomiting does not occur. Some people are prone to vomiting, and some diseases can cause vomiting. In a minority of cases vomiting, or fear of vomiting, can be such a problem that it is not possible to use oral drugs.
1856
1857To minimize the risk of vomiting, an anti-vomiting (‘anti- emetic’) drug is usually taken for a period of time before the consumption of the lethal drug. There are a number of drugs used for this purpose.
1858
1859Anti-emetics are readily obtained, although the most effective are prescription items. The most common are metoclopramide (Maxolon, Pramin, Paspertin) and prochlorperazine (Stemetil, Stemazine). One common procedure is to take six tablets (ie 60mg metoclopramide as a ‘stat’ dose) about 40 minutes before taking the lethal drug. Another procedure is to take the anti-emetic for a full two days before the lethal drug is to be consumed (here the usual dose is two tablets every 8 hours). With this method there is then no need to synchronise the time at which the anti-vomiting drugs are taken with the taking of the lethal drugs.
1860
1861The Peaceful Pill eHandbook
1862
1863If anti-vomiting drugs are taken, the risk of vomiting is very low and problems are rare, except in cases where vomiting is a known specific problem. In these cases alternative methods should be explored.
1864
1865Unless there are specific questions of hypersensitivity or aller- gy (which are very unusual), the anti-emetic ‘Maxolon’ is rec- ommended. The dose (60mg stat or 20mg 3x/day for 2 days) is independent of the quantity of the lethal drug.
1866
1867If vomiting does occur, the individual should bring up (vomit up) as much of the drug from their stomach as they can and the attempt to end their life should be abandoned. Ipecac Syrup can be used to encourage vomiting. It is advisable to have some on hand and can be obtained from the local pharmacy.
1868
1869Fig 9.1: The common antiemetic metoclopramide
1870
1871Introduction to Drugs Drugs & Alcohol
1872
1873Alcohol is often used as a supplement when drugs are used to end life. It serves several functions. Firstly, lethal drugs taken orally are often bitter and leave a prolonged unpleasant after- taste. Even when the drug is consumed in a few quick mouthfuls, a seriously ill person can find this taste quite distressing. Strong alcohol is effective in removing this after-taste. As this is to be the person’s last drink a favoured spirit or liqueur is often chosen. People sip at their favourite Scotch or Baileys Irish Cream and the bitter taste quickly disappears.
1874
1875Secondly, alcohol plays a useful role in ‘potentiating’ the lethal drug. To follow the drug with an alcoholic drink will usually enhance its speed of action and potency. This is true of most of the commonly-used lethal, oral drugs.
1876
1877Thirdly, alcohol is a useful calming agent (anxiolytic) in what is inevitably a stressful time. It is important that any alcohol is taken after the consumption of the lethal drugs so that there is no clouding of a person’s mind.
1878
1879Note though, people should not force themselves to drink alcohol, especially if they find the thought distasteful. The drugs described in this book cause death, with or without alcohol. The most likely effect of excluding the alcohol is that the process will take longer. Liquid morphine (Ordine) can be used as a supplement/potentiator by people with an aversion to alcohol.
1880
1881The Peaceful Pill eHandbook Drug Tolerance
1882
1883Exposure to a particular drug over a prolonged period of time can often lead to the development of an insensitivity to that drug. If a drug is being taken for a particular medical purpose (eg. the relief of pain), one might find that after a while the same pain relief can only be obtained by increasing the dose. This is known as ‘tolerance.’
1884
1885Some drugs are particularly prone to this effect. The body’s response to opiates like morphine or pethidine is an example. After taking morphine for even a short time, the effect of a particular dose will lessen and greater amounts will be needed to achieve the same pain-relieving effect.
1886
1887After a period off the drugs, one’s sensitivity usually returns. This explains why people often accidentally die when taking illegal narcotics like heroin. A person who regularly uses heroin soon develops a tolerance for it. If they are unable to continue taking the drug - perhaps because their supply has broken down or perhaps they have spent time in an institution, they will redevelop their sensitivity. When a new supply becomes available, their greater sensitivity increases the likelihood of accidental death (see the Chapter on the ‘opiates’ for further discussion).
1888
1889Tolerance to a particular drug can be an important factor when choosing a drug to end one’s life. If a seriously ill person has been taking a drug for some time and has developed a tolerance for this particular drug, the necessary ‘lethal dose’ for the drug can be higher than that usually quoted.
1890
1891Introduction to Drugs Slow Release (SR) & Enteric Coated (EC) Drugs
1892
1893Some drugs are treated in some way so as to effect the rate or manner in which they are absorbed into the human body. Examples include ‘Slow release’ and ‘Enteric Coated’ forms of the pharmaceutical.
1894
1895Drugs packaged in a way that allows a slow, steady absorption from the gut into the blood stream are called ‘Slow release’ and often given the initials ‘SR’. Some of the drugs are used to provide a peaceful death are available in SR forms, but one should be aware that these forms of the drug are usually less effective than standard preparations.
1896
1897This is because the drug’s lethal effect usually depends on a rapid rise in the level of the drug in a person’s blood (ie. at a rate that is too fast for the body’s normal excretion mechanisms). Slow Release forms do not cause a steep rise in the blood level of the drug. Crushing or dissolving the drugs before consumption is unlikely to alter this. Powdered, slow release drugs are still slow release. Morphine (NOT the best end of life drug - see Chapter 10) is often prescribed in slow release tablet forms to ensure long periods of pain control, and is less effective in this form.
1898
1899Enteric Coating, is a way of treating some pharmaceuticals so that the active ingredient passes to a more receptive part of the gut before being absorbed into the bloodstream. Examples include those drugs that may be partially destroyed by the strong acid environment of the stomach, but are stable, potent and readily absorbed in the alkaline duodenum and upper small intestine. Enteric coatings inevitably slow the release of active pharmaceuticals and are best avoided. Some anti-emetic (anti vomiting) drugs come in EC forms.
1900
1901The Peaceful Pill eHandbook
1902
1903Alternative Routes of Administration of Drugs Stomach PEGs & Nasogastric (NG) Tubes
1904
1905People who have difficulty swallowing sometimes have a surgical procedure that allows the introduction of liquid food directly into the stomach. This feeding tube is inserted through the wall of the abdomen and is called a percutaneous endoscopic gastrostomy (PEG tube) ‘stomach peg’.
1906
1907The administration of drugs is often easier for a person who has a peg. There are no concerns over bitter taste, vomiting, or the person’s ability to swallow the required quantity of the drug. For a person with a PEG, a drug can be injected directly into the stomach.
1908
1909Nasogastric tubes are also occasionally used to provide fluids to someone who is having difficulty swallowing. This temporary procedure sees a small diameter tube positioned through the nose and down the throat into the stomach. It is possible to deliver fluids directly into the stomach through such a tube. Lethal drugs given in this way need to be in liquid form.
1910
1911Fig 9.2: Intravenous drug administration
1912
1913Introduction to Drugs Intravenous Drugs
1914
1915Many drugs are delivered directly into the body through a needle or cannula that is placed into a vein. Drugs delivered by this route must be liquids. The procedure of inserting a needle into a vein requires a degree of expertise and this can be difficult for people who have not had some medical or nursing training.
1916
1917The speed of action of any drug administered in this way is much greater than for those administered orally. The rapid effect of such administration can occasionally cause difficulty. If the person decides to inject the drug themselves they may loose consciousness before the required dose has been delivered.
1918
1919To ensure that the full lethal dose is administered intravenously, a bag of saline can be used. The saline bag is attached to a cannula through a standard intravenous ‘giving set’ (Fig 9.2). The drugs are added to the saline and continue to flow, even if consciousness is lost, although there is always the risk that the intravenous access will be lost if the cannula is mechanically dislodged.
1920
1921One advantage of intravenous administration is that it extends the range of drugs that can be used. Some drugs that are not well absorbed through the gut when taken orally, drugs like potassium, can cause death when administered intravenously.
1922
1923Rectal Administration
1924
1925Drugs are occasionally administered rectally using suppositories, or by direct infusion (enema). This is usually done if there is difficulty swallowing or if vomiting is a problem. Some lethal drugs can be quickly absorbed in this way, and occasionally this provides a way of proceeding if there are intractable difficulties associated with oral administration.
1926
1927The Peaceful Pill eHandbook Resuscitation
1928
1929The act of taking a lethal drug does not result in an immediate death. Rather, the time that elapses from consuming the drugs until death, depends on a number of factors, and this time can occasionally lead to failure.
1930
1931Some drugs or substances taken orally act very quickly. In some cases, speed of death is an important factor, such as the case of a spy taking a suicide pill to prevent interrogation or torture. For example, Hermann Goering used cyanide in his cell the night before he was due to be executed. Although Goering was being watched very closely, his death was so quick that resuscitation was impossible. However, such a rapid death is rarely a consideration for a seriously ill person wanting to put an end to their suffering.
1932
1933People often think of a ‘peaceful death’ as dying in one’s sleep, and drugs that cause this are sought out. The time spent asleep before death can vary considerably. The longer this time, the greater the likelihood of some unexpected intervention. To reduce any chance of this, it is in the person’s interest to obtain those drugs which bring about sleep, loss of consciousness, then death, relatively quickly. This is one clear advantage of the barbiturate, Nembutal where sleep occurs within minutes of consumption of the drug and alcohol, with death following usually within the hour.
1934
1935Other commonly-used drugs have a much longer ‘window period’ when intervention can occur. For the common propoxyphene/oxazepam combination, this window period may be a matter of hours. This means that considerable planning may be needed to reduce the chance of discovery during this time. The possibility of unwanted intervention is why many people
1936
1937Introduction to Drugs
1938
1939prefer to take lethal drugs in the evening when there is an expected period of several hours before any chance of discovery. If the deeply unconscious person were to be found before death, this can present a significant problem to the person tasked with, or who accidentally, finds them. Even if they are aware of the unconscious person’s plan, the discoverer must do something to protect themselves.
1940
1941It would not be acceptable, for example, to claim in the morning that you noticed that your friend or partner was unconscious but you chose to do nothing about it. During the night a person might argue that they had been asleep and hadn’t noticed, but in the morning, the situation changes. A person in this position needs to consider their options carefully.
1942
1943If an ambulance is called, the discoverer will be protected, but the attending paramedics will attempt to resuscitate the unconscious person and this may well thwart their wish to die. Remember, ambulance paramedics are generally under no legal obligation to abide by a person’s Advance Medical Directive (AMD) (Living Will/ Do Not Resuscitate (DNR) notice). The Officers attending will usually say that these issues ‘can be sorted out at the hospital.’ (For more discussion about the pros and cons of AMDs and role of emergency workers see my first book - Killing Me Softly: Voluntary Euthanasia and the Road to the Peaceful Pill.)
1944
1945Alternatively, someone discovering an unconscious person may protect themselves by calling the family physician. The physician should be aware if a AMD exists and can avoid initiating resuscitation without risking legal repercussions. A doctor who knows the background may well begin a morphine infusion (“to make the patient comfortable”), and allow their patient to peacefully die.
1946
1947The Peaceful Pill eHandbook The Shelf Life of Drugs
1948
1949Most drugs are subject to some form of degradation over time. This may be brought about by chemical, physical or microbial breakdown. The main impact of degradation on a drug is the loss of potency.
1950
1951To ensure that drugs are as effective as possible, manufacturers include storage instructions and an ‘expiry date’ with each item. The time taken from manufacture to expiry date is referred to as the drug’s ‘shelf life’ and it is in the manufacturers’ interest to make this as long as possible. Clearly a drug will not be rendered ineffective after the stated expiry date. Rather, this date merely indicates that if stored correctly, no significant chemical, physical or microbial degradation of the drug will have occurred before this date.
1952
1953Research shows that many drugs remain highly effective for many years after their expiry date. For modern medicines, expiration dates are usually set for two to three years after the date of the manufacture of the drug. This is the case for veterinary liquid Nembutal which has a shelf life/ expiry date stamped on the side of the bottle, but has been shown to be very effective for many years after this date.
1954
1955Also, the form of the drug will often effect its shelf life. For example, pills and capsules stored in their original, air-tight containers at cool room temperatures and free from humidity are often viable for around 10 years. This is much longer than the stated expiry date. The powdered form of a drug has similar longevity, especially if it is vacuum-packed (using a standard kitchen food vacuum-sealer) and kept cool and away from light. For drugs in liquid form, the shelf life is commonly shorter.
1956
1957Introduction to Drugs
1958
1959Video: Packaging & Shelf Life of Veterinary Nembutal
1960
1961Video: What is the Shelf Life of Nembutal?
1962
1963The Peaceful Pill eHandbook
1964
1965To determine if a drug has deteriorated, there are some common sense guidelines.
1966
1967In the case of a liquid, the drug’s appearance is important. One should check its colour and clarity (has it become cloudy); particulate matter (eg. are there tiny visible particles); preservative content (if stated); sterility (has the bottle been tampered with or opened) and whether the drug has interacted with its enclosure (bottle or lid). If none of these signs are present, then the liquid in question is more likely to be viable, than if there were any signs of degradation.
1968
1969If the drug is in tablet form, signs of degradation include the tablet’s appearance, moisture content, hardness (have the tablets become as hard as rocks), friability (uncoated tablets), disintegration time (when placed in water) and uniformity of content. Again, any of these tell-tale signs may indicate chemical degradation.
1970
1971Of course, the only certain way of establishing whether significant degradation has taken place is by carrying out a chemical assay on the product. For drugs that are hard to obtain and difficult to replace with fresh samples, an assay makes a lot of sense. A detailed discussion on the testing of the purity and potency of Nembutal is given in a later Chapter.
1972
1973Introduction to Drugs Conclusion
1974
1975This Chapter details some of the most important issues that should be considered if a person is planning to use drugs to achieve a peaceful, dignified death.
1976
1977Specific issues such as preparation, administration, vomiting, and the shelf-life of a drug are common to all drugs, and an understanding of these issues reduces the chance of failure. This Chapter should be read in conjunction with the following chapters that detail the use of particular drugs.
1978
197910 Morphine & Slow Euthanasia Introduction - The Doctor’s Loophole
1980
1981‘Slow Euthanasia’, ‘Terminal Sedation’ or the ‘Doctrine of Double Effect’ as it is also called, is the only way that a caring doctor can hasten the death of a patient and escape any legal consequence.
1982
1983Known commonly as the ‘doctor’s loophole’ slow euthanasia allows a doctor to end a patient’s life by slowly increasing the amount of a pain-killing drug. In the eyes of the law it doesn’t matter if, in the course of treating a person’s pain, the person dies.
1984
1985It is the administration of the pain-relieving drug that causes the double effect; it relieves pain but it also causes death. As long as the stated primary intention is the treatment of the person’s pain, the doctor is legally safeguarded.
1986
1987While slow euthanasia is relatively common, few doctors will ever admit their involvement. Even while administering slow euthanasia, some doctors will argue that they are only treating the patient’s pain.
1988
1989Others know exactly what their ‘prime
1990
1991intention’ is, but wisely decide to keep quiet about it. Others just prefer not to think about it too closely.
1992
1993Morphine & Slow Euthanasia
1994
1995It is a pity that this practice is so cloaked in secrecy. Clearly, it would be better if there were open and honest communication between the medical system (represented in the doctor and health care team), the patient and the patient’s family. However, with laws in place that make it a serious crime to hasten a patient’s death, but make it no crime at all to aggressively treat pain, there is little prospect of change.
1996
1997How Slow Euthanasia Works in Practice
1998
1999A doctor practising slow euthanasia usually gives a narcotic analgesic (morphine), while periodically reviewing the patient’s pain. The claim is then made that treatment is inadequate, and the morphine dose increased.
2000
2001If this review takes place every 4 - 6 hours, morphine levels will rise. Eventually lethal levels will be reached and the patient will die. The doctor defends his or her actions by simply saying that they were trying to control the patient’s pain. Death, they argue, was an unplanned consequence of either the patient’s disease or the necessary treatment for the pain.
2002
2003It can take days for the levels of morphine to become high enough to cause death. It is important for the doctor’s safety that the process is slow. Indeed, it is the length of time taken that gives credibility to the argument that there was effort put into establishing just the right dose of morphine.
2004
2005If, for example, a single large dose of morphine was administered and death resulted, it would be almost impossible for the doctor to argue that their prime intention was the treatment of the patient’s pain. Slow euthanasia is necessarily slow; it must be, to safely exploit this loophole.
2006
2007The Peaceful Pill eHandbook
2008
2009Another way of understanding the process of slow euthanasia is to consider the link between cause and effect. The time taken for the morphine to end life muddies the water and blurs the connection between the cause (the commencement of morphine) and the effect (the patient’s death).
2010
2011By blurring this link, a doctor can help a patient die and escape the legal consequences.
2012
2013Problems with Slow Euthanasia Slow euthanasia has a number of features that limit its appeal to a patient. Firstly, it is the doctor who is in control. While a patient might ask for this form of help, it will be the doctor who decides if and when it will be provided. Just because you - the patient - feel that now is the right time to begin the process, there is no guarantee that the doctor will agree.
2014
2015They may feel you should wait; wait until you become sicker, perhaps until your haemoglobin drops a few points, or your respiratory function tests deteriorate further. The sicker you are, the safer it is for the doctor to go down this path. If the doctor disagrees with you and thinks the ‘best time’ to help should be several weeks away, there is absolutely nothing you can do about it.
2016
2017Another drawback of slow euthanasia is the restriction on the range of drugs that a doctor might use to help a person die. If the doctor’s defence is to be that it was the treatment of the patient’s pain that caused the death, then a pain-relieving drug like morphine must be used.
2018
2019Morphine & Slow Euthanasia
2020
2021A doctor could not, for example, administer a large dose of a barbiturate. While a barbiturate might provide the most peaceful and quickest death, barbiturates are not pain relieving drugs, and the claim that such a drug was being used to treat pain makes no sense.
2022
2023This use of morphine by doctors to end life has led to the common community misconception that the best drug to use to end one’s life is morphine - it must be, because that’s the drug doctors use! This unfortunate misunderstanding leads to many failed suicide attempts.
2024
2025And the process must be slow. Indeed, slow euthanasia can often take days or even weeks. Often the patient is given a sedative that keeps them asleep through the whole process; midazolam is the drug of choice.
2026
2027Coupled with morphine, this morphine - midazolam mix (known as ‘Double M Therapy’) places the patient in an induced coma for the time needed to raise the morphine level sufficiently. Double M therapy allows the patient to sleep through their own death and gives rise to another name for the process - ‘pharmacological oblivion.’
2028
2029The doctor still makes the assessment about the need for larger and larger morphine doses. Here the decision is based not on the patient’s complaints, but upon a clinical assessment of the unconscious person.
2030
2031The doctor will also choose the place of death. It is unusual for slow euthanasia to take place in a patient’s home. Usually it occurs in an institution, commonly a hospital or hospice.
2032
2033The Peaceful Pill eHandbook
2034
2035In an institution, a team is often involved in providing care and several doctors might participate in the relentless increase of the morphine. This further blurs the link between cause and effect and makes it even safer for the medical staff involved. While slow euthanasia could take place at the patient’s home, in practice this presents many logistical difficulties. The doctor would need to make many visits, perhaps several a day, to facilitate the relentless increase in drugs.
2036
2037Also full nursing care is required; an unconscious patient needs to be moved regularly and watched constantly to ensure the flow of drugs is not interrupted. This is often an extremely difficult time for those close to the patient as they find themselves participating in this deliberate, slow death watch.
2038
2039For these reasons, few people opt for slow euthanasia as their preferred choice for a peaceful, dignified death. More commonly, it is an option of desperation, when few alternatives exist. In such dire circumstances, if a doctor does offer help (usually through a nod, a wink and an understanding), patients will grab the chance, reasoning correctly, that this is better than nothing.
2040
2041Those who are left often see this as an example of a doctor helping someone to die, and this leads to the commonly expressed view that there is no need for euthanasia legislation. People say ‘I can’t see what all the fuss is about with voluntary euthanasia – it goes on all the time – doctors are always helping people to die.’
2042
2043It is as well to remember that ‘what goes on all the time’ is the grim process of suspending a sick person by a thread between life and death for an arbitrary time, until the thread breaks.
2044
2045That is slow euthanasia!
2046
2047Morphine & Slow Euthanasia Asking for Slow Euthanasia
2048
2049The process of slow euthanasia is always controlled by the doctor. Because of this, there is usually little a patient can do to ensure that the option is available. Often when patients realize that they have a deteriorating medical condition, they ask their doctor whether or not they will be able to help them ‘at the end.’ The doctor may even volunteer to have this discussion and this is encouraging - but be careful.
2050
2051When doctor and patient begin speaking in this tangential way, there is a very real chance that significant misunderstandings can occur. It is not uncommon for a doctor to promise ‘every assistance when the time comes’ and for the patient to draw immense comfort from this.
2052
2053A patient might even imagine that the doctor is saying that ‘when things deteriorate I will give you access to lethal drugs.’
2054
2055In
2056
2057reality, this is highly unlikely. Few medical doctors would risk de-registration and a significant jail term. The only assistance likely from the doctor, is for them to initiate slow euthanasia, with the patient being admitted to an institution, a hospital or hospice. And there may well be argument about when the process should commence.
2058
2059Exit suggests that in situations where slow euthanasia has appeal, that early discussions between patient and doctor take place. Be blunt. If the doctor promises help ‘when the time comes’, insist on knowing who will decide when that time is, and exactly what sort of help is being promised?
2060
2061If there is any attempt to skirt or dismiss your questions, be very wary. Try discussing the issue with another doctor, or look into an alternative end of life strategy.
2062
2063The Peaceful Pill eHandbook The Role of Opiates & Opioids
2064
2065Opiates are naturally occurring compounds that originate from the sap of the poppy, papaver somniferum. Substances derived from these compounds are opioids. These compounds all effect the same receptors in the brain and are generally used for the control of strong pain.
2066
2067While morphine is the commonest example, other examples include, pethidine, codeine, methadone and fentanyl. The illegal drug heroin is also an opiate. All opiates have properties that make them difficult drugs for a person to use to reliably end their life.
2068
2069The biggest problem associated with taking opiates is predicting the effect. There is remarkable individual variability in sensitivity to these drugs within the normal population. People who are similar physically (same height, weight, sex etc) can have a vastly different response to the administration of an opiate.
2070
2071A small dose of morphine may have almost no effect on one person, while that same dose could kill another.
2072
2073Predicting
2074
2075the effect of the drug on an individual is difficult. When these drugs are used clinically the rule of thumb has been to ‘start low and go slow’ until the individual’s sensitivity to the drug is established.
2076
2077Another difficulty with opiates is the rapid development of tolerance when the drugs are taken for any period of time. Within days, the morphine that initially had a powerful effect on the pain can become almost ineffective.
2078
2079Morphine & Slow Euthanasia
2080
2081To obtain the same pain relief the dose must be increased. If these drugs are taken for long periods, very large doses might be needed to provide adequate pain control. These required doses can become so large that if they were taken before the tolerance had developed, death could well have been the result.
2082
2083It is this development of tolerance, and its rapid loss once the drugs stop, that often leads to the accidental death of people who self-administer opiates, especially heroin. If there is a break in supply and the acquired tolerance is lost, a sudden resumption may result in an unexpected fatal overdose.
2084
2085Opioids
2086
2087Natural Opium Morphine Heroin Codeine
2088
2089Semi Synthetic Heroin
2090
2091Synthetic Pethadine Methadone Fentanyl
2092
2093Fig 10.1: Liquid morphine
2094
2095The Peaceful Pill eHandbook
2096
2097Morphine is commonly prescribed as a slow release (SR) tablet. MS Contin and Kapanol are marketed forms. These may be taken once or twice a day and slowly release the morphine to give ‘background’ pain control. For the onset of sudden (breakthrough) pain, a fast release form of the drug, liquid morphine is often prescribed (Ordine).
2098
2099Many very sick people receive these drugs for the pain of serious illness and sometimes go to great lengths to stockpile tablets believing that they will soon acquire a lethal dose. But knowing how many morphine tablets to accumulate is like asking the length of a piece of string?
2100
2101A single dose of SR tablet morphine may cause death, but the result is often unpredictable. The fast-acting liquid morphine may be a more effective form of the drug, but the problems of sensitivity and tolerance remain.
2102
2103For these reasons it is difficult to advocate the opiates as stand- alone, single-dose, oral agents to provide a reliable death. One exception to this general rule is propoxyphene. When this drug is taken with a (non-lethal) benzodiazepine, a reliable death will occur.
2104
2105The opiates do, however, have a role as supplementary or potentiating agents, (ie. a drug taken to enhance the effectiveness of another drug). This role is usually filled by alcohol, but for people who do not drink, morphine liquid can be a good alternative.
2106
2107Morphine & Slow Euthanasia The Use of Heroin
2108
2109Exit is occasionally asked about whether heroin should be obtained from ‘the street’ and used to end life. These questions are often prompted by news reports of people dying from a heroin overdose. In reality, there is little to be gained by using heroin.
2110
2111As an opiate heroin suffers from the problems of tolerance and sensitivity mentioned above. In addition there is the question of the uncertainty of the dose with heroin. Because it has been acquired on the streets, one can never be exactly sure what or how much one has actually purchased. It also needs to be injected intravenously. In Exit’s experience, few elderly and seriously ill people have these skills.
2112
2113Note: If heroin is taken orally, it turns back into morphine in the gut and offers no advantage over prescription tablet morphine, where at least the exact dose is known.
2114
2115One final point on the opiates. If one does die taking these drugs, the death is likely to be very peaceful. Morphia is, after all, the goddess of dreams.
2116
2117The Peaceful Pill eHandbook Conclusion
2118
2119In Exit’s internal polling of over 1000 of our supporters, less than one percent (0.3%) of Exit members say that they would prefer Terminal Sedation/ Slow Euthanasia by their physician compared to the self-determined taking of a Peaceful Pill (89%). Slow Euthanasia is, therefore, one of the least-preferred methods of dying, and one that is usually avoided when other options exist. Given a choice, people prefer to have control of the dying process.
2120
2121This is not the case with slow euthanasia. It is relatively rare to find someone who wants to spend their last days in a drug- induced coma. When people decide that their suffering is so great that death is preferable, they want their passing to be quick.
2122
2123This is why slow euthanasia is almost always an option of last resort. It is the method accepted when nothing else is on offer, and the only alternative is relentless and ongoing suffering.
2124
2125Finally, there remains a common belief that the ‘opiates’ are the best drugs to end life. This undeserved reputation comes from their almost-universal use in slow euthanasia, where doctors have little choice.
2126
2127While a single overdose of morphine may cause death, individual sensitivity and tolerance to these drugs make this an uncertain and unpredictable process. The opiates are best used to do the job they are designed to do, control strong pain. There are better euthanasia options available.
2128
2129Morphine & Slow Euthanasia The Exit RP Test for Morphine
2130
2131Morphine (or any of the other opiates) do not score particularly well on the RP Test. When used as a drug and taken as a single dose by a person wanting to die, the difficulty of establishing the lethal dose significantly reduces Reliability (4/10). Peacefulness though is good (10/10).
2132
2133Minor criteria scores are inconsistent. Availability (3/5), sometimes morphine is available - if a person is suffering from a recognised painful disease. But the use of the opiates as drugs of addiction and their place in the illegal narcotic trade can also make them occasionally very difficult to obtain. Preparation is easy (5/5), although constricted ‘pinpoint’ pupils can often alert a medical officer to the presence of these drugs in the system (Undetectability = 2/5). Death can also take some time, depending on one’s tolerance and resuscitation is often straightforward using the opiate antagonist Naloxone (Speed = 2/5). There are no safety issues (Safety = 5/5), and the drug has a moderate shelf life (Storage = 3/5).
2134
2135Exit RP Test - Morphine
2136
2137Criteria Reliability
2138
2139Peacefulness Availability Preparation
2140
2141Undetectability Speed Safety
2142
2143Storage Total
2144
2145Score 4/10
2146
214710/10 3/5 5/5 2/5 2/5 5/5 3/5
2148
214934 (68%)
2150
215111 Propoxyphene Introduction
2152
2153A useful, lethal drug, still prescribed in a handful of countries, is ‘Propoxyphene’. The drug is marketed under various names and used as an oral analgesic (pain reliever). If prepared in a certain way, and taken in combination with a common benzo- diazepine sleeping pill such as oxazepam (Serepax), propoxy- phene will provide a reliable, peaceful and dignified death.
2154
2155Fig 11.1 Propoxphene capsules (Doloxene)
2156
2157Propoxyphene The Various Forms of Propoxyphene
2158
2159Propoxyphene is marketed under a number of names, exam- ples include Darvon, Doloxene, and Depronal.
2160
2161Regardless of its name, the key necessary ingredient is pro- poxyphene – either as the hydrochloride or napsylate, and it is important that the drug labels are read very carefully. In some video segments included in this chapter the name Doloxene is used to refer to propoxyphene.
2162
2163Propoxyphene capsules have only one active ingredient (dex- tropropoxyphene napsylate).
2164
2165However, the drug propoxy-
2166
2167phene is often marketed in combination with other common analgesics such as paracetemol (acetaminophen) and marketed as Di-Gesic (Darvocet).
2168
2169These combination products are of limited use. Taking a large amount of the associated drug can complicate the process. The ingestion of a substantial quantity of paracetemol (acetami- nophen) for example may well lead to death, but it would not be regarded as particularly peaceful.
2170
2171Note: With the withdrawal of the barbiturate sleeping tablets from the medical prescribing list, Doloxene has become the most common doctor-prescribed medication used by seriously ill people to end their lives. Recently, the unique properties of Doloxene have begun to attract attention; first in the UK, then New Zealand and more recently in the US and Canada where it has now been removed from the prescribing schedule.
2172
2173The Peaceful Pill eHandbook When is Propoxyphene Prescribed?
2174
2175Propoxyphene (dextropropoxyphene napsylate) is almost al- ways available from a doctor on prescription, where it is used for pain management.
2176
2177Propoxyphene is usually prescribed
2178
2179when over-the-counter pain relievers prove inadequate and when other, more common prescription pain-relievers (eg. Panadeine Forte or Tylenol-Codeine - a mixture of paracet- emol and codeine) prove unsatisfactory.
2180
2181Propoxyphene can be used whenever there is a need for gen- eral pain relief. Before their removal in 2010 in the US (and Canada), propoxyphene and combinations were the 12th most prescribed generic drug (Public Citizen, 2006)
2182
2183How Lethal is Propoxyphene?
2184
2185Propoxyphene has a very narrow therapeutic margin. The dif- ference in dose between that providing analgesia and that caus- ing death is small. Like the opioids, the outcome from a par- ticular dose can be difficult to predict, but this drug produces a cardiotoxic metabolite when it breaks down which increases its usefulness as a self deliverance agent.
2186
2187When another drug, the readily-available, non-lethal sleeping tablet, oxazepam, is added, along with alcohol, the result is certain. Exit has no reported failures from this combination.
2188
2189As the reputation of propoxyphene has grown, so script sizes have been reduced. The standard packaging number for pro- poxyphene is now 50 capsules. All capsules contain the same 100mg of dextropropoxyphene napsylate.
2190
2191Propoxyphene
2192
2193If 10gm of dextropropoxyphene napsylate powder is obtained from 100 capsules and taken with 10 or more moderately, long-acting sleeping tablets like oxazepam, death will follow.
2194
2195Propoxyphene is usually prescribed at the rate of 4-6 capsules per day (400 - 600 mg) to deal with pain. Ten grams of the drug would provide around 2 to 3 weeks of pain control.
2196
2197The Role of Oxazepam
2198
2199Oxazepam (Serepax) is a moderately long-acting, non-lethal sleeping tablet. Another moderately long-acting sleeping tab- let often used in combination with propoxyphene is nitrazepam (Mogadon). These modern sleeping tablets are members of a drug class known as benzodiazepines and when taken by them- selves are not usually lethal, even if taken in large amounts. When taken in combination with propoxyphene, oxazepam or nitrazepam reinforce the effect of a propoxyphene and a lethal combination is the result.
2200
2201Fig 11.2: The common sleeping tablet - oxazepam (Serapax)
2202
2203The Peaceful Pill eHandbook
2204
2205Note: Duration of action of the benzodiazepine is important - shorter acting drugs like temazepam are not recommended.
2206
2207When is Oxazepam Prescribed?
2208
2209Well known as sleeping drugs, oxazepam and nitrazepam are available on prescription from a doctor. They are prescribed for insomnia (when a person is unable to sleep). Oxazepam is usually prescribed in packets containing 25 sleeping tablets, which come in two sizes, 15mg and 30mg.
2210
2211People using propoxyphene, often take a full packet of 30mg oxazepam tablets as the supplement.
2212
2213Using Propoxyphene
2214
2215The drugs are taken sequentially. Prepare the propoxyphene by pulling apart 100 x 100mg capsules (or cut them open with scissors) and empty the 10gm white dextropropoxyphene na- psylate powder into a glass. In another glass place 10 or more 30mg oxazepam tablets and cover them with water.
2216
2217It is wise to take an anti-emetic (eg metoclopramide) either as a single stat dose or for 48 hours before the planned death. After having something light to eat, add enough water to the 10gm of propoxyphene powder so that stirring allows the drug to be drunk. Note: the napsylate does not dissolve in the water, stir with a spoon and then drink the suspension of particles. Stir the second glass with the oxazepam and water till this also can be taken as a drink.
2218
2219Video: Using Propoxyphene Propoxyphene
2220
2221The Peaceful Pill eHandbook
2222
2223Fig 11.3: 100mg pink Propoxyphene Capsules
2224
2225Fig 11.4: Doloxene packaging
2226
2227Propoxyphene
2228
2229Alcohol is useful to take away the bitter drug after-taste and will speed the process. Sit comfortably. In 10 - 20 minutes sleep will occur and death will follow usually in 4 - 6 hours.
2230
2231Shelf Life of Doloxene
2232
2233Propoxyphene has a relatively long shelf life. Prescribed cap- sules have an expiry date stamped on each card and this is usually 2 or 3 years into the future. Although this provides only a rough guide, in the absence of any available testing of the drug, it is the only indication one has. Capsules that have reached their expiry date should be treated with caution (See earlier Chapter on discussion on shelf life).
2234
2235The Future of Propoxyphene
2236
2237Propoxyphene faces an uncertain future. The withdrawal of the drug from the prescription schedule in the UK in early 2005. The drug has also been withdrawn in the European Union, the US, Canada and in New Zealand. In November 2010 the FDA announced that the drug would be also removed from the US market.
2238
2239See: http://nyti.ms/9iPzgD
2240
2241At the time of press, propoxyphene is still available on pre- scription in Australia, Mexico and a range of South American and Asian countries.
2242
2243The Peaceful Pill eHandbook
2244
2245Fig 11.5: Propoxyphene powder ready for mixing with water
2246
2247Fig 11.6: 10gm propoxyphene ready to drink
2248
2249Propoxyphene
2250
2251Video: The Preparation of Propoxyphene (Doloxene)
2252
2253Video: What is the Shelf Life of Doloxene?
2254
2255The Peaceful Pill eHandbook RP Test for Propoxyphene
2256
2257Propoxyphene scores well on the RP Test. Exit has no con- firmed reports of failure and it rates 9/10 for Reliability. The time before sleep occurs is longer than other drugs like Nemb- utal and this can cause anxiety. Peacefulness (7/10).
2258
2259In the minor categories: Availability is listed at 4/5. Most people who set out to get this drug will acquire it. Remem- ber though that if the drug is withdrawn, availability will drop to zero. Preparation is more complicated than with other in- gestibles (Pr=3/5). The drug is undetectable - unless there is an autopsy, although constricted pupils may cause suspicion (D=3/5). The process is slow (Sp=2/5) the drug presents no risk to others (Sa=5/5). The drug has a moderate shelf life (St=3/5). Total 36 or 72%
2260
2261RP Test for Propoxyphene
2262
2263Criteria Reliability
2264
2265Peacefulness Availability Preparation
2266
2267Undetectability Speed Safety
2268
2269Storage Total
2270
2271Score 9/10 7/10 4/5 3/5 3/5 2/5 5/5 3/5
2272
227336 (72%)
2274
227512 Amytriptyline Introduction
2276
2277Amitriptyline is the most useful in a class of drugs known as tri- cyclic antidepressants (TCAs). These drugs can be lethal if taken in a certain way.
2278
2279The TCAs date back to the early 1960s where they established themselves as useful antidepressants. However, their narrow ther- apeutic margin (the dose needed for therapy as an antidepressant and that which is toxic is close) meant that there were dangers in prescribing these drugs, especially to depressed people, from either accidental or intentional overdose.
2280
2281Their implication in a large number of deaths from overdose meant that other classes of safer antidepressants such as the sera- tonin re-uptake inhibitors (SSRI) like fluoxetine (Prozac) found favour and largely displaced the TCAs.
2282
2283Since this time the TCAs have undergone something of a resur- gence for the treatment of intractable neuropathic pain (such as trigeminal neuralgia) and migraine.
2284
2285Amitriptyline
2286
2287Using Tricylics for a Peaceful Death
2288
2289The drugs have several characteristics that make them useful as reliable and lethal drugs. In particular they exhibit cardiotoxic and central nervous system (CNS) effects. CNS symptoms in- clude sedation and coma, but it is the cardiotoxic effects that reduce cardiac output, lower blood pressure and disrupt car- diac rhythm that bring about death.
2290
2291The toxic effects are accentuated if the drug is rapidly absorbed from the gut and this occurs in the alkaline environment of the small intestine. Preparation as a drink facilitates this, as does the use of an anti-emetic like metoclopramide (Maxolon) which speeds gastric emptying.
2292
2293Fig 12.1 The tricyclic antidepressant amitriptyline
2294
2295The Peaceful Pill Handbook
2296
2297Amitriptyline is one of the most sedating of the TCAs and par- ticularly useful as a lethal drug. The drug is marketed as Endep or Elavil tablets. The amount required is 8gm.
2298
2299Preparation of Amitriptyline
2300
2301The drug is usually packaged as tablets in 10, 25, 50 or 100mg amounts (Fig 12.1) and is usually supplied in packets of 50 tablets. Two packets of 100mg tablets is (100 x 100mg) or 10gm of the drug.
2302
2303For a peaceful death, open the blister packs and place 100 of the 50mg tablets in a glass. Add enough water to cover the drug and with gently agitation allow the drug to dissolve.
2304
2305Fig 12.2 Amitriptyline with metocloptamide, oxazepam and Gin
2306
2307Amitriptyline Video: Preparing Amitriptyline
2308
2309The Peaceful Pill Handbook
2310
2311Take 6 x 10mg metoclopramide tablets and wait 40 minutes before drinking the dissolved amitriptyline. Follow this with 10 or more benzodiazepine sleeping tablets, then finish by tak- ing alcohol to potentiate the action of the drug, and take away the bitter drug after-taste.
2312
2313Note: Although amitriptyline is a strong sedative and sleep will quickly result, it is common to include a benzodiazepine sleep- ing drug after taking the amitriptyline and before the whisky. Serapax (oxazepam) is useful. A full card (20 x 30mg tablets) can be crushed, mixed with water and taken as a drink after the amitriptyline.
2314
2315Once the drink has been consumed, settle back and take the alcohol. The drug cocktail will work quickly inducing sleep in about 15 minutes. Sleep will then deepen as consciousness is lost and the cardiotoxic properties of the drug bring about death. This period can vary and it is a good idea to have pre- pared a situation where there is no likelihood of disturbance for a period of up to 24 hours. (Fig 12.2 & Video)
2316
2317Amitriptyline How does Amitriptyline score on the RP test?
2318
2319Exit has no confirmed reports of failure using this regime and it rates 9/10 for Reliability. The time before sleep occurs is longer than with the barbiturates and this can cause anxiety. Peacefulness (7/10).
2320
2321In the minor categories: Availability 2/5. It can be a difficult drug to acquire. Preparation is more complicated than with other ingestibles (Pr=3/5). The drug is undetectable - unless there is an autopsy.
2322
2323There is nothing about the death that suggests the use of this drug - the person looks as though they have died of a cardiac arrest (which they have - D=3/5).
2324
2325The process is however slow (Sp=2/5) and the drug has a mod- erate shelf life (St=3/5). The drug presents no risk to others (Sa=5/5).
2326
2327Total 34 or 68%
2328
2329The Peaceful Pill eHandbook
2330
2331RP Test for Amitriptyline
2332
2333Criteria Reliability
2334
2335Peacefulness Availability Preparation
2336
2337Undetectability Speed Safety
2338
2339Storage Total
2340
2341Score 9/10 7/10 2/5 3/5 3/5 2/5 5/5 3/5
2342
234334 (68%)
2344
2345Amitriptyline
2346
234713 Chloroquine Introduction
2348
2349This under-rated and useful end of life drug is making some- thing of a comeback since it was first promoted by the French suicide manual Suicide Mode d’Emploi in 1982. The ready avail- ability of this anti-malarial, either online or over-the-counter in many countries, has contributed to its growing use as a means of providing a reliable death. Cambodian despot, Pol Pot, is be- lieved to have used chloroquine (in conjunction with Valium) on the eve of the announcement by the Khmer Rouge that they planned to hand him over to international authorities for trial.
2350
2351First synthesised in the 1930s as a substitute for naturally pro- duced quinine, the drug was found to be effective against malaria. However, its widespread use was delayed until after the Second World War, because of concerns over the drug’s narrow therapeu- tic range. Blood levels for effective treatment are in the order of 0.02-0.5 mg/l. However, toxic symptoms have been reported with as little as 0.5 - 1.0 mg/l, and levels of >3.0 mg /l are often fatal.
2352
2353Chloroquine
2354
2355Packaging & Availability
2356
2357The drug is commonly marketed as ‘chloroquine phosphate 250mg’ and comes in blister packets of 20 tablets. Brand names include ‘Avloclor’. When for sale online, a purchase of these tablets will often require the completion of a questionnaire. A vacation to an area where malaria is present, but not chloroquine resistant malaria (CRM) (eg. Peru, Bolivia or other countries west of the Andes) is an excellent reason why one would purchase chloroquine phosphate.
2358
2359Fig 13.1: Blister pack 250mg Avloclor (chloroquine phosphate) tablets
2360
2361The Peaceful Pill eHandbook Dosage
2362
2363Quantities in excess of 5gm will constitute a lethal blood lev- el of the drug. 250mg chloroquine phosphate tablets have ~150mg of active chloroquine base, so anything in excess of 2 packets (40 x 250mg tablets) would be a lethal dose.
2364
2365Administration
2366
2367The drug is taken by mouth whereby it is rapidly and completely absorbed from the gut. Administration involves crushing 50 tablets and then dissolving them in 100ml of water. This method will lead to rapid absorption. However, this small drink will be extremely bitter.
2368
2369Note: If there are significant concerns over the bitter taste of the drug, the tablets could be crushed into a powder and then repackaged into ‘00’ or ‘000’ gelatine capsules (See the previous Chapter on Cyanide).
2370
2371The first symptoms of overdose will take place within 30 min- utes of ingestion. Death will usually occur within 1 - 3 hours. Drowsiness and dizziness quickly progress to loss of con- sciousness and shock. Death follows from cardiac arrest.
2372
2373The Use of Potentiating Drugs
2374
2375The use of benzodiazepines to potentiate the lethal effect of many drugs has in the past been advised (eg oxazepam or di- azepam with propoxyphene or chloral hydrate). However, in the case of chloroquine, this is not needed. The reported pro- tective effect of Valium (diazepam), in particular, has been the
2376
2377Chloroquine
2378
2379subject of considerable debate. However, the medical litera- ture reveals that the administration of Valium in cases of se- vere overdose is a life-saving measure. For this reason, in- tercurrent use of benzodiazepines should likely be avoided.
2380
2381This is not to say that other drugs cannot be usefully used to increase the lethal effects of chloroquine. For example, al- cohol, along with respiratory depressants (barbiturates) or cardiac inhibitors (B blockers) can serve this purpose.
2382
2383Fig 13.2: Chloroquine Phosphate Tablets
2384
2385The Peaceful Pill eHandbook The RP Test for Chloroquine
2386
2387The drug scores well on reliability, speed and availability, but relatively poorly on peacefulness.
2388
2389RP Test for Chloroquine
2390
2391Criteria Reliability
2392
2393Peacefulness Availability Preparation
2394
2395Undetectability Speed Safety
2396
2397Storage Total
2398
2399Score 8/10 5/10 5/5 4/5 3/5 4/5 5/5 3/5
2400
240137 (74%)
2402
2403Chloroquine
2404
240514 Insulin Introduction
2406
2407There has been a lot of recent interest in the use of Insulin to provide a peaceful death. Reasons for this are easy to understand. In developed nations there is a huge growth in the numbers of people with Type 2 diabetes, and a corresponding increase in the number of people with ready access to this drug. An additional factor is the common chronic complications that often accom- pany severe forms of this disease. These symptoms can often so limit a person’s quality of life, that the option of a peaceful death is sought.This drives interest in the use of this drug.
2408
2409What is Insulin & is it effective?
2410
2411Insulin is a substance produced in the pancreas that controls sugar levels in the body. If the pancreas fails (type 1 diabetes), or if the insulin produced fails to have the expected effect (type 2 diabe- tes), blood sugar levels (BSL) rise and disease results. Synthetic insulin can then be used to drive down the BSL to normal levels.
2412
2413Insulin
2414
2415However, if an overdose of this drug is taken, the blood sugar can be pushed dangerously low, and diabetic hypoglycemic coma and death result.
2416
2417A hypoglycemic death from Insulin overdose, where the brain is starved from sugar, can be relatively peaceful. Initial symptoms of confusion and incoordination (often confused with drunken- ness) can lead on to a rapid loss of consciousness.
2418
2419Significant problems using Insulin
2420
2421The biggest problem with using the drug in this way is that Insu- lin must be injected. As yet there are no oral forms of the drug. The problems of intravenous administration have been described in the former Chapter about different aspects of drugs. Although
2422
2423Fig 14.1: Typical subcutaneous Insullin administration
2424
2425The Peaceful Pill eHandbook
2426
2427insulin can also (and usually is) given by subcutaneous injection, trying to administer an excess of 1000U of the rapid acting form of this drug, by the subcutaneous method can be practically im- possible.
2428
2429The other issue is that the growing number of people with access to this drug have the form of the disease where their bodies are unresponsive to the drug (Type 2 diabetes). While 1000U admin- istered rapidly might peacefully end the life of a non-diabetic, those with the disease need to be much more careful.
2430
2431In theory, one can pre-sensitise oneself, by taking alcohol (which restricts the body’s emergency release of sugar), fasting, and by the administration of a significant dose of oral hypoglycemics before the insulin is injected. (eg ~50mg Glimepiride), the risks and uncertainties of the administration of a large subcutaneous injection remain.
2432
2433Fig 14.2: ‘NovoRapid’ rapid acting insulin ampoule, 1000U in 10ml with 0.5ml syringe for subcutaneous administration
2434
2435NOTE: 20 full syringes would need to be quickly injected to administer 1000U
2436
2437Insulin Conclusion
2438
2439In summary, Insulin is not reliable enough to recommend if sub- cutaneous injection is the only method of administration avail- able.
2440
2441The RP Test for Insulin
2442
2443Insulin scores poorly at 60%, having a questionable reputation in the mjor indices of reliability and peacefulness. Insulin is difficult to prepare, administer (it must b given by injection) and to store (refrigeration is required), however as the drug is injected, the speed of action is quick.
2444
2445RP Test for Insulin
2446
2447Criteria Reliability
2448
2449Peacefulness Availability Preparation
2450
2451Undetectability Speed Safety
2452
2453Storage Total
2454
2455Score 5/10 5/10 3/5 2/5 2/5 5/5 5/5 3/5
2456
245730 (60%)
2458
245915 Chloral Hydrate Introduction
2460
2461One of the earliest know sedatives, chloral hydrate has developed a reputation over the years as a useful end of life drug. It’s contin- ues availability (often requiring a medical prescription) has led to a number of questions on Exit Forums about the drugs usefulness as an agent for a peaceful and reliable death). This information is summarised here.
2462
2463The drug was first synthesised in 1832 by chlorinating alcohol in acid and shortly after this the drug’s sedative properties were realised. Its solubility in alcohol saw it being used as an early form of ‘knockout drops’ or date-rape drug. The drugs infamous use as the so called Micky Finn in Chicago’s Lone Star Saloon in the early 1900s drew attention to its possible use as a drug to peacefully end life.
2464
2465Chloral Hydrate still finds some use as a pre-operative sedative agent, often used in paediatrics, as a means of settling the child before surgical or dental procedure. It is marketed as a syrup, usu- ally in the concentration of 100mg/ ml, or as gelatine capsules
2466
2467Chloral Hydrate
2468
2469In the 200ml bottle shown, there would be 20gm of chloral hy- drate. Purchase of the drug in most countries is restricted by pre- scription. Home manufacture of chloral hydrate is however rela- tively easy.
2470
2471The lethal dose of chloral hydrate is subject to some debate, but generally 0.25gm/Kgm is the figure quoted. This means that for an 80Kg individual, a full bottle of the syrup shown would need to be drunk, something that would seem impractical. However, the solubility of the drug in alcohol and the synergistic effect of the alcohol/ chloral hydrate combination does lead some to con- sider this as a viable option for a peaceful death. Other drugs that can usefully enhance the lethal action of chloral hydrate include the benzodiazepines (such as oxazepam/ serapax).
2472
2473The sedative effects take place after 15 - 20 minutes post inges- tion, death is usually caused by persistent interference with car- diac conduction, cardiac insufficiency associated with arrhythmia and associated cerebral death. Cardiac pacemakers are contrain- dicated.
2474
2475Note also, that the drug in more concentrated forms causes ir- ritation to the lining of the oesophagus and stomach, irritation that can lead to vomiting, scarring, even perforation. Dilute forms of the drug are preferable, but this of course pushes up the vol- ume that needs to be drunk. If capsules are used, water should be drunk beforehand.
2476
2477The Peaceful Pill eHandbook
2478
2479Conclusion
2480
2481There are much better oral drug options available. If you do elect to use this drug, ensure that you have sufficient (dilute) quantity (>20gm) and use an anti-emetic like meto-clopramide taken 40 minutes before the chloral hydrate. The drug needs to be taken with alcohol, along with other potentiators such as benzodiaz- epines.
2482
2483Fig 15.1: 200ml bottle of Chloral Hydrate syrup (1gm/10ml)
2484
2485Chloral Hydrate
2486
2487The RP Test for Chloral Hydrate
2488
2489Chloral Hydrate has a questionable reputation in the mjor indices of reliability and peacefulness, and scores poorly at 60%. Criteria
2490
2491Reliability
2492
2493Peacefulness Availability Preparation
2494
2495Undetectability Speed Safety
2496
2497Storage Total
2498
2499Score 5/10 5/10 3/5 3/5 2/5 3/5 5/5 4/5
2500
250130 (60%)
2502
250316 Drug Options - Nembutal
2504
2505I am hoping to get access to your ‘peaceful pill’ – not for immediate use, but to have on hand should my health deteriorate too much in the future. Arthur, 77 years
2506
2507Introduction
2508
2509The barbiturate Sodium Pentobarbital is the drug that comes closest to the concept of the Peaceful Pill. Exit defines the ‘Peaceful Pill’ as a pill, tablet or mixture that can be taken orally and that is guaranteed to provide a peaceful, dignified death at a time of one’s choosing.
2510
2511A Short History of Barbiturates
2512
2513Sodium Pentobarbital or Nembutal as it is commonly called is an important and historically significant drug. Although Nembutal is one of over 50 barbiturate derivatives to have been used medically, it is the drug of choice when it comes to dignified, peaceful dying.
2514
2515All Barbiturates are derivatives of barbituric acid which was first synthesized by Adolph von Bayer in 1864. A ‘condensation’ of malonic acid and urea, barbituric acid is said to have acquired its name after St Barbara’s Day (4 December) - the day on which it is believed to have been discovered.
2516
2517Nembutal
2518
2519Fig 16.1 Nembutal women’s magazine advertisment from 1950’s
2520
2521The Peaceful Pill eHandbook
2522
2523Video: A Short History of Nembutal
2524
2525Video: What Everyone Should Know about Sleeping Tablets
2526
2527Nembutal
2528
2529Other historians have speculated that the discovery may have been named after the chemist’s favourite barmaid, Barbara. Either way, the name stuck and barbituric acid has enjoyed an infamous history ever since (Mendelson, 1980). Barbituric acid was found to have no physiological effect and it took another 40 years before chemists, Emil Fischer and Joseph von Mering, discovered that the introduction of two additional side-arms onto the molecule produced a range of compounds with marked physiological activity. It was only then that it became known that the nature of the sedative, hypnotic, or anaesthetic properties of the substance were determined by the characteristics of the side-arms attached.
2530
2531The first of these di-substituted barbiturates was Veronal. Here two ethyl side-arms were added to produce diethyl-barbituric acid a weak hypnotic/ depressant which was marketed by the Bayer company as ‘Veronal’ in 1904. This was followed by phenobarbital (Luminal) in 1913. While barbituric acid is a German discovery, during the First World War when German shipping was blockaded, American chemists made use of the ‘Trading with the Enemy Act,’ to copy the work of the Germans and manufacture their own modifications of barbituric acid.
2532
2533Barbiturate Sleeping Pills
2534
2535In the first half of the 20th Century, barbiturates were manufactured around the world, with production peaking in the 1950s. By then there were more than 20 marketed forms of barbiturates, with most sold as sleeping tablets.
2536
2537Fig 16.2: Pentobarbital (Nembutal) sleeping tablets
2538
2539The Peaceful Pill eHandbook
2540
2541Along with the original Veronal, there was Barbital, Amytal, Seconal, Soneryl, Nembutal and several others.
2542
2543While these barbiturates were highly effective sleeping tablets, a significant problem was the very serious side-effect associated with their overdose - death. This was found to be especially true if the pills were taken with alcohol. Many famous people have died - some deliberately, some inadvertently - from an overdose of barbiturates. Marilyn Monroe, Judy Garland and Jimmy Hendrix are a few.
2544
2545Fig 16.3: Amylobarbital (Amytal) sleeping tablets
2546
2547Barbiturates as Drugs of Abuse
2548
2549In the 1960s, the image of barbiturates suffered further when they were found to be useful mood-altering drugs. At this time, the depressant effect of the drugs was exploited. By carefully adjusting the dose, a desirable soporific and tranquil state could be achieved and they became known as ‘downers.’ As downers, barbiturates would often be intermixed with ‘uppers’ - drugs like amphetamines. This type of usage led to a set of slang street terms for these drugs such as ‘Pink Ladies’, ‘Yellow Bullets’, ‘Peanuts’ and ‘Dolls’ (from Barbie dolls) (Mendelson, 1980).
2550
2551Nembutal
2552
2553With only a small margin of safety in dose between the desired sleep, euphoria and death, there was considerable danger associated with the prescription of these drugs. History shows they fell out of favour with the medical profession once newer, safer sleeping tablets became available.
2554
2555The Advent of Non-barbiturate Sleeping Pills
2556
2557The first of the new class of sleeping drugs (the benzodiazepines) was diazepam (Valium), which became available in the early 1960s. These drugs were welcomed by the medical profession as a safe alternative to the barbiturate sleeping tablets. At this time there were many prescribed forms of barbiturates on the market but with the introduction of these new benzodiazepines, the use of the barbiturates steadily declined.
2558
2559By the mid 1990s, there was only a handful of barbiturate sleeping tablets left; amylobarbital (Amytal) and pentobarbital (Nembutal). Nembutal was withdrawn with little notice in 1998 with Amytal following suit in 2003. Today, the only barbiturate commonly prescribed by doctors is the slow-acting Phenobarbital. This drug still finds a niche in medicine as an anti-convulsant, but is a poor substitute to the specific barbiturate sleeping tablets in providing a reliable, peaceful death.
2560
2561Barbiturate Use in Veterinary Practice
2562
2563The veterinary use of the barbiturates has persisted. Nembutal, in particular, is used as an agent for euthanasia. A large dose delivered intravenously, quickly and peacefully ends an animal’s life. This green-dyed form of the drug, known as Lethabarb or Valabarb, is also known as ‘the green dream.’
2564
2565The Peaceful Pill eHandbook
2566
2567A sterile form of Nembutal has also persisted as a useful complete anaesthetic agent that can quickly render an animal unconscious for surgery. Pentobarbital continues to play a role in veterinary practice to this day even though its use by the medical profession has all but disappeared. A development that has led to a resurrection of these outdated drugs is their increasing use as the drugs of choice for voluntary euthanasia (and state-sanctioned executions in some states of the US).
2568
2569Nembutal in Countries where Assisted Dying is Legal
2570
2571Nembutal is the drug of choice in countries where VE and Assisted Suicide are legal and is used in The Netherlands, Belgium, Switzerland and the US states of Oregon and Washington
2572
2573When the Rights of the Terminally Ill Act was passed in the Northern Territory, I had the challenge of deciding which drug or substance would produce the most humane, peaceful reliable death.
2574
2575Fig 16.4: The ‘Deliverance’ euthanasia machine
2576
2577After much research and consultation - a process that even saw us seeking information about the drugs used for execution in the US - a decision was made to sanction the use of a large intravenous or oral dose of Nembutal.
2578
2579Nembutal
2580
2581The four people who died using the ROTI Act all injected themselves with Nembutal (with the help of the Deliverance Machine, now on display in the British Science Museum). See: http://en.wikipedia.org/wiki/File:Euthanasia_machine_(Australia).JPG
2582
2583While these people could also have simply drunk the liquid Nembutal, each preferred intravenous administration. When delivered in this way, loss of consciousness is almost immediate (seconds), with death following a short time later.
2584
2585Drinking Nembutal is often the preferred option and means no other person need be involved in administration. For example, in the state of Oregon in the US, a doctor is only allowed to prescribe as opposed to administer a 10 gm oral dose of barbiturates to a patient. The patient must drink the drug themselves. In Switzerland, too, it is the client who must administer the drug him/her self. In Holland and Belgium, it is lawful to provide barbiturates as an injection to a dying patient. The drug used in each these places is Nembutal.
2586
2587Fig 16.5:
2588
2589Sterile veterinary Nembutal
2590
2591The Peaceful Pill eHandbook How Barbiturates Work
2592
2593Barbiturates effect the action of the brain chemical GABA in that they enhance the effect of GABA on the brain, and may even act in its place. GABA slows the activity of the brain. Enhancing its action causes sedation and sleep. In larger doses, the barbiturate may even replace the GABA in the brain. An overdose of a barbiturate can depress brain function so severely that respiration ceases and the person dies.
2594
2595As discussed above, the depressant effect of barbiturates can be useful in counteracting the irritability and paranoia that can result from the use of amphetamines. Barbiturates have also been reported to be effective in alleviating the symptoms of heroin withdrawal. In the 1960s, injecting drug users were reported to have substituted barbiturates for opiates like heroin and methadone if such drugs were not available.
2596
2597Available Forms of Nembutal
2598
2599For human use, Nembutal was extensively marketed as sleeping tablets or capsules in the 1950s & 1960s. Even though Nembutal disappeared off the market over a decade ago, many people have old stocks which are still potent. One hundred of these capsules (100 x 100mg = 10gm of barbiturate) is a lethal dose.
2600
2601Barbiturates are also well absorbed rectally and some countries have marketed forms of suppositories. ‘Nova Rectal’ in Canada is one such example. Sterile ampoules of injectable Nembutal for intramuscular and intravenous administration as a hypnotic, anti-convulsant and pre-operative sedative still find a small place in medicine in some countries including the US.
2602
2603Nembutal
2604
2605The veterinary forms of the drug are also still used in either the sterile injectable form for anaesthesia, or a non-sterile form (Valabarb or Lethabarb) for animal euthanasia.
2606
2607The sterile form of this veterinary barbiturate (fig 16.5) is marketed in small, sealed 100ml bottles that are protected with a metal seal. This metal cap makes tampering obvious. The Nembutal inside is a clear liquid with concentration of 60 mg/ml. Each 100ml bottle has a total of 6 gm of Nembutal - enough to provide a peaceful death.
2608
2609Fig 16.6: Non-sterile coloured
2610
2611Non-sterile Nembutal liquid (‘Lethabarb’, Fig 16.6) is used for animal euthanasia, is colour dyed for safety, and has a much higher concentration of barbiturate (300mg/ml). 30ml taken orally is lethal.
2612
2613Since 2010, the powdered form of the drug (sodium pentobarbital) has become available as an assay-grade laboratory reagent. For details of this useful form of the drug (see the following Chapter).
2614
2615Pentobarb & Phenobarb – Confusing Names
2616
2617Nembutal is the commercial or trade name for the barbiturate whose chemical name is pentobarbital (‘pent-o-barb-it-al’). This drug is different to another barbiturate called phenobarbital. Phenobarbital is a slow-acting drug, used predominantly as an anti-convulsant to stabilise people suffering from epilepsy.
2618
2619The Peaceful Pill eHandbook
2620
2621While phenobarb can be lethal in overdose, it has a much slower action than Nembutal and is not an ideal method for self-deliverance. These two barbiturates should not be confused.
2622
2623Sources of Nembutal
2624
2625In most western countries there are now no medically prescribed barbiturate sleeping tablets. What remains in the public consciousness, however, is the belief that an overdose of sleeping tablets - any sleeping tablet – will cause death. This misconception leads to many failed suicide attempts as elderly or seriously ill people often stockpile, then take, large numbers of modern, non-lethal sleeping tablets.
2626
2627Let us be clear. There is no point in asking your doctor for sleeping tablets if you plan to end your life. Tablets obtained this way will not be barbiturates and the drugs obtained will be unlikely, even in significant overdose, to cause death.
2628
2629The commonest source of life-ending barbiturates in most western countries is the veterinary profession, and even this supply is likely to diminish in time. There is no legitimate or plausible reason for a vet to provide this drug to any member of the public. You can hardly tell your vet that you’re planning to operate on the cat this weekend!
2630
2631Nembutal and Veterinarians
2632
2633Veterinary Nembutal has been used by vets to euthanase animals or as an anaesthetic in surgery for many decades. Before 1998, when Nembutal was still being prescribed by doctors, it may just have been possible to argue that your insomnia was so
2634
2635Nembutal
2636
2637bad that only the rare and dangerous Nembutal could help you get a good night’s sleep. But there is simply no excuse one can give a vet to obtain this drug!
2638
2639If a vet were ever to provide Nembutal - knowing what the person has in mind - they could face a charge of assisting a suicide. De-registration and a prison term would be the likely consequence. In 2001 the Australian
2640
2641Fig 16.7: Non-sterile veterinary
2642
2643Veterinary Board became concerned about the increasing use of veterinary
2644
2645Nembutal as a human euthanasia option and put out a warning to its members urging caution in the storage and use of the drug. (see Veterinary Surgeons Board, 2003).
2646
2647Exit knows of only a handful of cases where seriously ill people have been able to obtain Nembutal from their Vet. When there is public mention of this possibility, the Veterinary Associations have reacted quickly denying the practice.
2648
2649Moves to further restrict the use of veterinary Nembutal has meant that the anaesthetic form of the drug (see Fig 16.5) is becoming more difficult to obtain. This is the form of the drug favoured by those wanting it for their own use, comforted by the fact that it comes in a clearly-labelled sterile sealed bottles.
2650
2651The non-sterile green dyed form is more concentrated than its clear counterpart. Marketed as Valabarb (Fig 16.7) or Lethabarb (Fig 16.6) the concentration of this type of pentobarbital is 300mg/ml (five times higher than in the sterile anaesthetic form). A single 30ml sample will contain 10gm of Nembutal and be lethal. This non-sterile green liquid needs to be decanted from
2652
2653The Peaceful Pill eHandbook
2654
2655Veterinarians and Nembutal
2656
2657Nembutal and the Black Market
2658
2659Nembutal
2660
2661a larger 500ml bottle. If drunk it can stain the lips and tongue. With such staining it is unlikely that an attending doctor will cite natural causes on the death certificate.
2662
2663A Case Study in Nembutal
2664
2665When asked about Nembutal at Exit workshops, I tell people that it can be very handy to know a vet. Some time ago, I was making a clinic visit to the bedside of Harry, a dying patient. With his wife at his side Harry asked me about ‘the best drugs’, the ones that would let him peacefully end his own life.
2666
2667I explained that the ‘best’ drug was Nembutal, but that this was only available from a vet. ‘How many vets do you know really well’ I asked, ‘ones that will risk jail helping you?’ His silence answered my question, and we went on to talk about other more easily available, but less effective, drugs.
2668
2669After the visit, I left the bedroom and had a cup of tea in the kitchen with Harry’s wife, Esme. Tentatively she said, ‘you know when you asked about knowing a vet?’ I looked at her, confused. She went on ‘well, I knew a vet, very well indeed.’ I waited, not knowing what was to follow. She continued. ‘In fact, some time back I had an affair with a vet. My husband knows nothing about it, and I want to keep it that way. But that vet owes me some bloody big favours and I’m going to call them in!’
2670
2671A few weeks later, Harry died of his disease. I heard that Esme did indeed call in the favour, obtaining the 100ml bottle of liquid Nembutal. She told me that the bottle sat in the bedroom with Harry during his last weeks and that he drew immense comfort from knowing it was there. As he faced every new day, he was
2672
2673The Peaceful Pill eHandbook
2674
2675reassured by the knowledge that if the day became too difficult, he could leave at any time. Indeed, the presence of the drug prolonged Harry’s life.
2676
2677The number of people who have a vet as their best friend, a friend prepared to risk jail for them is very small. There has only been a handful of occasions when I have seen help provided in this way, and Harry’s was one of them. Perhaps the question put to patients should be rephrased, perhaps I should be asking ‘have you ever had an affair with a vet?’ When I told this story at a recent public meeting, one elderly woman shouted back ‘I wish you’d told me that 40 years ago.’
2678
2679Nembutal and the Black Market
2680
2681Exit receives occasional reports of people paying a very high price on the black market for Nembutal. Desperate for the drug, some have paid over $5000 for a single 100ml bottle of veterinary Nembutal. This same bottle would retail to a vet for less than $50. Despite the huge potential profit to a dealer, Nembutal is rarely found this way. The usual laws of supply and demand that govern the illegal drug trade do not apply, as no one will ever want more than one bottle of this drug. Supply chains do not therefore develop.
2682
2683The Nembutal that does find its way on to the street is usually in the form of the sterile veterinary liquid. It is presumed that it is obtained when veterinary clinics are broken into by people looking for tradeable veterinary steroids.
2684
2685If the seal and labelling of a Nembutal bottle is intact and the expiry date not exceeded, the drug is likely to be effective.
2686
2687Nembutal
2688
2689Nevertheless, one is advised to test the substance if planning to use such sources. The Exit barbiturate test kit is available at: http://bit.ly/9swOxk
2690
2691The Exit Test Kit enables people who have acquired liquid Nembutal to self-test the drug.
2692
2693Note: The ‘Exit Spot Test Kit’ provides qualitative evidence of the presence of the drug. The Max Bromson Quantitative Test Kit provides a test for purity (eg. drug concentration and strength) .
2694
2695The Shelf Life of Liquid Nembutal
2696
2697Event though most liquid Nembutal will have an expiry date of around two years, this is one substance that is known to remain effective for much longer.
2698
2699If stored in a cool place and kept
2700
2701in its sterile, sealed bottle, liquid Nembutal can be expected to have a shelf-life of many years.
2702
2703A detailed discussion of the shelf life of both liquid and powdered Nembutal can be found in the following Chapters.
2704
2705Conclusion
2706
2707The barbiturate pentobarbital (Nembutal) is the best euthanasia drug and comes closest to the concept of the Peaceful Pill. In countries and states where it is lawful to help someone to die and any drug or substance could be used, the choice is always Nembutal.
2708
2709The Peaceful Pill eHandbook
2710
2711Yet Nembutal is a hard drug to obtain with doctors in most western countries no longer able/ willing to prescribe the drug. Nembutal’s restricted use by vets makes it increasingly difficult to access.
2712
2713However, Nembutal can be obtained from overseas, in South America, SE Asia, and in powdered form from China. The next chapter gives a detailed outline of where to go and how to buy Nembutal. This information changes frequently and is regularly updated for The Peaceful Pill eHandbook.
2714
2715The RP Test for Nembutal
2716
2717Nembutal is the ‘gold standard’ of the euthanasia drugs, a reputation derived from the peaceful and reliable death this drug provides. The drug can be difficult to access and loses points here, but with an overall rating of 88% it is easily the best end of life option available.
2718
2719Nembutal
2720
2721Exit RP Test - Nembutal
2722
2723Criteria Reliability
2724
2725Peacefulness Availability Preparation
2726
2727Undetectability Speed Safety
2728
2729Storage Total Score
2730
2731Score 10/10 10/10 2/5 5/5 4/5 4/5 5/5 4/5
2732
273344 (88%)
2734
273517A Availability of Nembutal Introduction
2736
2737For many years now, Nembutal has been available in a number of countries. In most western countries, however, the drug remains heavily restricted with anyone importing or even possessing the drug almost certainly breaking the law.
2738
2739Where and how one can obtain Nembutal is a moveable feast. In recent years, solid sources of supply have emerged in countries as diverse as Peru and China. This information continues to change constantly.
2740
2741In this chapter the following issues are covered:
2742
2743• Types of Nembutal for sale • Legal Issues & Warnings • Drug Labelling • Nembutal Over the Internet • Nembutal Over the Counter • TOR Router, Bitcoins & the demise of the Silk Road • Countries where Nembutal is lawfully sold
2744
2745Since this Handbook was first published in 2006, Exit has established a global network of travellers who have purchased Nembutal around the world. This reader feedback is collated and published as updates to The Peaceful Pill eHandbook. This acts as a type of ‘Neighbourhood Watch’ where this drug is concerned.
2746
2747The availability of Nembutal can and does
2748
2749change without warning. Old stores close and new stores open. Websites appear and disappear, seemingly overnight. Scammers operate in a relentless manner.
2750
2751Historically, Mexico has been the country where Nembutal is most freely available for over-the-counter sale. However, reader feedback on this varies greatly. As those well-known expats Carol Schmidt, Norma Hair and Rolly Brook say of the country:
2752
2753what is true today may not be true tomorrow, or true to the border agent in the next lane, or even to the same agent before and after lunch ... the authors can provide no guarantees that what we publish today won’t change tomorrow ...
2754
2755Another US tourist to Mexico was more specific.
2756
2757Mexican border towns are depressed and scruffy-looking and it is almost always possible to get just about anything you want. This is all the more so given the currently depressed economy -- and this is important to remember. No matter what the government may do, it will always be possible to get Nembutal here unless its manufacture gets prohibited. How to get it is the challenge!
2758
2759In addition to countries such as Mexico, Peru or Thailand where Nembutal has been available over-the-counter, the Internet has since proven a serious alternative source. Although this brings with it a new set of dangers of which readers ought to be aware.
2760
2761The Peaceful Pill eHandbook Types of Nembutal on Sale
2762
2763Nembutal (Pentobarbital Sodium) can be purchased over-the- counter and online as a liquid solution. It can be purchased online as the white crystalline salt. Only rarely is the drug available as tablets or capsules for human use as a sleeping agent.
2764
2765Liquid Nembutal is a veterinary product that is used for animal anaesthesia or euthanasia. The anaesthetic form comes packaged as a sterile clear liquid in either 50ml or 100ml bottles and has a concentration of 65mg/ml (ie a 50ml/100ml bottle contains 3.25 gm/6.5gm of Nembutal).
2766
2767A new (euthanasia) form of the drug has recently become available. At 20mg/ml, a standard 100ml bottle contains 20gm of the drug. A single 100ml bottle of ‘Dolethal’ (see Fig 17.11 would contain enough Nembutal to reliably end the lives of two people. This form of the liquid Nembutal is dyed pink for safety.
2768
2769White crystalline powder is the form of Nembutal sold over the Internet from China. Nembutal tablets for human use are still available in some countries on prescription as sleeping tablets.
2770
2771Drug Labelling
2772
2773The retail brand names for Nembutal vary depending upon the country. Liquid Nembutal (Pentobarbital Sodium) is sold in Mexico as: Anestesal, Pisabental, Barbithal, Sedalpharma, Sedalforte, Pentovet, Pentomax and Dolethal. In Peru and Bolivia, veterinary Nembutal is retailed as Halatal or Penta- Hypnol. In Thailand, the liquid is marketed as Nembutal.
2774
2775Mail-order Chinese powder Nembutal is sold as reagent grade ‘Sodium Pentobarbital’, CAS No. 57-33-0.
2776
2777Availability of Nembutal Legal Considerations
2778
2779If a reader elects to purchase Nembutal overseas they should be aware that importation of the drug back to their country of origin is likely to be against the law. If you take this course of action you will almost certainly be breaking the law.
2780
2781The legal penalties for the importation of Nembutal vary depending on the country. The penalty for the importation of a single bottle of Nembutal could be a fine, a conviction or even a period of imprisonment. If larger quantities are imported, the person could find themselves facing a trial jury.
2782
2783In general, the way in which the importation of a border- controlled substance such as Nembutal is dealt with by the authorities will depend on the amount and purity of the substance imported. The way in which the crime of importing a ‘border- controlled’ (read illegal) drug is determined, will also depend on how the authorities measure the amount imported. (ie. is it enough to constitute a ‘traffickable’ or ‘commercial’ quantity?) In some countries, a ‘traffickable’ quantity’ of Nembutal (ie. the amount which makes the importation of this drug a serious offence) might be 200gm, in other countries it might be 500gm.
2784
2785Any person who chooses to import a single bottle of Nembutal may find themselves facing a fine. Admitting that you are importing the drug for another person (eg. trafficking) is one sure way to turn what some might call a minor importation offence into a significant crime.
2786
2787The Peaceful Pill eHandbook
2788
2789Video: Laredo, Mexico
2790
2791Availability of Nembutal
2792
2793Fig 17.1: Mexican veterinary sterile Nembutal: Anestesal
2794
2795Fig 17.2: Mexican veterinary sterile Nembutal: Sedal-Vet
2796
2797The Peaceful Pill eHandbook
2798
2799Fig 17.3: Mexican veterinary sterile Nembutal: Pentobarbital Injectible
2800
2801Fig 17.4: Mexican veterinary sterile Nembutal: Sedalphorte
2802
2803Availability of Nembutal
2804
2805Fig 17.5: Mexican veterinary sterile Nembutal: Barbithal
2806
2807Fig 17.6: Mexican veterinary sterile Nembutal: Sedalpharma
2808
2809The Peaceful Pill eHandbook
2810
2811Fig 17.7: Mexican veterinary sterile Nembutal: Pentovet NRV
2812
2813Availability of Nembutal
2814
2815Fig 17.8: Mexican veterinary sterile Nembutal: Sedalpharma
2816
2817Fig 17.9: Mexican veterinary sterile Nembutal: Pentomax
2818
2819The Peaceful Pill eHandbook
2820
2821Fig 17.10: Mexican veterinary sterile Nembutal: Pisabental
2822
2823Availability of Nembutal
2824
2825Fig 17.11: Mexican veterinary sterile Nembutal: Dolethal
2826
2827The Peaceful Pill eHandbook
2828
2829Video: Buying Nembutal in Mexico
2830
2831Availability of Nembutal
2832
2833Fig 17.12 Australian Government publication March 2011
2834
2835The Peaceful Pill eHandbook
2836
2837Note: Drugs such as barbiturates have been of secondary concern to authorities who seem far more interested in substances such as methamphetamines, cocaine, cannabis and party drugs such as ecstasy and GHB. It is the supply and distribution of these latter drugs, rather than barbiturates, which is linked with international organised crime syndicates. The barbiturates have lost their appeal as drugs of addiction/ abuse and feature little in black market trade. After all, one person will only ever need 10gm of Nembutal.
2838
2839Despite this, in 2011 the Australian Government, for instance, issued a warning against the importation of barbiturates for personal use. The document was designed to discourage people from taking this course and referred to the penalties ranging from imprisonment to fines up to A$850,000.
2840
2841http://www.customs.gov.au/webdata/resources/files/ImportingBarbiturates.PDF
2842
2843Exit has put considerable effort into ensuring that readers of The Peaceful Pill eHandbook have all the information necessary to make their owned informed choice. The authors make it clear that in providing this information they are not encouraging the reader to break the law of their or any other country.
2844
2845What happens to those charged with importing Nembutal?
2846
2847To date, Exit knows of only four people charged with importation offences. Three have been Australians and one a British citizen. The first person, Ann, a middle-aged Melbourne woman with breast cancer, was charged in early 2009 with importing two bottles of Nembutal. Her crime was detected after her consignment was intercepted by Australian Customs and referred to the Australian Federal Police (AFP) .
2848
2849Availability of Nembutal
2850
2851At her court hearing the following year, Ann pleaded guilty to the importation offence. The court subsequently issued her with a fine of AUD$500, a 12-month good behaviour bond and ordered her to pay AUD$1000 to the court fund. No conviction was recorded.
2852
2853See: http://bit.ly/bECnzG
2854
2855A second person, a Queensland woman called ‘Lynn’, was charged in May 2014. Lynn pleaded guilty at first instance. She received a two-year good behaviour bond, 12-month probation and no conviction.
2856
2857See: http://bit.ly/1r9q78v
2858
2859The third person was a man in his 60s called ‘Rupert’ who lives in the small Western Australian town of Albany. In August 2014, Rupert pleaded guilty to possessing 12 gms of Nembutal powder. He was fined AUD$1400 and had no conviction recorded.
2860
2861See: http://ab.co/1wMPY6L
2862
2863In April 2016 Exit became aware of a fourth person charged in relation to possessing or importing Nembutal. This person is due in their local court in the UK in May 2016. Exit will report further on the outcome in the next update. But to be clear. For the legalities on the importation and possession of Nembutal in your particular country or state, you are best to consult a local solicitor or attorney.
2864
2865Note: In the US, the barbiturates are listed in the Federal Controlled Substances Act under DEA schedule II. In the UK, barbiturates are classified as a Class B drug under the Misuse of Drugs Act. Possession can attract a fine and up to five years imprisonment.
2866
2867The Peaceful Pill eHandbook Nembutal Over the Internet: Mexico
2868
2869In 2015, readers identified a new reliable supplier of Nembutal from Cholula in Mexico: ‘Samuelle Pindolon’. The brand name of this person’s Nembutal is ‘Pisabental’ (sodium pentobarbital in 100ml bottles, 6.3gm/bottle). The website description states that they ship anti-emetics. Payment by Bitcoin or Western Union.
2870
2871Web: http://www.fotolog.com/pindolonsilver/ & http:// www.silverpindolon.com Email: samuellepindolon@gmail.com Email: samuellepindolon@riseup.net (encrypted) or
2872
2873Email: <cochetartaruga@protonmail.com> (encrypted)
2874
2875A different Mexican supplier identified by readers is ‘Alejandro Vasquez’. This person also sells the same ‘Pisabental’, but has recently announced that he will also sell ‘Dolethal’.
2876
2877Web: http://www.pisaagropecuaria.com.mx/pisabental/ Email: alejandrovasquezmvz@yahoo.com.mx Email: <alejandrovasquezmvz@protonmail.ch> (encrypted)
2878
2879The price is quoted at ~US$400 for one ‘Pisabental’ bottle or US$600 for two, (ie 13gm of Nembutal). Payment has been reported as being by Bitcoins, Western Union, or cash in a letter.
2880
2881Some offers include the anti-emetic drug, metoclopramide for an extra $50.
2882
2883Note - both these suppliers have encrypted (Protonmail) addresses.
2884
2885Note - in Mexico metoclopramide is available over-the-counter for a few dollars.
2886
2887Availability of Nembutal A Note on Interpol
2888
2889In May 2016, Exit was informed of a number of separate inci- dents in the UK, Australia and Canada where people, who alleg- edly ordered Nembutal from the second person listed (Alejan- dro Vasquez), were subject to Interpol-directed police raids on their homes. In some cases the people concerned were told that they were receiving a ‘welfare check’. Some waived their right to remain silent and spoke to the police. In another, the police were sent away to obtain a warrant before entering. At the time of press, the police had not returned. In one of the UK cases, the alleged imported substance was handed over on request.
2890
2891At this point Exit does not know how these police visits came about or what was behind them, and why these par- ticular readers of the Peaceful Pill eHandbook were tar- geted. But the development is concerning and Exit takes this opportunity to warn all readers of what is going on.
2892
2893As one of these readers wrote to Exit:
2894
2895I believe the Mexican supplier gave Interpol details of his customers.
2896
2897My purchase was 18 months ago, so unlikely any email exchange was picked up randomly.
2898
2899All police visits have followed open online communication between the person visited and the person known as Alejandro Vasquez. This seems more than mere coincidence.
2900
2901Needless to add, and in general legal terms, one does not have to speak to the police other than providing one’s name and address. There is a right to silence. Of course, legal advice should be sought before any police interview is agreed to. Remember, there is no such thing as an informal or ‘off-the-record’ chat with the police.
2902
2903The Peaceful Pill eHandbook Legal Recap
2904
2905In come countries, it may be lawful for an elderly, or seriously ill person to possess Nembutal. However, in most Western countries this is simply not possible.
2906
2907While a person may be very, very ill and near death and simply wanting to put an end to their suffering, this does not make it lawful. In this area of life (and death), the right thing is not necessarily the lawful thing.
2908
2909Clearly, if you elect to obtain Nembutal in a country where possession is not controlled, there will be no problem. But the point is, the moment you bring your ‘insurance policy for the future’ back to your home country, you will be breaking the law.
2910
2911It matters not if you do this by the regular mail service or on your person. The law will not differentiate. Recent activities by Interpol in the UK and other countries suggest that concerted efforts are being made by the authorities to inquire into anyone who has gone down this road.
2912
2913Furthermore, reports from May 2016 that Interpol are suspected to have obtained a list of past, present and future orders of Nembutal from the second supplier listed is cause for ongoing concern.
2914
2915Availability of Nembutal Reader Feedback
2916
2917Over the past 10 years, Exit has received a range of feedback about online sources of Nembutal. The Peaceful Pill eHandbook has always sought to publish such information in a legally and practically responsible way.
2918
2919To this end, the May 2016 update to the eHandbook published a comprehensive list of global scammers. Some of these scammers have impersonated Exit founder Dr Philip Nitschke.
2920
2921Some scammers purport to be associated with Exit. Some purport to represent Exit International. What needs to be made clear is the following:
2922
2923• Exit has no relationship with any source listed in the Peaceful Pill eHandbook
2924
2925• Exit does not endorse or dis-endorse any supplier listed • If a reader wishes to use the information published in this book, they do so at their own risk and this is their own informed decision
2926
2927• Exit does caution that legal advice is recommended before using the Internet to obtain Nembutal.
2928
2929The Peaceful Pill eHandbook Chinese Powder Nembutal
2930
2931Since Exit has been aware of China as a source of powder Nembutal, more than 14 different Chinese chemical companies have been noted. Exit’s independent laboratory testing undertaken in 2012 - 2014, consistently found the product to contain purities of greater than 95%. Since that time readers have reported varying results using Exit’s home test kits. There is no clear solution to these test results at the current time.
2932
2933Nembutal from China has generally been sold flat-packed (see Figs 17.16 - 17.18). The cost is generally ~US$600 for 25 gms (including shipping). Sometimes the packaging consists of small plastic screw-top containers, each containing 12 gms in each (see Figs 17.15 - 17.15).
2934
2935Sources of Chinese Nembutal Powder
2936
2937Johnson The only reported current supplier of Nembutal from China is ‘Johnson’. His/her quoted price is US$450 for 25 gm, includes shipping. Their email address is: Johnson0@msn.cn or <johnsonpph@protonmail.com> (encrypted) Payment by Bitcoin, Western Union, or direct bank transfer.
2938
2939Testing of Sources of Chinese Nembutal Powder
2940
2941Random samples from the suppliers listed below have provided results showing 99% purity.
2942
2943• Rundong Chemical, Quzhou • Haihang Industry Co • David Zhang • Cherry Chemical, Hangzhou • Johnson
2944
2945Availability of Nembutal
2946
2947With the exception of the last name listed above (Johnson), none of above sources of Nembutal are operating. Indeed, some may now be scammers.
2948
2949Fig 17.13: Powder Nembutal as shipped from China
2950
2951Fig 17.14: Nembutal from 3B Scientific International
2952
2953The Peaceful Pill eHandbook
2954
2955Fig 17.15: gms powder from China
2956
2957Fig 17.16: Sample 1: Flat-packed powder from China
2958
2959Availability of Nembutal
2960
2961Fig 17.17: Sample 2: Envelope of flat-packed powder from China
2962
2963Fig 17.18: Sample 3: Package of flat-packed powder from China
2964
2965The Peaceful Pill eHandbook Using the TOR Browser to access the ‘dark web’
2966
2967TOR is free software that allows anonymity in searching the internet, and access to the ‘dark web’, areas of the internet inaccessible by normal browsers.
2968
2969In years past, TOR allowed access to the online black market website, ‘Silk Road’, which was an effective, but illegal, source of online drugs. The FBI closed the site amidst much international fanfare and sensation in October 2013.
2970
2971See the New York Times report at: http://nyti.ms/19qbnWc
2972
2973In May 2015, Silk Road’s founder, Ross Ulbricht, was sentenced to multiple life sentences without parol, sending a strong message to others who seek to replicate his actions.
2974
2975The Guardian newspaper provides an excellent portal on the rise and fall of the Silk Road market place.
2976
2977See: http://www.theguardian.com/technology/silk-road
2978
2979Replacement sites have since sprung up on the Net, and there are now (2016) reports that such sites facilitate the sale of end- of-life drugs such as Nembutal.
2980
2981One market place, AlphaBay, accessible by TOR, is reported to be offering the sale of the drug.
2982
2983For further discussion see: http://www.peacefulpillhandbook.com/forums/
2984
2985Availability of Nembutal Using Bitcoin Virtual Currency for Payment
2986
2987While speaking about the dangers of the Internet black market, not everything is bad and evil. For example, the new digital currency, Bitcoin, provides an excellent, lawful means of online privacy.
2988
2989Bitcoin is a digital currency that uses free open source, peer-to-peer technology that allows instant worldwide payments at a very low cost. This virtual currency also enables anonymous online payments. For example, if you wish to buy the eHandbook anonymously, Bitcoins is the way to go.
2990
2991To use Bitcoins, you will first need to choose an online ‘wallet’ to install on your computer or mobile phone.
2992
2993Upon installation, your wallet will generate a Bitcoin address, and allow you to purchase (and spend) your Bitcoins in an anonymous way.
2994
2995In mid 2016, Mexican and Chinese providers of internet Nembutal indicated that they accept payment using Bitcoins.
2996
2997For general information on Bitcoins see: http://bitcoin.org/en/
2998
2999To create a Bitcoins Wallet go to: https://www.bitcoin.com/
3000
3001For further discussion see: http://www.peacefulpillhandbook.com/forums/
3002
3003The Peaceful Pill eHandbook
3004
3005Legal Recap: The possession of Nembutal in many countries is a criminal offence. Exit advises that potential purchasers check the laws of their local jurisdiction before proceeding down this path.
3006
3007The Politics of Buying Nembutal over the Internet
3008
3009As with much in life, supplies of Nembutal over the Internet can be unreliable. To this end, a number of readers report to have had their orders intercepted (and lost their money). However, relatively few people seem to have been prosecuted as a result. The outcome is more likely to be a letter from Customs and no further action. Note: This does not make the activity legal.
3010
3011One explanation for the lack of criminal charges is that the work required for a successful prosecution possibly exceeds societal benefit. Prosecuting an elderly, hitherto law-abiding citizen, for trying to import a one-off, small quantity of this precious euthanasia drug for their own possible future consumption, would attract considerable public interest. Furthermore it would draw attention to the failure of the political process in addressing end of life issues.
3012
3013One consequence of this stalemate has been the tendency for purchasers to take receipt of their order in a country where there are no legal restrictions. Such countries include Mexico, Peru, Bolivia and Hong Kong. Reader feedback to 2016 suggests that internet orders are freely delivered in this way.
3014
3015Availability of Nembutal
3016
3017On 2 May 2016, Australian Dr Craig Wright claimed he was the founder of Bitcoin. His claim is disputed.
3018
3019Read Wired Magazine’s report at: http://bit.ly/1rrjKyw
3020
3021Fig 17.18a: Bitcoin Founder - Dr CraigWright
3022
3023The Peaceful Pill eHandbook
3024
3025Video: Crossing the US Border
3026
3027Video: Disguising a Bottle of Nembutal?
3028
3029Availability of Nembutal
3030
3031Purchasing Nembutal in Person: Mexico
3032
3033Over recent years, Exit staff and members have visited many Mexican cities with the purpose of researching reliable sources of peaceful end-of-life drugs. During this time, Exit has also received accounts from travellers regarding their experiences in this country. This section includes material that relates to travellers obtaining Nembutal in Mexico from 2010 to the present.
3034
3035Mazatlan
3036
3037In 2011, Exit received its first report of the availability of Nembutal in the beachside resort of Mazatlan in the state of Sinaloa across from the Baja California peninsula. After unsuccessful attempts to purchase Nembutal in Tijuana the year before, an Exit member who we shall call ‘Bob’ took a vacation at Mazatlan.
3038
3039His purchase was straight forward. The price was excellent at US$30 for a 100ml, sealed bottle with an expiry date of July 2013. The outlet where the purchase was made was the hole- in-the-wall El Arca de Noe (Noah’s Ark) pharmacy located at:
3040
3041Ejercito Mexicano No. 5 (near Playa Norte) area of Mazatlan
3042
3043Bob says that he used the photos in the Handbook to explain to the sales attendant the precise drug he was after. The retail brand he purchased on this occasion was ‘Sedalpharma’.
3044
3045The Peaceful Pill eHandbook
3046
3047Playa del Carmen
3048
3049In 2010, Exit received its first report of the availability of Nembutal in the tourist resort town of Playa del Carmen. Sandy wrote:
3050
3051On my recent trip to Playa del Carmen we visited 5 or 6 shops and were always turned away; I was about to give up when the driver said he knew of one other place. I don’t remember the name of the pet store but it was on the outskirts of town. It was just a hole in the wall.
3052
3053I told the owner I had a large dog with Displazia and he was sympathetic and produced a 100 ml bottle of Barbital which I purchased for about US$40.
3054
3055I already have a test kit from Exit International which I will use when the time comes. The bottle, though, is sealed correctly, fresh from the factory. I will keep it in a cool, dry place until needed - if it is needed.
3056
3057I cannot thank you enough for all of your help and your book. I am 83 years old and I live now with a great sense of relief.
3058
3059By December 2015, another traveller, Ted, had a more unproductive time in this tourist town.
3060
3061I went to Playa Del Carmen - didn’t go to the vets but to the drug dealers on the tourist street - they rejected me too, one guy tried to make me pay in advance and scam me. They were not aware of this drug and only interested in selling coco/ weed/prostitutes, i.e. fun.
3062
3063Availability of Nembutal
3064
3065Video: Up Close: A Bottle of Anestesal (Nembutal)
3066
3067Video: The dangers of bringing Nembutal home
3068
3069The Peaceful Pill eHandbook
3070
3071Fig 17.19: Playa Norte in Mazatlan, Mexico Puerto Vallarta
3072
3073In early 2014, field research found that Nembutal is generally not available over-the-counter in this tourist hotspot. It is, however, available on prescription from some of the larger Clinica y Farmacia Veterinaria such as Animal Central at Av. Los Tules No. 196, Col. Jardines de Vallarta.
3074
3075Valladolid
3076
3077Valladolid is a small city in Yucatán, about 2 hours drive from Cancun. Best known for its colonial architecture, especially its cathedral, the town is also used as a touring base for visiting the nearby Maya ruins.
3078
3079Nembutal was first reported as being available with no prescription, over-the-counter in Valladolid back in 2010. Since then, other reports have emerged stating the same, but with some variations. In 2010, the cost of two bottles of Nembutal was 180 pesos each. In 2012 the price had risen to 600 pesos for two.
3080
3081Availability of Nembutal
3082
3083One store where Nembutal is available is Farmacia Veterinaria Los Potrillos at:
3084
3085Calle 41 177-I Col Valladolid Centro Yucatan
3086
3087At this animal pharmacy, the retail brand of Nembutal is Pisabental. Don’t be surprised if the store does not have any bottles on the shelves. It is not uncommon for a store to send a messenger to the depot for collection. For the customer this may mean a return visit in an hour or twos time.
3088
3089Fig 17.20: Farmacia Veterinaria Los Potrillos
3090
3091The Peaceful Pill eHandbook Tijuana
3092
3093Exit continues to receive mixed reports about the availability of Nembutal over-the-counter in Tijuana. Some folk report buying it easily. Others say they were turned away at multiple veterinary pharmacies. Other need-to-know things about Tijuana.
3094
3095Ten years ago, Tijuana was a bustling tourist destination. Five years ago it was a town wracked by drug war violence. At that time the very visible presence of the military made the city a frightening and intimidating place to visit. In 2016 Tijuana is a relatively safe city to visit for a day trip or longer although some Exit Members have reported that there is still a visible police presence throughout the city.
3096
3097Another notable change in Tijuana is the dearth of vet stores. Whereas in mid 2000, there was a vet store on every block, there is now only a handful of farmacia veterinaria in operation.
3098
3099One store that has hitherto been a reliable seller of Nembutal over-the-counter is in a small street called Del Travieso. This is a pedestrian lane that is bordered by Av Constitucion and Revolucion and Benito Juarez Segunda and Carillo Puerto (see the map in Fig 17.22). At the close of 2015, a bottle of Pentobarbital at this veterinaria cost ~US$125; a considerable mark-up from the $45 it sold for in 2004. In April 2016, however, one Exit Member wrote:
3100
3101I traveled to Mexico to purchase Nembutal, but without success. In Tijuana, the Del Treviso centre appeared to have closed and there was a heavy police presence around Avenida Negrete so didn’t chance it.
3102
3103John, USA, 8 April 2016
3104
3105Availability of Nembutal
3106
3107Fig 17.21: Farmacia Veterinaria on El Travieso, Zona Centro Tijuana
3108
3109Fig 17.22: Map featuring Farmacia Veterinaria on El Travieso
3110
3111The Peaceful Pill eHandbook
3112
3113John’s April 2016 feedback contrasts with that of Gary who wrote in December 2015:
3114
3115I drove to Tijuana and found the Veterinary Farmacia identified in your literature on Del Travesio, between Revolution and Constitution. I walked in the veterinary farmacia and showed him the picture, from the Handbook, and he said ‘yes’ and showed me the box. I shopped for an hour and returned to pick up the Nembutal.
3116
3117In a similar manner, Steve from Australia reported to Exit that in January 2016 he purchased Nembutal over-the-counter at ‘Granero Los Alazanes’.
3118
3119Exit can trace this business back to at least 2007 when it was first featured in this Handbook. It seems to have sold Nembutal on and off for many years.
3120
3121The veterinary pharmacy can be found at:
3122
3123Calle Benito Juárez 2da 8557 Zona Centro, Tijuana
3124
3125Fig 17.23: Granero Los Alazanes Business Card
3126
3127Availability of Nembutal
3128
3129Fig 17.24: Granero Los Alazanes
3130
3131Fig 17.25: Map featuring Granero Los Alazanes
3132
3133The Peaceful Pill eHandbook
3134
3135A second vet farmacia that is back selling Nembutal over-the- counter is Farmacia Veterinaria Jael. Exit first reported on this outlet in 2007. Since that time the gang violence of Tijuana has come and gone, allowing local businesses to reopen to the public.
3136
3137This outlet is extremely close to the pedestrian footbridge into Tijuana.
3138
3139Jael’s street address is: Ave Negrete # 727-4 Zona Centro Tijuana
3140
3141Prescription Request for Purchase in Mexico
3142
3143For many years, the legal status of purchasing Nemb- utal
3144
3145over-the-counter has been unclear. In some cas- es and locations a script is needed, in others it is not.
3146
3147For both the above pharmacies, a prescription is likely to be needed. If you have not visited a veterinarian prior to pur- chasing your Nembutal, travellers report that a USD 100 bill is a good substitute. James has written that when he was re- cently asked for a prescription, he withdrew the $100 note and asked if this was sufficient. In all cases the answer was ‘yes’.
3148
3149Legal Recap
3150
3151The importation of Nembutal into many countries is a criminal offence. Exit advises that travellers check the laws of their local jurisdiction before taking the Nembutal, that they have lawfully purchased in Tijuana, back to their home countries.
3152
3153Availability of Nembutal
3154
3155Fig 17.26: Farmacia Veterinaria Jael
3156
3157Fig 17.27: Map featuring Jael Farmacia
3158
3159The Peaceful Pill eHandbook
3160
3161Fig 17.28: Vetson Clinic
3162
3163Fig 17.29: ab Clinic
3164
3165Fig 17.30: Centro Cambiario
3166
3167Availability of Nembutal Nogales
3168
3169The Mexican border city of Nogales lies one hour’s drive (70 miles) due south of Tucson, Arizona. While the route is not serviced by Greyhound there is a plethora of private shuttle buses which ply the route. If you are driving, there is one principal crossing point which can be very busy.
3170
3171For bus services see: http://www.mexicandoctorsdir.com/sahuaro_shuttle.htm
3172
3173Once in Nogales, there are three outlets that were reported in early 2016 to sell Nembutal over the counter (as long as a prescription is provided - see previous discussion). Each are some distance from the border so a cab is advisable.
3174
3175These are:
3176
3177Clinica Veterinaria Vetson Cnr Ingenieros, no 321 Nogales Centro Tel 312 22 10
3178
3179ab Medicina Veternaria Calle Ana Gabriela Guevara, no 74 Nogales Tel 631-304-3312
3180
3181Imelda Lopez Centro Cambiario (ask for Jose) Tel 631-129-7556
3182
3183The Peaceful Pill eHandbook
3184
3185Video: Juarez, Mexico
3186
3187Availability of Nembutal
3188
3189SOUTH AMERICA Purchasing Nembutal in Person: Peru
3190
3191For many years now, Nembutal has been available over-the- counter in Peru and Bolivia. Some positive accounts from Ecuador and Columbia have also been received, and these are currently being investigated.
3192
3193In Peru, sodium pentobarbital is known by unique Peruvian names. The most common brand in this part of the world is ‘Halatal’. A less common brand is called Pento-Hypnol. In Peru (unlike Mexico) Nembutal is sold in small 50ml bottles as opposed to 100ml bottles. However, the concentration is the same as that for the larger Mexican bottles. The concentration of both Halatal and Pento-Hypnol in Peru is 6.5gm per 100ml.
3194
3195Fig 17.31: Suni Agro in Lima - Peru
3196
3197The Peaceful Pill eHandbook
3198
3199Lima - Peru
3200
3201As a sprawling capital city of 10 million, it is not surprising that Nembutal is available in Lima if one knows where to look. As in much of South America, it is the Agro-Veterinarias which sell Nembutal over-the-counter. These stores differ from Mex- ican Farmacia Veterinaria in that they specialise in medicines and treatments for the rural sector and for farm animals, rather than domestic pets. One of the easiest to find is on a busy in- tersection adjacent to the ‘Norte’ (or northern) entrance of the ‘Estadio Nacional’ (national stadium), the home of the Peru national football team.
3202
3203Located at the intersection Santa Beatriz in central Lima, Zoo Farma is an Agro Veterinaria which takes 20-30 minutes by
3204
3205Fig 17.32: Zoo Farma Agro Veterinaria
3206
3207Availability of Nembutal
3208
3209taxi ride from the popular tourist hotels of the Miraflores dis- trict, depending upon the traffic. (In Lima, taxis are relatively cheap with the average rate per hour costing between 25 and 30 Peruvian soles. Hotels routinely organise cabs for guests which is one way of guaranteeing guest safety for the inexpe- rienced traveller). The entrance to Zoo Farma can be found at street level on the front corner of the large bright blue, six- story landmark building (see Fig 17.32), directly across the street from the stadium.
3210
3211This outlet may or may not have Halatal to sell you (Exit has received mixed reports). If they do have stock, expect to pay anywhere between 16 soles and 60 soles for a standard 50ml bottle of ‘Halatal’. If you find that you cannot buy Halatal at Zoo Farma, other outlets exist close by. This feedback was received from a Reader in early 2016.
3212
3213I went to Lima a few days ago and stayed at Miraflores. The Estadio Nacional is a short 12 soles ride (local drivers will often try to scam foreigners into paying 20+ soles).
3214
3215Neither AgroSuni (the biggest store in the region, I believe you name it as “Suni Agro” in your book), nor Zoofarma (also pictured in your book) would sell me Nembutal. Both had Halatal on display, but their sellers refused to sell me without a prescription.
3216
3217There is, however, a third Agroveterinaria there. It´s a small place, without a name (or, at least, I could not find its name) a few meters to the right of AgroSuni (Zoofarma being a few meters to its left).
3218
3219The Peaceful Pill eHandbook
3220
3221First time I went there the seller just told me to come back the following day, after 14:00. I went there at 14:45 to find a sign stating the store was closed from 13:30 to 14:30. It opened at 15:00. After he saw me, the seller tried twice calling someone over the phone while dealing with the other customers (the place was full, with a bigger number of customers than AgroSuni), with no success.
3222
3223After 30 minutes he finally reached the other guy and, within 15 minutes, I had 3 bottles of Halatal in my hand. I paid 162 soles in total. The seals were intact, and shelf life was 2017.
3224
3225This Agroveterinaria is a small place in the green and white building that also houses the “Asociacion de sub-oficiales tecnicos y especialistas de la policia nacional del peru”.
3226
3227http://bit.ly/1SBmOSV
3228
3229One can barely see its corner through google street view, next to the orange house. It´s quite ironic that a place that sells Nembutal freely shares the same building with police officials. The place sells all sorts of medicines, and, based on the many customers I saw while there, it´s the go-to place to buy things without prescription.
3230
3231Terri, Brazil, February 2016
3232
3233Availability of Nembutal
3234
3235As if to verify the previous report, Bill also wrote:
3236
3237I just returned from Lima Peru ,stayed there from the 9th to 23 of september and managed to buy 3 bottles of pentobarbital sodium, 50ml/6.5 g produced by a company called Montana.
3238
3239I bought it in Lima,as mentioned in the book near the Es- tadio Nacional, although not in the Zoofarma because they turned me down, saying they needed a prescrip- tion. But if you stand in front of the Zoofarma, facing it and walk to the left side, around 300 mtrs,you will find a very small veterinario which sold me happily 3 bot- tles exactly the same bottle as showed on page 275 in the book,total cost 105 soles plus 30 soles for the taxi.
3240
3241I tried several big veterinarios, but they all turned me down, because they wanted a prescription for N, so probably only the small back street shops will sell it in Lima. Hope this is a useful update for the book.
3242
3243Bill, Germany, September 2015
3244
3245The Peaceful Pill eHandbook
3246
3247Cuzco - Peru
3248
3249For those who are up for adventure, the UNESCO world herit- age city of Cuzco makes for an easy shopping trip. An hour’s flight SE of Lima, the city of Cuzco is mostly known as the jumping off point for visitors to the beautiful hidden Inca vil- lage of Machu Picchu. Cuzco is also a relatively easy place to purchase Nembutal over the counter.
3250
3251The Agro Veterinarias in Cuzco are all located in a street called ‘Calle Tres Cruces de Oro’ (the three golden crosses) which is quite close to the tourist area of the old colonial city. Depending on one’s ability to deal with the 3500m altitude of Cuzco, it is pos- sible to walk to these stores.
3252
3253In
3254
3255daylight hours, this area of Cuzco is safe for tourists to stroll around. However, if you prefer to take a taxi, the hotel will call a trusted one for you. The cost for the cab is around 10 soles (~US$3) which includes the 5 minutes wait time needed for you to do your shopping.
3256
3257Fig 17.33: One of the many Agro Vet- erinarias in Calle Tres Cruces de Oro in Cuzco, Peru
3258
3259Some stores have the boxes on open display either on the shelf behind, in front of the counter, or in a glass cabinet under the counter. Generally speaking, to purchase Halatal from any of the stores in these streets, one needs only to know the drug name, although a photo of a bottle can be useful. Usually, the store attendants are keen to make a sale.
3260
3261Availability of Nembutal
3262
3263Stores which have been known to sell Nembutal in Calle Tres Cruces de Oro include:
3264
3265• Casagroveto, El Progreso at No. 461 • Agroveterinaria Belen (Principal) at No. 496 • Progensa EIRL at No. 485 • Sucursal (Branch) at No: 421
3266
3267In February 2016 Sharon wrote:
3268
3269Hello , I would like to inform you that Penta- Hypnol bottles of 50ml containing 3.5g of Pentobarbital sodico can be eas- ily found on Casagrovet El Progreso, Tres Cruces Calle de Oro 461, Cusco Peru. I could get 6 bottles at 16 soles each .
3270
3271Hearsay received at the end of 2015, however, was less posi- tive:
3272
3273I am a member of your organization and subscribe to the Peaceful Pill Handbook. A friend (who was born in Buenos Aires and speaks fluent Spanish) went on a business trip to Lima, where she has been frequently. I sent her all the relevant information from your handbook, with instructions to purchase the medication and send it to me. She stayed in a hotel which used to have dolphins in the swimming pool, so her taxi driver was familiar with all the vet pharmacies in Lima. She visited three. I believe, and each one told her she requires a prescription. She explained she needs this for relatives in Buenos Aires who have a ranch, but she was unsuccessful. She was told by one pharmacist that the problem is so many foreigners have come to request this drug to kill themselves that a prescription is now required!
3274
3275The Peaceful Pill eHandbook
3276
3277Fig 17.34: Peruvian Halatal
3278
3279Fig 17.35: Peruvian veterinary sterile Nembutal
3280
3281Fig 17.36: Peruvian veterinary sterile Nembutal
3282
3283Availability of Nembutal
3284
3285WARNING: In late 2015 Exit received reports from Peru that those seeking to purchase Ha- latal
3286
3287were being sold
3288
3289‘Halatal KT’ instead. The reason was that “‘Halatal’ was no longer available”. ‘Halatal KT’ was said to be an equivalent.
3290
3291Both drugs are available in 50ml bottles and ap- pear to have similar la- belling, but they are DIFFERENT DRUGS!
3292
3293Fig 17.37: Halatal iKT, 50ml of 10% Ketamine
3294
3295Halatal KT is 10% Ketamine and contains NO Nembutal. As such it is useless as a reliable end of life drug.
3296
3297Fig 17.38: Nembutal boxes on display under the counter
3298
3299The Peaceful Pill eHandbook La Paz - Bolivia
3300
3301La Paz in Bolivia is the highest capital city in the world and, as such, its altitude may not suit all travellers.
3302
3303Like Cuzco,
3304
3305Nembutal is readily avail- able in La Paz if you know what to ask for. In La Paz, Nembutal is sold under the trade name ‘Halatal’. A cab ride to a local vet store should prove a simple way to make your purchase. If the store you visit does not have any in stock, they should offer to order it in.
3306
3307To purchase Nembutal in Bolivia, you need no papers, no pre- scription, there are few reported complications. One traveller even had the vet offer to deliver his Nembutal order to his hotel. He paid US$10 for each 50ml bottle. Other travellers to this country have reported paying up to US$40 for a 100ml bottle. Either way, the price is appropriate and there is no sign of profiteering.
3308
3309In La Paz, one pentobarbital is commonly sourced from the veterinary outlet at:
3310
3311Av. Saavedra No 1004 Zona Miraflores, La Paz
3312
3313Availability of Nembutal SE ASIA
3314
3315Since 2009, Nembutal has been over-the-counter for sale in Southeast Asia. However, as with South America, the availability of this drug seems to change with alarming frequency. What was true last month, is not true now.
3316
3317Bangkok - Thailand
3318
3319In 2011, Nembutal could be obtained over-the-counter from veterinary pharmacies in Bangkok. This has since ceased.
3320
3321The Eieng Sew Tung Dispensary - on Ratchaprarop Road in Bangkok was once a reliable source. This store now claims that it no longer sells Nembutal, not even to Thai nationals.
3322
3323If you’d like to prove us wrong, however, here are the details:
3324
3325Eieng Sew Tung Dispensary 475/9 Ratchaprarop Rd, Makkasan, Ratchatewee, Bangkok 10400 Tel : +66-2251-1482 Fax: +66-2251-7238
3326
3327In the past travellers paid 850 Thai Baht (US$25) per 100 ml bottle. The retail name was Nembutal and the drug was manu- factured by the French company CEVA.
3328
3329The Peaceful Pill eHandbook Southern Thailand
3330
3331Exit has recently received a report of the purchase of Nem- butal over-the-counter of liquid, veterinary Nembutal in the town of Trang (near Phuket Island).
3332
3333Trang Animal Hospital 184/1-3, Wisetkul Road Tambon Thap Thiang Amphoe Mueang Trang, 92000, Thailand
3334
3335The liquid Nembutal on sale is labelled injectable solution, 100ml, pentobarbital sodium 5.47g. The Ceva brand is made in France.
3336
3337The reported price for Nembutal from the Animal Hospital is 1,500 Thai Baht per bottle. This equates to around USD$40.
3338
3339Fig 17.39: Map featuring Trang Animal Hospital
3340
3341Availability of Nembutal
3342
3343Fig 17.40: Sterile veterinary Nembutal as it is retailed in Thailand
3344
3345Concluding Comments
3346
3347Nembutal continues to be sold over-the-counter (lawful) and over the Internet (check your local laws regarding legality) from several countries around the world.
3348
3349However, while the purchase of Nembutal might be quick and legal in some countries, the importation of Nembutal to your home country is almost certainly illegal and may attract penalties. You will need to check the particular laws of the jurisdiction in which you reside to be absolutely certain.
3350
3351That said, if a seriously ill person purchases Nembutal lawfully in one country and then takes the drug and ends their life in that country, it is likely no laws will be broken.
3352
335317B Nembutal Scams Introduction: Proliferation of Scammers
3354
3355Since people began to successfully use the Internet to source and import Nembutal back to their home countries, scammers have attempted to exploit the growing market demand for this drug by cheating those attempting to make a purchase..
3356
3357In recent times, scammers have proliferated online with some becoming very successful and wealthy as they rip people off in US Dollars. It is a lucrative ‘business’ indeed. And it’s not hard to do.
3358
3359Scammers create Western Union and Money Gram accounts. They then mock-up websites - often using broken English - courtesy of Google Translate. On their websites they steal the genuine images and logos used in this book. And then they tout for business. Your business. On the Internet, if it sounds too good to be true. It is too good to be true.
3360
3361In some cases scammers have impersonated Dr Philip Nitschke. They also state openly that they are part of/ endorsed by/ support by Exit International and/ or The Peaceful Pill eHandbook. But this is all false. None of these sites are related to Dr Philip Nitschke, Dr Fiona Stewart or Exit International USA.
3362
3363This new Chapter provides a definitive list of known scammers at the time of publication. Although, as has happened previously when Exit has sought to reveal scammers’ online operations, as soon as this information is published, the scammers move on. They create new websites with new names, new accounts and so the patten repeats itself. The list provided with be constantly monitored and updated.
3364
3365In this Chapter the following issues are covered:
3366
3367• The Proliferation of Scammers • A-Z List of Scam Sites • How Internet Scammers Work • The Dangers of Internet Scammers • How to Pick a Scammer • Scam Websites & Addresses • Previous Scammers no Longer Operating • Neighbourhood Watch for Scammers
3368
3369A-Z List of Scam Sites
3370
3371The following is a current listing of scam websites that DO NOT SELL Nembutal, despite what they claim/ promise etc.
3372
3373Exit has received reports about each of these websites/ email addresses/ contacts. Exit knows people who have lost their money to each and every of the contacts listed her. Our advice therefore is clear.
3374
3375DO NOT have anything to do with the following list of names, websites, email addresses. They are criminals and you WILL lose your money.
3376
3377The Peaceful Pill eHandbook A-Z List of Scam Sites (as of August 2016)
3378
3379• Anonymous Pharm/ Meryl Pest Control <http://merylspestcontrol.com/wp-page/nembutal. php>
3380
3381• •
3382
3383Berlin Pharmacy <Berlinpharmacy@dr.com> Cho Collins Cameroon
3384
3385• Cameroon 1. El-Hazzi Jal – Saeed <jalsaeedelhajjis@yahoo.com> • Cameroon 2. “Derek” <nembutalmeciation@gmail.com> Tel + 273 676 1644 79 & + 1 6267 250 821
3386
3387• EMS Express Mail Service (fake courier) • Export Ph <http://export.ph/offers/view/2861&#62; •
3388
3389Glomedstore <glomedstore@gmail.com> •
3390
3391• How to Order Nembutal Europe <https://sites.google.com/site/pentobarbitalineurope/how- to-order-nembutal-online-in-europe-where-to-buy-nembutal-online-in-europe> Info Nembutal <info.nembutalpentobarbital@gmail.com>
3392
3393• <janislesis86@gmail.com> tel +1 (423) 523-9563 • • • • • • •
3394
3395Jonas <euthanasiaexitgroup@gmail.com> Jones from Peaceful Pill Directory <info@peacefulpilldirectory.com>
3396
3397Jorge Hernandez <nembutal@jorgehernandez.me> <http://www.jorgehernandez.me/&#62; Jorge Ramires and Vital Finale <http://vitalfinale.com/&#62; Kapital Natalya Ukraine Malvin Castrol Marvin Castrol
3398
3399• Mezam Pharmacy <http://www.mezampharmacy.com> <nembutalforyou@gmail.com> • • •
3400
3401Muller Gomez Nembutal for You <nembutalforyou@gmail.com> Nembutal for Euthenesia (sic) <http://nembutalforeuthenesia.com/&#62;
3402
3403• Nembutal Group USA <Nembutalgroup@usa.com> • Nembutal Group Norway <https://ukeuthanasiasolution.wordpress.com> •
3404
3405• • • • • •
3406
3407• •
3408
3409Nembutal Online <www.nembutalonline.com>
3410
3411Nembutal Online Ukraine <www.nembutalonline.com> & <contact@nembutalonline.com> Nembutal Peaceful Exit Solution <www.nembutalpeacefulexitsolution.com> Nembutal Supplier Group
3412
3413Peaceful Exit Solutions <https://www.linkedin.com/in/ordernembutaldrug&#62;
3414
3415Peaceful Pill Directory “Jones” <www.peacefulpilldirectory.com> <info@peacefulpilldirectory. com>
3416
3417Perfecto Relief <http://perfectorelief.com/order-nembutal-online/&#62; Quality Nembutal Pentobarbital and Others
3418
3419• <https://qualitynembutalpentobarbitalsupplyandothers.wordpress.com/el-hajjis-jal-saeed- supply-ltd-money-back-guarantee/>
3420
3421• Shawn Hardy <shawnhardy2001@gmail.com> •
3422
3423UK Euthanasia Solution <https://ukeuthanasiasolution.wordpress.com>
3424
3425• Vital Finale (see Jorge Hernandez) <http://vitalfinale.com/&#62; • Weiku.com <http://www.weiku.com/Inorganic-Chemicals/buy-nembutal-sodium- pentobarbital.html>
3426
3427• And, Exit International USA Newark!
3428
3429Nembutal Medication <www.nembutalmedication.com> “Derek” Claims to work for Exit International! (see Cameroon)
3430
3431Nembutal Scams
3432
3433How Internet Scams Work The modus operandi of scammers is generally the same.
3434
34351. You send an email outlining your desire for Nembutal. Even if you say you are a suicidal teenager, this will be no disincentive to a scammer.
3436
34372. The scammer will reply recommending the amount of liquid/ powder you will need and quoting a price including delivery. Delivery will often be promised as next day service. They often add that insurance is included. And that if you do not receive the parcel, they will send another free of charge. Or a full refund if you prefer.
3438
34393. The scammer will then provide you with payment details. For example, Malvin Castrol of Vital Finale will state the following as one of their Western Union names:
3440
3441Name: Xavier Paddy Address: 2804 Evergreen Ave, Baltimore MD 21214 Amount: $832 (for 300ml, concentration unspecified)
3442
3443In broken English, they remind you to include:
3444
3445“Also your complete delivery address and phone number. As soon as we get this from you, we will get parcel prepared and register parcel for shipping and delivery then send you a tracking code as soon as parcel have been shipped. “
3446
3447If your alarm bells are not going off now, they should be! Sounds too good to be true? It is too good to be true!
3448
3449The Peaceful Pill eHandbook
3450
3451But wait there is more. In a vain attempt to prove they are careful, responsible and genuine, some purchasers have been asked by one scammer, Vital Finale, to complete a questionnaire before taking things further.
3452
3453Here is an example:
3454
34551) Is the Nembutal for you or someone else? Me.
3456
34572) Why do you need Nembutal, for suicide or as an aid against pain ?
3458
3459Initially to end life due to incurable ongoing chronic pain/ condition which is physically incapacitating, however am open to suggestions for management using this drug if it is an option.
3460
34613) Have you ever bought Nembutal before ? No.
3462
34634) What is your experience and what do you know about buying Nembutal online ?
3464
3465I’ve done extensive research & understand there are scams out there. 5) Your age ? 43
3466
3467Nembutal Scams
3468
34696) How soon do you want to buy? ASAP 7) Your order quantity?
3470
347115g powder but understand I only need 6g & want advice on the quickest/painless method.
3472
3473Please make sure you answer all the above questions because your answer will determine whether we will provide you with the drug
3474
3475Thank you and awaiting your reply
3476
3477Dr Malvin Castrol VITAL FINALE
3478
3479Email: info@vitalfinale.com Website: http://www.vitalfinale.com/
3480
3481The problem is that once you have replied the scammer the transaction complete and you will never hear from them again. You will not be able to contact them and they will never contact you? They have your money. Done deal!
3482
3483The Peaceful Pill eHandbook The Dangers of Internet Scammers
3484
3485It can be dangerous to become involved in online scams for Nembutal. Indeed, Exit has received reports that some scammers have tried extortion, demanded more and more in the way of payment from you, threatening to report you to the police if you complain. One purchaser who refused to pay the extra “insurance money” found themselves at the receiving end of the following email. This is the ugly side of Internet Nembutal trade and care is advised.
3486
3487Did you ever experience witchcraft in your life? and do you want to experience it? You dare with me, I talk with my Indian guy and we put you in deep pain right now. Just dare it ... Hope you read my last email. If it rings a bell in your head then you must be very careful at this moment as its now getting off hand. I can put you in greater pain for your whole life.
3488
3489Tips to Pick a Scammer
3490
3491It is often not that hard to pick a scammer. The purchase of Nembutal is unlawful in most countries, including US, Canada, UK and Australia. Therefore, if you live in one of these places, you and your Nembutal supplier are both breaking the law. If the supplier was genuine, they would be risking significant jail time as a commercial Internet trafficker in Nembutal. Not many people are prepared to take that risk.
3492
3493Exit cannot emphasise this enough. Scammers will take your money, but provide you with nothing. Much safer for them than being a genuine supplier. Here are some useful tips to pick a scammer:
3494
3495Nembutal Scams
3496
3497• Is their English good or are they using Google Translate? • Does their website state an association with Exit International, Exit International USA, Dr Philip Nitschke?
3498
3499• Do they say they have been approved/ endorsed by The Peaceful Pill eHandbook?
3500
3501• Do they say they send/ have sent samples of Nembutal to Exit International for testing?
3502
3503• Do they advise you how to take the Nembutal? • Do they use a fake courier company? Have you checked? • Is their address in the Ukraine or Cameroon? • Have they demanded more and more money from you?
3504
3505The above are common features of the listed scammers. As mentioned earlier the business of scamming changes quickly. As soon as Exit publishes the latest on Internet Nembutal scams, the criminals involved change names, websites and email addresses. While the list at the start of this Chapter gives a good overview of current scammers, it can never be definitive. The below provides details of all those listed.
3506
3507The Peaceful Pill eHandbook
3508
3509Anonymous Pharm/ Meryl Pest Control http://merylspestcontrol.com/wp-page/nembutal.php
3510
3511Berlin Pharmacy <Berlinpharmacy@dr.com> Since you had some probleme with us the last time because of shipping and delivery , we can ship the 2 bottle to you as soon as you want them at €250 . We are given you a discount of € 150 . But if you can take 3 bottle which is €550 then we shall offer you a €300 with a discount of € 250 Get back to us if you aggree to any of those
3512
3513* This scammer has scammed the person once and is now offering a discount for a second order. Talk about a con!
3514
3515Cho Collins Cameroon Name used is: El-Hajjis Jal-Sawed Offer: 10 grams= US $422
3516
3517Scam Website - from Cameroon?
3518
3519Nembutal Scams
3520
3521EMS Express Mail Service (fake courier) I have sent you two copies of emails from scammer VITAL FINALE and EMS Express mail service. Both are a complete fraud.
3522
3523I had to pay by Money Gram for the first scammer. I paid. Then I received notice from second scammer requiring insurance to ship. The loss was $407 plus Money Gram fees of $12. With Money Gram there is no need for a name and address of the recipient only the State in which they live.
3524
3525After paying, you give the recipient via email a reference number. With that number they can go to any Money Gram outlet in the State and collect your money with nothing needed except reference number. The state was Maryland. Please warn others. Thank you, David
3526
3527Export Ph http://export.ph/offers/view/2861
3528
3529Glomedstore < glomedstore@gmail.com>
3530
3531How to Order Nembutal Europe https://sites.google.com/site/pentobarbitalineurope/how-to- order-nembutal-online-in-europe-where-to-buy-nembutal- online-in-europe
3532
3533Info Nembutal <info.nembutalpentobarbital@gmail.com>
3534
3535The Peaceful Pill eHandbook Jorge Hernandez & Vital Finale
3536
3537This scammer is long-standing, having managed to evade the authorities since at least 2014. To be clear:
3538
3539Jorge Hernandez = Malvin/ Marvin Castro = Vital Finale
3540
3541Exit has much reader feedback about the person’s criminal ways, and we have continued to publish this since 2014. Despite this, he still manges to pull in the desperate and the vulnerable. The real Jorge Hernandez is a famous Cuban swooner thus adding to the mystery. The imposter variously claims to be Mexican yet resident in the US. And to visit Mexico daily.
3542
3543Below is a sample of the questions that Exit continues to be asked about Jorge Hernandez.
3544
3545Do you know anything about this individual, who claims to go to Mexico almost every day? http://jorgehernandez.me. I also found Vital Finale today, but someone on your FB site, says they are a scam. Both websites contacted me back within a couple of hours. Both want Western Union, and this is how I have been scammed in the past. I haven’t ordered anything lately, as I can’t afford to lose more money.
3546
3547Reader 1
3548
3549I ran across the web site jorgehernandez.me and was wondering if you have any knowledge of whether this is a legitimate site and if it is trustworthy as a supplier? Do you know of anyone who has had experience with them?
3550
3551Reader 2
3552
3553This past week, I found someone online named Jorge Hernandez, promising to send me high quality Nembutal (3 bottles). I lost my $1,240.00.
3554
3555Nembutal Scams Reader 3
3556
3557I have contacted Jorge Hernandez via his website (http:// jorgehernandez.me/). He was very nice and informative. I paid him more than $600 for 2 bottles, but haven’t heard from him since. The money sure went somewhere.... but he does not answer the many e-mails I sent him.
3558
3559Reader 4
3560
3561I was sent an “excerpt” from peaceful pill handbook from Jorge Hernandez showing that your organization listed him as a trusted vendor for Nembutal. Well I just lost $530. The man has not answered my emails after getting paid. If he is listed he needs to be de listed in your next update.
3562
3563His email is nembutal@jorgehernandez.me. That’s also his website. If you have any questions I’m available.
3564
3565Scam Website - How to Order Nembutal Europe
3566
3567The Peaceful Pill eHandbook
3568
3569The various faces of Jorge Hernandez & Vital Finale
3570
3571Nembutal Scams
3572
3573Jorge Ramires Greetings, my name is Jorge Ramires, veterinary doctor graduated from the Polytechnic University of Sao Paulo, currently I am a resident in the city of Guanajuato Mexico and is for that reason that I would offer my services as a distributor of Nembutal / Pentobarbital in 100ml liquid and 6.5gr active formula for the purposes you agree.
3574
3575The product is original and is guaranteed by laboratories, I ship anywhere in the world. I appreciate your attention and time, if you wish to contact me my email is: phdramires@ gmail.com, May God bless you.
3576
3577Kapitan Natalya Ukraine In December I paid 300 USD to Exit international USA in Newark. I then paid 500 euros to KAPITAN NATALYA Ukraine, a further 500 euros, 3 times 300 euros to have my parcel delivered within 3 days 30 December. To date nothing and no contact. This is ROBBERY a Super Con of an 80 year old who only wanted to die peacefully. Thank you.
3578
3579Malvin Castrol & Marvin Castrol Dr Malvin/ Marvin Castrol, alternatively known as Jorge Hernandez, at Vital Finale, is described above. Exit routinely receives questions about him/ her/ it. Here is how they reply to enquiries. Note the broken English.
3580
3581We recommend you to take the 100ml Nembutal oral solution will cost you $400 with an extra $32 for shipping and delivery making a total of $432. This you will drink and it will give you a peaceful life exit rest with no waste of time. We will offer you a free express delivery service of you parcel.
3582
3583The Peaceful Pill eHandbook
3584
3585All we need from you to proceed are the following delivery details:
3586
3587Full names...................... Address........................... Postal zip code................. Mobile Number................ Your order...............100ml ($432 USD)- $578 Australian Dollars
3588
3589As soon as we get this information from you, we will be sending over to you our payment address which you will use to do payments over to us through western union or money gram. As soon as payments is being confirm by us through western union or money gram, we will immediately get your parcel registered at the courier service and a tracking number will be sent over to you for your parcel update till delivery is made at your address.
3590
3591Awaiting to confirm your delivery details. Thanks
3592
3593Mezam Pharmacy http://www.mezampharmacy.com <nembutalforyou@gmail.com>
3594
3595Muller Gomez
3596
3597The scammer who promises to get people Nembutal goes by the name of Muller Gomez. They get the money sent to Cameroon. He even called me, texted me, and swore that he would deliver the product overnight mail. He has done none of what he said, so please try to warn others of this person. To do that to a suffering person is horrible.
3598
3599Nembutal Scams
3600
3601Hunter Thompson, the famous author, took his life due to chronic pain, but he had tons of guns, and balls of steel. I could not shoot myself, but I could drink Nembutal.
3602
3603These crooks need to be caught. They’re preying on people who are suffering, and it’s wrong.
3604
3605Nembutal for You <nembutalforyou@gmail.com>
3606
3607Nembutal Group USA Email: <Nembtalgroup@usa.com> Phone: +1(916)741-3687
3608
3609Nembutal Group Norway https://ukeuthanasiasolution.wordpress.com
3610
3611Nembutal Supplier Group https://groupeuthanasiamedication.wordpress.com/tag/ nembutal-supplier-group-ltd/
3612
3613Thank you for your concern, I now have to complete this plan the nasty way. Sad news for me, the money is of no importance Just wanted a peaceful end pre 80 yrs.
3614
3615I emailed Nembutalsuppliergroup@gmail.com, they said delivery was by couriersems@gmail.com
3616
3617The parcel of pills, is now held by Customs. They say it is now in the hands of the Police Chief for investigation. What a mess. Thank God it will all be over soon. Susan
3618
3619The Peaceful Pill eHandbook
3620
3621Nembutal Online Ukraine www.nembutalonline.com 16/2 Prorizna St, Kiev 01001 <contact@nembutalonline.com>
3622
3623Peaceful Exit Solutions https://www.linkedin.com/in/ordernembutaldrug
3624
3625Peaceful Pill Directory A new and slick site using Exit images and text, replete with fake 5 star rating on various sources!
3626
36271800 26th St S Arlington, VA 22206 USA tel: +1(469)607-0971 www.peacefulpilldirectory.com
3628
3629Perfecto Relief http://perfectorelief.com/order-nembutal-online/
3630
3631Quality Nembutal Pentobarbital and Others https://qualitynembutalpentobarbitalsupplyandothers. wordpress.com/el-hajjis-jal-saeed-supply-ltd-money-back- guarantee/
3632
3633UK Euthanasia Solution
3634
3635https://ukeuthanasiasolution.wordpress.com & https://ukeuthanasiasolution.wordpress.com/2015/06/28/ most-legitimate-supplier-of-nembutal-the-only-real-source-of- nembutal-online-buy-nembutal-online-from-united-kingdom/
3636
3637Nembutal Scams
3638
3639Weiku.com http://www.weiku.com/Inorganic-Chemicals/buy-nembutal-sodium-pentobarbital.html
3640
3641The dynamic website of Nembutal Online Ukraine
3642
3643The Peaceful Pill eHandbook
3644
3645Peaceful Pill Directory scam website
3646
3647UK Euthanasia Solutions scam website
3648
3649Nembutal Scams
3650
3651Previously Listed Scammers (no longer operating)
3652
3653Below is an incomplete list of scammers and some screenshots of websites that have disappeared or have been closed down.
3654
3655Peaceful Exit Community & Dr John Harris Email: info@peacefulexit.com http://www.peacefulexit.com
3656
3657Exit Foundation Facebook Page https://www.facebook.com/pages/Buy-Nembutal-online-Exit- Foundation/1418156448451388
3658
3659Buy Nembutal Online Wordpress Blog See: https://euthanasiachat.wordpress.com/
3660
3661Lonely End http://www.lonelyend.com
3662
3663Speedy Express Int (fake courier site) http://www.speedyexpressint.com
3664
3665This was a fake courier site that allowed purchasers to enter their fake tracking number and get false updates (since replaced with fake EMS courier).
3666
3667Ekow Anderson Western Union details show the following address: Address:122, Florya Metro, Istanbul, 34000, Turkey
3668
3669The Peaceful Pill eHandbook
3670
3671Chi Germain Akenji Western Union details show the following address: Address:1213 Alexandria Ave, Bitola, 7000, Macedonia
3672
3673Philip Force Western Union details show the following address: Address: 325 Lanham Rd, Laurel, 20708, MD, USA
3674
3675Pristupa Yuliya Western Union details show the following address: Address: 03 Oktyabrskaya St, Poltava, 21000, Ukraine
3676
3677A previous scam website - Exit Foundation
3678
3679Nembutal Scams
3680
3681“Lonely End” scam Site
3682
3683‘Peaceful Exit Community’ scam website no longer operating
3684
3685The Peaceful Pill eHandbook
3686
3687Fake Facebook pages offering Nembutal
3688
3689Nembutal Scams
3690
3691Neighbourhood Watch for Scammers
3692
3693As this Chapter makes clear, keeping a tab on scammers is a on-going challenge. The information changes fast and the duplicitous, dishonest nature of their operations, and the desperate plight of many seeking this drug ensures that there is always someone who is willing to risk their luck, and their money.
3694
3695To stay abreast of these criminal activities, Exit asks that feedback is provided on an on-going basis. No bit of informa- tion too small or insignificant. It is only through extensive reader feedback that Exit can continue to issue warnings and alerts in real time, when and as they appear.
3696
3697That said, we return time and time again to the cliché.
3698
3699‘If it sounds too good to be true, it likely is too good to be true.’
3700
3701Caveat Emptor!
3702
370318
3704
3705Testing and Storing your Nembutal Sample
3706
3707• Taking a Sample for Testing • Types of Tests (Qualitative v Quantitative) • Home Qualitative testing - Exit Spot Test • Home Quantitative testing - the ‘Max Bromson Triple Test’ • Additional Home Tests • Laboratory Quantitative testing • Storage & Shelf Life of Powder/Liquid • Note about Nembutal capsules, tablets and long term storage
3708
3709Taking a Sample for Testing
3710
3711The tests described in this Chapter require only a very small sample of the powder or veterinary liquid to be tested ( ~ 0.5gm of powder or 6ml of veterinary liquid is enough to carry out all of the tests).
3712
3713A sample of veterinary liquid Nembutal for testing can be obtained as follows:
3714
3715The veterinary packaging is designed so that variable amounts of the drug can be withdrawn from the 100ml bottle using a syringe and hypodermic needle without breaking the sterile seal. Although there is no need for the Nembutal to be sterile for a peaceful death, the drug will keep longer if the seal is not damaged and the solution remains sterile.
3716
3717Testing & Storing Nembutal
3718
3719The bottle should only be fully opened (by breaking the seal and removing the rubber stopper) when the drug is either ready to be used or it is to be discarded.
3720
3721To take a test sample of the liquid, remove the outer plastic cap from the bottle cap (if present) and then use a small knife, nail scissors or screwdriver to remove the small central circular metal piece covering the rubber stopper (Fig 18.1) that you will find underneath the plastic cap. The rubber stopper will then be exposed.
3722
3723Fig 18.1: Removing a sample of Nembutal
3724
3725The Peaceful Pill eHandbook
3726
3727When the rubber stopper is exposed, the needle of the hypodermic can be pushed through the stopper into the bottle. Use the hypodermic syringe supplied with the Exit Nembutal Test Kit (or an equivalent). With the needle in place, invert the bottle and carefully withdraw the syringe plunger until there is liquid in the syringe.
3728
3729The Difference between Qualitative vs Quantitative Testing?
3730
3731Qualitative testing shows ‘Yes’ or ‘No’ if the sample being tested is Nembutal. Qualitative testing uses monoclonal antibodies to indicate whether the Barbiturate Nembutal is present even in minute quantities.
3732
3733NOTE: Qualitative testing gives NO information on the purity of the sample. A Qualitative test only confirms that Nembutal is present. This is also called the qualitative ‘Spot’ Test.
3734
3735In contrast, Quantitative testing establishes the purity of the sample. Quantitative testing therefore shows if a sample has deteriorated over time, or from poor storage. A Quantitative test will also show if a sample has been contaminated in some way. If this is the case, the sample in question may need to be discarded (or the dose increased to compensate for the deterioration or adulteration).
3736
3737Quantitative testing of a sample that has been stored for a period of years (or is from an uncertain source) is useful for peace of mind.
3738
3739Fig 18.2: Weighing out Nembutal powder for testing
3740
3741Testing & Storing Nembutal The Qualitative ‘Spot’ Test
3742
3743The Exit Spot Test Kit is a quick screening test that can be quickly undertaken to establish that Nembutal powder from China or liquid Nembutal from countries such as Peru or Mexico is, in fact, Nembutal.
3744
3745The test can be done at home and as stated previously, only a very small sample is needed for the test (~0.1gm of powder, or 0.1ml of veterinary liquid). The Exit Qualitative Test Kit contains a sealed dip-card cassette and 0.5ml hypodermic syringe.
3746
3747For veterinary liquid Nembutal, the steps are as follows:
3748
37491. Use the syringe provided to remove a small sample from the bottle of liquid to be tested using the method shown in the videos ‘Testing Nembutal - Obtaining the Sample’.
3750
37512. Remove the Nembutal test cassette from its foil and remove the plastic cap to expose the absorbent tip. Saturate the absorbent tip of the dip-card with the veterinary liquid you have removed with the syringe, and replace the plastic cap.
3752
37533. At ~5 minutes, read the results of the test off the dip-card. After 10 minutes the results cannot be relied upon.
3754
3755To use the Exit Spot Test for powdered Nembutal, the steps are as follows:
3756
37571. Use a clean knife to separate out a small sample of the powder (see Fig 18.2).
3758
37592. Dissolve a small amount of powder in a few ml of distilled water. Saturate the absorbent tip of the dip-card, and proceed as above as per step 3 to read the results on the cassette.
3760
3761The Peaceful Pill eHandbook
3762
3763Reading the Qualitative Test Results Positive Result
3764
3765One red line in the control region (C). NO line appears in the test region (T). The absence of a test line indicates a positive result for Nembutal. Negative Result
3766
3767Two lines appear. A red line in the control region (C), and a red or pink line in the test region (T). Invalid Result NO line appears in the control region (C).
3768
3769Fig 18.3: A positive ‘Spot’ Test
3770
3771Testing & Storing Nembutal Video: Testing Nembutal: Obtaining the Sample
3772
3773Video: Exit Triple Test Acid Conversion Test (ACT)
3774
3775The Peaceful Pill eHandbook The Max Bromson Quantitative Test
3776
3777There are three quantitative tests that can be carried out at home. Together, they are called the Max Bromson Quantitative Test. Together, will give a reliable indication of the sample purity.
3778
3779The Max Bromson Quantitative Test Kit can be obtained at: http://www.exitinternationalstore.com Each Exit Max Bromson Quantitative Test Kit contains:
3780
3781• Digital scales with accuracy of +/- 0.001gm • Glass Melting Point capillary tube (x2) • Digital probe thermometer (00
3782
3783C to 2500
3784
3785• Spot test cassettes (x6) • 2ml micro-pipettes (x6) • 3ml syringes (x6) • 25G hypodermic needles (x4)
3786
3787C)
3788
3789Fig 18.4: Exit ‘Max Bromson Triple Test’Kit (Spot test cassettes not shown)
3790
3791Testing & Storing Nembutal Video: Melting Point Test (MPT)
3792
3793Video: Dilution Purity Test (DPT)
3794
3795The Peaceful Pill eHandbook
3796
3797Note: In May 2016 the consumables provided in the Max Bromson Kit were doubled, so that more than one sample could be tested.
3798
3799The results of these tests on a sample of Nembutal powder (or liquid) will give a reliable indication as to whether the sample has undergone significant deterioration, or has been contaminated or adulterated.
3800
3801The 3 Tests are:
3802
3803a) The Acid Conversion Test (ACT) b) The Melting Point Test (MPT) c) Dilution Purity Testing (DPT)
3804
3805a) The Acid Conversion Test (ACT)
3806
3807Nembutal (sodium pentobarbital) is in the form of a soluble salt. When dissolved in water the salt forms a clear alkaline liquid (with pH ~10). This explains the bitter taste.
3808
3809Conversion into the insoluble crystalline form can be achieved by acidifying the solution and driving the pH down, so that an insoluble precipitate is formed.
3810
3811If the original salt sample is 100% pure sodium pentobarbital, the weight of the precipitate formed should be 90% of the original (the ratio of the molecular weights of both substances). In other words if one dissolve half a gram (500mg) of 100% pure Nembutal powder, acidifies, separates, dries and weighs the precipitate, one would expect a weight of 450mg.
3812
3813Testing & Storing Nembutal
3814
3815Method: Place the scales provided on a flat surface and check the calibration with the 10gm weight included. (Use the tweezers to move items on and off the scales)
3816
3817Weigh out approximately 500mg (1/2 gram) of powder for testing. Record the accurate weight and dissolve the sample in approximately 50ml of distilled water.
3818
3819When the sample is fully dissolved, use a syringe from the kit to drip in 5ml of white vinegar. Note the cloud of white precipitate that forms with each drop. Let the precipitate settle.
3820
3821Weigh and record the weight of the dry laboratory filter paper provided in the Kit. You will then need a small plastic funnel. Fold the paper so that it fits inside the small plastic funnel. Pour the mixture (liquid and precipitate) into the funnel so that it drains through the filter paper. To ensure that all the precipitate has been washed into the filter paper, rinse the container containing the mixture using a syringe of distilled water.
3822
3823Repeat the process by adding another 5 ml of vinegar to the clear filtrate. Again let the precipitate that forms settle, then pour through the same filter paper and rinse the precipitate again. Repeat until the further addition of vinegar leads to no visible precipitate.
3824
3825Place the filter paper in an oven set at low heat (~1000 C), and
3826
3827allow the filter paper to dry. Re-weigh the filter paper plus the dried precipitate.
3828
3829Calculate the weight of the total precipitate by subtracting the weight of the filter paper.
3830
3831The % purity of the original sample is obtained by: (Weight of salt/ Weight of precipitate) x 90
3832
3833The Peaceful Pill eHandbook
3834
3835Note: If one is testing the purity of a sample of veterinary liquid Nembutal, remove 6ml of liquid for testing and measure the exact volume using one of the graded pipettes. Add distilled water and proceed as described above.
3836
3837Note: The quoted concentration on the bottle of the Nembutal to be tested is usually 65mg/ml. The original weight of the salt would be 6 x 65 = 390mg, and if pure ,would precipitate 350mg.
3838
3839Set aside the dried pentobarbital crystals for use in the melting point test (MPT).
3840
3841The ACT Test is shown in the video ‘Purity Testing for Nembutal Powder’.
3842
3843Note: In the video, only 200mg of powder was used for the test, and the process of serial dilution using small 5ml vinegar samples was not employed. The process of serial dilution and filtration avoids the possibility of re-absorbtion of the precipitate by over dilution, and the use of a larger (500mg) sample gives greater ACT test accuracy.
3844
3845b) The Melting Point Test (MPT)
3846
3847A pure test sample is expected to have a clearly-defined specific melting point. The melting point can be determined by using a thin-walled glass capillary tube to heat a small sample and then recording the temperature at which the sample melts (and changes colour).
3848
3849For Nembutal, the test must be carried out on the free acid - not the sodium salt. Items needed for the test include a sealed glass capillary tube, thermometer (mercury or digital) with a range > 1500
3850
3851C, and a glass container of cooking oil that can be heated slowly on the stove.
3852
3853Testing & Storing Nembutal
3854
3855Regardless of whether one has the powdered salt (from China), or a bottle of liquid solution of the salt, the process is as follows:
3856
3857Place some of the dry pentobarbital crystals from the previous acid conversion test into the capillary and suspend the capillary in the cooking oil. Keep the glass tip of the capillary close to the sensing tip of the digital thermometer. Heat the oil slowly on the stove while stirring the oil continuously. Watch for the point at which the melting of the crystals occurs. The crystals should change colour quickly from white to transparent at 1310
3858
3859C +/- 10 C.
3860
3861A video of the MPT is shown: ‘The Melting Point Test for Nembutal’.
3862
3863Note: In the video a magnetic laboratory stirrer is used to ensure a uniform temperature of the cooking oil being heated.
3864
3865c) The Dilution Purity Test (DPT)
3866
3867The DPT test looks for the point at which a sample of Nembutal (powder or liquid) becomes so dilute as to not give a ‘positive’ on the qualitative ‘Spot test’ cassette. Adulterated or degraded Nembutal samples will require less dilution to reach this point.
3868
3869Accurately weigh out 200mg of powder to be tested. Dissolve this powder in ~20ml of distilled water taken from one of the 2 liter distilled water bottles - label this bottle #1.
3870
3871Return the 20ml of water with the dissolved substance back into the 2 liter container. Re-seal and tip up and down several times to mix the sample thoroughly.
3872
3873The Peaceful Pill eHandbook
3874
3875Re-open the 2 liter container and insert the test strip of a spot test cassette into the liquid. Wait and read the result. A clear positive should be recorded. A clear positive is a single clear line at ‘C’ on the cassette, with no line forming at the ‘T’ level (see Fig 18.3).
3876
3877Use a 3ml syringe attached to a 2ml micro-pipette to take exactly 2ml of liquid from this 2 liter container and add this to the second 2 liter distilled water container - label this bottle #2.
3878
3879Reseal and again invert to mix thoroughly. Finally, use a new cassette to test bottle #2. Another positive should be recorded, although a faint line may now be noticed at ‘T’. A clear ‘C’ confirms that the test sample has a purity of better than 70%.
3880
3881Note: To test veterinary Nembutal liquid, use a syringe with a 25G needle. Remove exactly 3ml of the sample and add this directly into the first distilled water bottle - proceed as above.
3882
3883A video of the DPT is shown: ‘The DIY Home Nembutal Purity Test’.
3884
3885Max Bromson Quantitative Test Results
3886
3887Home purity testing requires care and the results obtained can sometimes be difficult to interpret. The benefit of the Max Bromson Triple Test is that it enables three tests to be carried out.
3888
3889A spurious or unexplained result from one test can then reasonably be disregarded if the other two tests return an adequate result.
3890
3891Testing & Storing Nembutal
3892
3893For example, a good purity result on the ACT (ie. better than 70%), with a MPT of 1300
3894
3895C would give confidence that
3896
3897ingestion of 10gm of this sample will bring about a peaceful death. The test that is most likely to give spurious results (false negative or positive) is the DPT as there are external factors that cannot be totally controlled, eg. the age and quality of the test cassettes.
3898
3899If, however, a sample fails all three tests, it would be wise to source an alternative sample, or seek a laboratory assay.
3900
3901Additional Home Quantitative Tests Water Content Test (WCT)
3902
3903The presence of water in any significant amount in a sample of Nembutal powder is an adverse finding. Nembutal powder will readily absorb water from the air. This is why it should always be kept tightly sealed in an air-tight container.
3904
3905To determine water content in Nembutal powder, accurately weigh out and record ~1 gm of the powder and place it in a laboratory oven with the temperature controlled at 1000
3906
3907C. After
3908
390930 minutes in the oven, let the powder cool in a desiccator and re-weigh to establish the percentage of water content. The percentage should be < 5%
3910
3911Acid Titration Testing (ATT)
3912
3913Reliable testing to quantify the presence of adulterants or degradation requires sophisticated equipment. A useful titration test can be carried out at home, but careful attention to detail is essential to ensure an accurate result.
3914
3915The Peaceful Pill eHandbook
3916
3917This method involves accurately weighing out a small sample of powder (~200mg +/- 0.5mg), drying it in an oven at 1000
3918
3919C
3920
3921to determine the presence of any significant amount of water, then dissolving it in distilled water and, finally, titrating with 0.1N hydrochloric acid. Methyl Orange is used as an indicator to determine the point at which the pH rapidly decreases.
3922
3923A detailed step-by-step account of this process has been provided to Exit by ‘htveld’ and is available on the ‘Prime Posts’ section of the Exit Forums. See: http://bit.ly/29LeP6a
3924
3925Exit is also grateful for the work of ‘chriskay’ & ‘ billleboeuf’ in the Exit Forums <http://peacefulpillforums.com/ > for their suggested refinement to the quantitative testing proceedures described in this chapter.
3926
3927Laboratory Quantitative Testing Using Gas Chromatography
3928
3929The gold standard for testing the purity of a sample of Nembutal is to use gas chromatography. The equipment needed to carry out such tests restricts this process to commercial laboratories. The Exit laboratory has used such equipment (see Fig 18.5) in the development of other simpler testing procedures.
3930
3931Over the years, Exit has tested samples of Nembutal sourced from China and Mexico using Gas Chromatography. There has been no evidence of significant adulteration or deterioration, even in samples that have been stored for long periods of time (some over 15 years).
3932
3933Testing & Storing Nembutal
3934
3935Fig 18.5: Exit Laboratory GC Machine Mobile Nembutal Testing
3936
3937The demand for reliable, confidential testing has grown significantly with the ready availability of powdered Chinese Nembutal. Legal problems have prevented the establishment of a testing service where members would forward a small sample of the powder (or veterinary liquid) to our laboratory for assay.
3938
3939In 2012 a mobile testing facility (laboratory van) operated for a short period of time to make testing equipment available to Exit members. For legal reasons, Exit did not take possession of the substance being tested. Ownership remained with the person carrying out the tests.
3940
3941The Peaceful Pill eHandbook Storage & Shelf Life of the Barbiturates
3942
3943The soluble barbiturate salts (ie. sodium pentobarbital - Nembutal) are very stable drugs. This is a particularly useful property of Nembutal, as it means the drug can be safely stored many years without losing its potency. This is true for both powdered and liquid forms of Nembutal.
3944
3945In powdered form, sodium pentobarbital should be kept tightly-sealed, away from any contamination or exposure to oxygen or atmospheric moisture. The product from China is usually supplied loosely packed in a small plastic sachet, so re- packaging is important. There are two recommended procedures for long term storage.
3946
3947The Storage of Powder Nembutal Method 1
3948
3949Obtain a suitable glass container with a airtight screw top. The size should just accommodate the powder, with little extra space for air. If testing is planned, remove ~500mg, then tightly seal the container before wrapping it in aluminium foil (to protect it from the light) and store it in a cool place. The refrigerator (~40
3950
3951C is fine). Method 2 (Courtesy of Alan Davies)
3952
3953An alternative strategy is to wrap the sample (minus 500mg if testing is planned) in aluminium foil, and place the package in a metallized Mylar (PET) bag. The bag is then vacuum sealed using a home vacuum food storage unit (eg. a Foodsaver vacuum sealer ) sold at stores such as Amazon, Argos or Walmart. http://www.foodsaver.com/vacuum-sealers/counter-top-vacuum-sealers/
3954
3955Testing & Storing Nembutal Fig 18.6
3956
395710gm of powder in foil
3958
3959Powder wrapped in foil
3960
3961Place in Mylar storage bag
3962
3963Silica Gel moisture absorbing sachet
3964
3965O2
3966
3967absorbing sachet
3968
3969Place the vacuum sealed Mylar bag inside a PE ‘Food Saver’ bag
3970
3971Above: Vacuum seal the Mylar bag inside a plastic PE bag along with moisture and oxygen absorbing sachets
3972
3973Right: The finished package ready for storage
3974
3975The Peaceful Pill eHandbook
3976
3977Pint size Mylar bags (10cm x16cm or 4”x6”) are ideal and provide ideal oxygen and moisture protection for the sample. The sealed Mylar bag is itself then vacuum packed inside a standard polyethylene food serve bag (Quart size,~20cm x 30cm or 8”x 12”), along with moisture (silica gel) and oxygen absorbing sachets. The finished sample is small and can then be conveniently stored in a cool place (< 200
3978
3979C).
3980
3981It will be obvious if the seal is broken as the package will become pliable, at which point the outer vacuum package can be replaced.
3982
3983Note: Extracting all the air from Mylar bags before heat-sealing can sometimes prove difficult because of the smooth finish of the bag. A solution to this is shown on YouTube:
3984
3985http://www.youtube.com/watch?v=r9dzaeC0hG0
3986
3987Note: Moisture and oxygen-absorbing sachets and Mylar bags are available at a small cost on the Internet. See: https://www.usaemergencysupply.com/
3988
3989Note: It has been suggested that metoclopramide anti-emetic tablets can be vacuum-sealed along with the sachets of Nembutal powder. However, it is not clear if the shelf life of the anti-emetic would be increased with this storage method.
3990
3991Testing & Storing Nembutal The Storage of Liquid Nembutal
3992
3993Veterinary liquid comes in sealed, sterile glass 100ml bottles. It is best not to disturb the seal on the bottle until it is needed.
3994
3995Do not break the seal or decant the liquid into another container as this will expose the drug to the air. Store the original bottles in a cool dark place. Refrigeration is fine, but do not freeze as the bottle can break.
3996
3997The liquid should be clear and colourless. Any coloration or precipitation of the liquid means that further testing and assay will be required.
3998
3999Note about Nembutal capsules, tablets and long term storage
4000
4001Note: Pharmaceutical grade Nembutal capsules or tablets are no longer produced. Those who have access to these drugs and are planning their use, should be aware that because of their age, these drugs are likely to have deteriorated, and should be tested.
4002
4003Note: Previous editions of The Peaceful Pill eHandbook outlined a method of long-term storage that involved the conversion of the salt (sodium pentobarbital, CAS No 57-33-0 ) to the free acid (pentabarbital CAS No 76-74-4).
4004
4005However, the success of long-term, vacuum-packing of the soluble salt has made this process unnecessary, and it has now been removed from the eHandbook.
4006
4007. 19 Administration of Nembutal Introduction
4008
4009It is very straight forward to take Nembutal for the purpose of a peaceful and reliable death. This is one of the reasons that it is Nembutal that is the drug of choice in places where assisted suicide and voluntary euthanasia are lawful.
4010
4011Things to Consider Powder Nembutal makes a clear liquid
4012
4013When a person decides to die, 10 or more gm of powdered Nembutal is placed in a glass, and then about 50ml of cold water is added. The powder should be stirred until it is fully dissolved. The liquid in the glass will be clear.
4014
4015Breaking the seal of Liquid Nembutal In the case of veterinary liquid, the bottle is opened by breaking the seal and pouring all the contents (100ml) into a clean glass.
4016
4017Note, these bottles are tightly sealed and the liquid inside is sterile. Breaking the seal can sometimes be difficult especially if vision is poor, or if you have arthritis in your hands. One method of opening the bottle is shown in the accompanying video ‘Opening a bottle of Nembutal’ (in the following Chapter).
4018
4019Administration of Nembutal
4020
4021Fig 19.1: The bottle of Nembutal & plastic cup as used at Dr John Elliott’s assisted death at Dignitas in 2007
4022
4023Anti-emetics
4024
4025In places where assisted dying is legal, Nembutal is invariably taken with a separate anti-emetic (anti-vomiting) drug. The anti- emetic will be taken as stipulated either for two days prior to the chosen night. Alternatively it can be taken as a single ‘stat dose’ around 40 minutes before the Nembutal is to be taken (see Chapter 9 for more explanation).
4026
4027Eating something light
4028
4029Have something light to eat so your stomach is not empty is generally considered a good idea. The chance of reflex vomiting brought on by drinking the bitter Nembutal liquid is reduced if there is something in the stomach. This should not be a significant meal that will slow the absorption of the drug. Something light is preferable, like tea and toast, an hour or so before taking the drug.
4030
4031The Peaceful Pill eHandbook
4032
4033A Safe Environment An important consideration will be a peaceful, safe environment where one will not be disturbed. Usually this is best achieved at night.
4034
4035Drinking Alcohol after the Nembutal
4036
4037The liquid in the glass can be drunk quickly in 2 or 3 swallows, and then followed by some alcohol, usually spirits or liqueur. Although not essential, alcohol is recommended as it alleviates the bitter Nembutal after-taste, and will speed the drug’s action.
4038
4039Mixing Nembutal with Something Else to take away the Bitter Taste
4040
4041It is always better to take one’s Nembutal straight. The likely result of mixing the Nembutal with something else (eg. yogurt) is the creation of a greater volume of an equally unpalatable substance. Furthermore, using a spoon to consume the drug, rather than drinking it, can mean a longer time to ingest the 100ml.
4042
4043Exit has received reports of people falling asleep before all of the drug is consumed. This is dangerous. It is best to drink the 100ml in a few swallows, then drink alcohol.
4044
4045How the Nembutal Takes Effect The drug is absorbed from the stomach, and as the level in the blood rises, some crosses the blood-brain barrier and effects the part of the brain that controls sleep.
4046
4047Within a few minutes of taking the drink the person falls into a deep sleep, quite often in mid-sentence when talking to family and friends!
4048
4049Administration of Nembutal
4050
4051As the level of drug in the bloodstream rises, more moves into the brain and sleep becomes deeper and deeper. At this point, another area of the brain is effected; that which controls the rate of breathing. The person’s breathing slows, and eventually stops altogether.
4052
4053With no oxygen entering the lungs, the person dies of ‘respiratory arrest’, where there is not enough oxygen in the circulating blood to maintain brain function. Lastly, the heart stops beating. Rarely is there any bladder or bowel motion.
4054
4055It is the most peaceful of deaths to witness. With Nembutal, you always die in your sleep.
4056
4057A Lethal Dose of Nembutal While there are several florid accounts of failure by people taking a full 100ml bottle of veterinary Nembutal, closer scrutiny shows a much more complex situation. Exit has examined the details and medical records of several such cases.
4058
4059In the vast majority of cases, one bottle (100ml @ 60mg/ml) of veterinary Nembutal will always be satisfactory and lead to a peaceful death, usually in ~1 - 2 hours. However, there is a small group (estimated at <1%) who may exhibit a prolonged comatose phase before death (sometimes up to 24 hours). Outright ‘failures’ remain extremely rare.
4060
4061Indeed, all of the
4062
4063reported failures investigated by Exit were associated with early discovery and subsequent medical intervention. This emphasizes the need for careful selection of the place of death.
4064
4065In some of the analyzed cases, the long comatose phase was associated with the prolonged use of anti-psychotic medication or chronic heavy alcohol use, prior to taking the barbiturate. It is presumed the induction of liver enzymes by these drugs
4066
4067The Peaceful Pill eHandbook
4068
4069causes increased degradation of the Nembutal, lowering the concentration in the brain.
4070
4071In these situations, increasing
4072
4073the quantity of drug taken (eg. to 2 bottles, 12gm) may not necessarily hasten the death.
4074
4075Exit has examined the use of several potentiating drugs which may be dissolved into the liquid Nembutal, removing any possibility of extended coma. The most useful, Dilantin, (phenytoin sodium) is discussed in this Chapter.
4076
4077Available Forms of Nembutal
4078
4079As discussed in the previous Chapter, Nembutal is available as both a liquid and a powder. Reagent-grade sodium pentobarbital powder is available from Chinese manufacturers (Fig 19.4)
4080
4081Sterile, veterinary liquid is most often found in South America. For over a decade, this form of Nembutal has been the most common form used for a peaceful death. (Fig 19.2). Very occasionally, pharmaceutical-grade Nembutal tablets or capsules, originally prescribed as sleeping medication, are obtained although this is uncommon. (Fig 19.3)
4082
4083Reagent-grade Nembutal is marketed as a white crystalline powder which readily absorbs moisture and is very soluble in water. It is non-sterile and often packaged in small, sealed screw- top plastic containers or loose in plastic sachets. Most people ordering the drug from China (see the previous Chapter) receive 25gm as flat-packed loose powder or in screw-top containers (see Fig 19.4). Note that 25gm is more than enough of the drug to provide a peaceful death for 2 - 3 people.
4084
4085Administration of Nembutal
4086
4087Fig 19.2: Sealed veterinary Nembutal
4088
4089Fig 19.3: Pharmeceutical Nembutal tablets
4090
4091Fig 19.4: 2 x 12.5gm screw top containers of Chinese powdered sodium pentobarbitol
4092
4093The Peaceful Pill eHandbook
4094
4095Video: Up Close: A Bottle of Anestesal (Nembutal)
4096
4097Administration of Nembutal
4098
4099In contrast, the veterinary liquid form of the drug is designed for intravenous administration in animals to provide anaesthesia for surgery. It is marketed as a sterile clear liquid with a concentration of 60 mg/ml of sodium pentobarbital in alkaline buffered solution with 10% ethyl (or methyl) alcohol and ethylene glycol. The usual packaging is a glass 100ml bottle (clear or tinted glass), sealed with a rubber stopper and metal seal.
4100
4101Pharmaceutical-grade Nembutal tablets or capsules are normally supplied in a screw top plastic container, showing a date of manufacture of more than 20 years ago, usually long past their expiry date.
4102
4103Interaction with Other Drugs
4104
4105Those who take Nembutal for a peaceful death are often taking other drugs due to their illness. When approaching the chosen day to take the Nembutal, an often-asked question is whether any inter-current medications should cease.
4106
4107There are only a few drugs that are known to interfere with the action of Nembutal. There is generally no need to cease taking other drugs in the preceding days.
4108
4109Nevertheless, it is
4110
4111common practice for those planning their death to cease all but the essential medication in the week before their planned exit.
4112
4113Chronic heavy alcohol use, for example, can lead to cross- tolerance and may impair the action of the barbiturate. In rare cases, taking another barbiturate, such as the anti-convulsant phenobarb, can lead to the development of a barbiturate- tolerance. In these cases, a larger dose of the Nembutal (12gm powder or 2 x 100ml bottles) would be advised.
4114
4115The Peaceful Pill eHandbook Video: Opening a bottle of Nembutal
4116
4117Video: Using Phenytoin
4118
4119Administration of Nembutal
4120
4121Some drugs enhance the effect of the Nembutal and can even be employed for that specific purpose. An example is the anti- convulsant Dilantin (phenytoin sodium Fig 19.5).
4122
4123Dilantin is useful as the drug dissolves in water forming an alkali solution which is compatible with the liquid Nembutal. Nembutal of uncertain quality can have its potency enhanced by dissolving 1- 2gm of phenytoin sodium in the solution before drinking. This process is shown in the accompanying video ‘Making Nembutal even more effective’. Although Dilantin is a drug that is usually only available on prescription, it is relatively easily obtained through Internet mailing sources. It is not a drug of interest to the authorities.
4124
4125Other Useful Barbiturates
4126
4127Two other barbiturates that still find wide (although decreasing) use in medicine can also be usefully employed for a peaceful death. These are the anti-convulsant Phenobarbital, and the anaesthetic induction agent, Pentothal.
4128
4129Phenobarbital
4130
4131As discussed in earlier, Phenobarbital and Pentobarbital are drugs that are often confused because of the similarity of their names. Although both are barbiturates, pentobarbital sodium (Nembutal) is the fast-acting soluble salt. This is the euthanasia drug of choice in all countries that allow assisted suicide
4132
4133Fig 19.5: Dilantin 100mg capsules
4134
4135The Peaceful Pill eHandbook and voluntary euthanasia. Phenobarb is a different drug. In
4136
4137its usual form, phenobarb is a slow-acting anti-convulsant, prescribed when there is a risk of convulsions (eg. brain trauma etc).
4138
4139Some people will have access to phenobarb, either from their own doctor or from overseas pharmaceutical suppliers. A drink of 10gm (~ 250 of the white 30mg tablets shown in Fig 19.6) crushed and mixed with water will be lethal.
4140
4141Fig 19.6: 30mg tablets of Phenobarbitone
4142
4143Note: There is no rapid loss of consciousness, as in the case of Nembutal. The time to death using phenobarbitone can be several hours. If one is found before death, resuscitation is very possible.
4144
4145Phenobarb can, however, be made more effective by raising the pH of the solution of the crushed tablets. This is done using Sodium Carbonate to convert the Phenobarbital to the more readily-absorbed sodium phenobarbital. If available, 1gm of Dilantin can be added to this drink with good effect.
4146
4147To reduce the time from taking the drink to loss of consciousness, a second drink made from a benzodiazepam sleeping drug is recommended (eg, Serapax, oxazepam or Mogadon, nitrazepam). Again, alcohol can be an effective supplement.
4148
4149Administration of Nembutal Pentothal (thiopentone sodium)
4150
4151For many years, Pentothal was the main intravenous induction agent used in anaesthesia. Its use has declined in recent years. When given intravenously, most patients are asked by the anesthetist to count back from 10. Few get past 7 before consciousness is lost.
4152
4153Note: This is the primary drug used in lethal injections in executions in the US. In November 2010, a worldwide shortage of the drug prompted the state of Oklahoma to investigate using Nembutal as an alternative.
4154
4155See: http://abcn.ws/dPu2Zr
4156
4157Pentothal is marketed as soluble thiopentone sodium powder in sterile ampoules. These are designed to be mixed with sterile water before being administered intravenously. The powder can be dissolved in water and taken orally with rapid effect. 10gm of the drug (the contents of 20 ampoules) dissolves rapidly in ~50ml of water, and if drunk leads to rapid loss of consciousness and death. Alcohol is a useful supplement.
4158
4159Fig 19.7: 500mg ampoule of dry Pentothal
4160
4161Exit has tested the vacuum- packing of 10gm of dry sodium pentothal powder mixed with 1gm of phenytoin sodium. This can be easily transported and stored. Reconstitution is then carried out by breaking the vacuum seal and dissolving the sachet of powder in ~50ml of water before drinking.
4162
4163The Peaceful Pill eHandbook Conclusion
4164
4165When rigorous scientific processes are used to establish the purity and efficacy of known drugs, ensuring a reliable and peaceful death, the need for legislative change is significantly diminished. This is because the act of dying well and at a time and place of one’s choosing is achievable. However, certain steps must be taken.
4166
4167When Nembutal has been sourced by the person themselves and then tested and verified by the person themselves, with a view to being taken by the person themselves, there is little role for the medical profession. Whether or not legislation exists also ceases to be of less importance. When the time is right, they will simply go to the cupboard!
4168
4169Administration of Nembutal
4170
417120 The Peaceful Pill Project Developing a Peaceful Pill
4172
4173The ongoing difficulties in obtaining the best euthanasia drug, Nembutal has prompted Exit to establish an ambitious research project - the synthesis of one’s own ‘Peaceful Pill’.
4174
4175The Peaceful Pill Project has run for several years. Many strategies have been explored and rejected with some significant advances made. In this Chapter we detail this Exit research and discuss in more detail the use of the drug Nembutal for a peaceful death.
4176
4177The synthesis of a barbiturate-like pill, involves the acquisition of restricted and hard-to-get chemicals and the use of processes that are difficult and occasionally dangerous for the novice. Nevertheless, as the pathways are established and simplified, safer processes are developed and recorded. An outline of the steps required for barbiturate synthesis and assay are described and illustrated where possible with video.
4178
4179The Peaceful Pill Project
4180
4181The Nicky Finn
4182
4183Exit’s first trials of the home-made Peaceful Pill – the ‘Nicky Finn’ - were completed in 2004. Named after the famous Micky Finn drink of the Lone Star Saloon in Chicago in the early 1900s, Exit’s Nicky Finn was made from alcohol and nicotine.
4184
4185Manufactured by chlorinating alcohol and combining this chloral hydrate with pure nicotine, the Nicky Finn should prove highly effective and highly lethal when taken as a drink. Although synthesis was straightforward, the difficulty in testing this untried product left questions about this strategy unanswered.
4186
4187Changing Focus
4188
4189A group of intrepid Exit International members launched the ‘Peanut Project’ in early 2005. Named after an old-fashioned street term for barbiturate (Peanuts), the Peanut Project brought together a group of elderly people to create their own barbiturate. Could they synthesise Nembutal?
4190
4191How could they make something that:
4192
4193• they could take orally • could be manufactured without outside assistance • would provide a peaceful and dignified death • would be reliable with negligible risk of failure.
4194
4195The Peaceful Pill eHandbook
4196
4197The first Workshop was held at the remote country property of former Australian Attorney General, Kep Enderby QC. The average age of participants was 80 years, although some were in their 90s. Several who participated were seriously ill.
4198
4199Legal Issues
4200
4201Setting out to manufacture one’s own barbiturate Peaceful Pill exposes those involved to significant legal risk with jail and fines of up to half a million dollars. In most western countries there are myriad laws that make it an offence to manufacture, possess, sell, supply and import certain narcotic and psychotropic drugs.
4202
4203Penalties depend upon the amount of the drug involved, but usually range from two years jail and a fine, to life imprisonment. In the Peanut Project, there was another additional legal question. If one member of the group ever died using the substance the group had collectively made, would the remaining members be guilty of having assisted with that person’s suicide?
4204
4205It was stated clearly at the start, that no one in the initial group would make more than they needed for themselves. No one was making a Pill for someone else, and no one would sell any of the substance manufactured. Finally, no one would acquire more than 10gm of the manufactured barbiturate (the common lethal dose). Any excess would be destroyed.
4206
4207The Peaceful Pill Project The Chemistry
4208
4209The processes used for the barbiturate Peaceful Pill synthesis have been known for many years. Barbiturates are derivatives of barbituric acid. This was first synthesized by Adolph von Bayer in 1864, by condensing malonic acid with urea.
4210
4211An easier method makes use of the di-ethyl ester of malonic acid (di-ethyl malonate) which reacts with urea in the presence of a catalyst sodium ethoxide; a base is formed by dissolving metallic sodium in absolute alcohol (ethanol).
4212
4213Di-Ethyl Malonate + Urea + (Sodium Ethoxide) = Barbituric Acid This synthesis is depicted above.
4214
4215The reaction takes place under reflux for a number of hours at 1100
4216
4217C. Crystals of barbituric acid are obtained by acidifying the
4218
4219reaction mixture, then filtering and cooling the filtrate. Barbituric acid, however, has no physiological activity. The process needs to be taken further to develop a barbiturate that can peacefully end life. The sedative, hypnotic, and anaesthetic properties of the barbiturates are determined by the characteristics of two additional side-arms (or side-chains) attached to the barbituric acid molecule.
4220
4221The Peaceful Pill eHandbook
4222
4223Video: Exit and the Synthesis of Nembutal (The Single Shot Project)
4224
4225Video: The First Attempt at a Peaceful Pill (The Peanut Project)
4226
4227The Peaceful Pill Project
4228
4229The di-substituted barbiturates of particular interest are amylobarbital (Amytal) and pentobarbital (Nembutal). The process of adding side-arms (di-substitution) needs to be undertaken before the condensation of the malonate and urea.
4230
4231In Amytal, the two alkyl side arms are (a) ethyl, introduced as ethyl-bromide and (b) 3-methylbutyl, introduced as 1-bromo- 3-methylbutane. In Nembutal, the two alkyl side-arms are (a) ethyl, introduced as ethyl-bromide and (b) 1-methylbutyl, produced from 2-bromopentane. In both substitution reactions the malonate is heated, either in a closed pressure system (autoclave) or under reflux first with one and then the second alkyl bromide. In both reactions sodium ethoxide is used as the catalyst.
4232
4233The final step in the production of sodium pentobarbital or sodium amylobarbital is heating of the resultant di-substituted malonate with dry urea in an autoclave or under reflux for another 12 hours. This is again done in the presence of dry alcohol and sodium. Excess alcohol is removed by distillation and the residue - predominantly sodium pentobarbital, or sodium amylobarbital - is dissolved in water to form the Peaceful Pill.
4234
4235In all of the di-substitution reactions and in the condensation with urea, it is essential that there be absolutely no water present. Care must be taken to ensure no atmospheric moisture reaches the autoclave or reactor vessel. All substances used must be dry. In particular, the alcohol used in the production of the sodium ethoxide needs to be as dry as possible (super dry).
4236
4237The Peaceful Pill eHandbook Equipment
4238
4239In the original project, the period of prolonged reflux was carried out using a two-litre glass reaction vessel with three Quickfit taper necks (24/29), fitted with an efficient double surface condenser (Fig 20.1). A heating mantle and a means of stirring the mixture and monitoring the temperature were also required. To protect the reacting substances from atmospheric moisture, calcium chloride guard tubes were used. To remove excess alcohol in the final stage, the double-surface condenser was attached to the reactor vessel by means of a distillation head. The alcohol that was distilled was collected in a glass receiving vessel that was also fitted with a calcium chloride guard tube (Fig 20.4). An accurate chemical balance, capable of measuring to 0.1g, was required to weigh out the necessary reactants.
4240
4241In the subsequent ‘Single Shot’ project, a specialised stainless steel pressurised reaction vessel (autoclave) was employed. This replaced the glassware and the reflux condenser. This sealed stainless steel vessel (autoclave) allowed the reaction to take place under pressure, shortened reaction time and reduced the problem of contamination from atmospheric moisture (Fig 20.2). Pressure was read directly from the gauge with the temperature in the reaction vessel read via a thermocouple (with an infrared thermometer used as backup).
4242
4243To remove the substituted malonates from the reaction vessel a condenser was employed. This was made from stainless steel tubing surrounded by a water jacket. Connected to a receiving vessel of stainless steel this was then vented using a calcium chloride guard tube and placed under reduced pressure in the distillation process using a water tap vacuum attachment.
4244
4245The Peaceful Pill Project
4246
4247Fig 20.1: Reflux system used for barbiturate synthesis
4248
4249The Peaceful Pill eHandbook
4250
4251The setup of the glassware for reflux used is shown in Fig 20.1. Note: the presence of the guard tube on the top of the reflux condenser. The distillation setup is shown in Fig 20.3.
4252
4253The single shot equipment is shown in Fig 20.2. The distillation set-up shown in Fig 20.3
4254
4255Special Dangers
4256
4257As with all chemical processes, care and attention to detail was needed at all times. The equipment was clean and dry before use. Many of the liquids used in the synthesis were flammable and naked flames were not used. Heating of the reaction vessel was by way of an electric hotplate. The most dangerous substances used in the process were metallic sodium and the strongly basic intermediary sodium ethoxide. Standard organic chemistry texts (eg. Solomons & Fryhle, 2004) spell out the dangers of handling these substances.
4258
4259CAUTION: Sodium must be handled with great care and under no circumstances should the metal be allowed to come into contact with water as an explosion and fire may result. Sodium is stored under paraffin or xylene and should only be handled with tongs or tweezers, not with fingers.
4260
4261Small waste or scrap pieces of sodium can be disposed of by placing them in a bottle containing large quantities of methylated spirits.
4262
4263The commercial sodium is covered with a non-metallic crust. A sodium press can be constructed to remove this and produce clean sodium wire for the reaction vessel. See ‘Betty cooks with Sodium’).
4264
4265The Peaceful Pill Project
4266
4267Fig 20.2 (above): The ‘Single Shot’ Autovclave
4268
4269A: Pressure Gauge B: Distillation coupling C: Pressure coupling D: Pressure safety valve E: Heat + Stirring F: Thermocouple
4270
4271G: IR thermometer patch
4272
4273Fig 20.3 (below): Vacuum distillation setup A: Autoclave B: Heat + Stirring
4274
4275C: Condenser water jacket D: Calcium chloride guard tube E: Vacuum line F: Collection vessel
4276
4277Fig 20.4: Autoclave pressure head
4278
4279The Peaceful Pill eHandbook Precursors
4280
4281The list of necessary precursors (with their Chemical Abstract Service number, ‘CAS No.’) includes the following:
4282
4283Di-ethyl malonate CAS No: 105-53-3 Alkyl sidechains:
4284
4285a) Ethyl bromide CAS No: 74-96-4 and
4286
4287b) 1-bromo-3-methylbutane CAS No: 107-82-4 or
4288
4289c) 2 Bromo-pentane CAS No: 107-81-3
4290
4291Catalyst
4292
4293Sodium ethoxide CAS No: 141-52-6
4294
4295or Sodium metal
4296
4297CAS No: 7440-23-5 &
4298
4299Absolute alcohol CAS No: 64-17-5
4300
4301Urea CAS No: 57-13-6
4302
4303The Peaceful Pill Project Video: The Future of the Peaceful Pill Project
4304
4305Video: Why can’t a larger quantity of the drug be made?
4306
4307The Peaceful Pill eHandbook
4308
4309None of the chemicals required are subject to specific government restriction. Application to a reputable chemical supplier for ethyl malonate and the chosen side-chain alkyl bromides is generally successful provided one can detail a legitimate purpose in the required end-user statement. Some endeavour may be required to obtain the sodium metal and dry ethyl alcohol. Alternatively, the catalyst sodium ethoxide can be purchased.
4310
4311Authors’ note - the chemicals required to make a Peaceful Pill may be classified as ‘precursors’ for the synthesis of a restricted substance. Possession of significant quantities of these items may be an indictable offence and could result in significant penalties.
4312
4313Acquiring Necessary Equipment
4314
4315Laboratory glassware is becoming increasingly hard to obtain. This is a reaction on the part of the authorities to the existence of clandestine laboratories that manufacture illegal drugs (predominantly amphetamines) for commercial gain. The award-winning TV series ‘Breaking Bad’ is an excellent example of what can occur in the dark underworld of blackmarket drugs. Some of the chemical techniques used in the synthesis of a Peaceful Pill are the same as those used to make illicit drugs.
4316
4317The synthesis in Exit’s projects required a prolonged period of reflux (Fig 20.1). A glass reaction vessel with 3 Quickfit taper necks (24/29), fitted with an efficient double surface condenser was needed. A heating mantle and a means of stirring the mixture and monitoring the temperature were also used. To protect the reacting substances from atmospheric moisture calcium chloride guard tubes are needed. The double surface condenser can be
4318
4319The Peaceful Pill Project Video: The Nature of Research & Development
4320
4321Video: Obtaining Nembutal in a Hurry
4322
4323The Peaceful Pill eHandbook
4324
4325Fig 20.5: Glass distillation system
4326
4327Fig 20.6: Single Shot on YouTube
4328
4329The Peaceful Pill Project
4330
4331attached to the reactor vessel by means of a distillation head. A glass receiving vessel, fitted with a calcium chloride guard tube, is needed to collect the distillate (Fig 20.5).
4332
4333An accurate chemical balance capable of measuring to 0.1g is required in order to weigh out the necessary reactants.
4334
4335Distributors of this specialized glassware (eg. reaction vessels with Quickfit necks, double-surface condensers, distillation heads, guard tubes etc) are often required to inform authorities of ‘suspicious’ purchases. For this reason it can be helpful to know someone who has access to laboratory glassware and glass-blowing skills.
4336
4337The manufacture of specialised equipment in stainless steel avoids some of these difficulties. The stainless reaction autoclave used in the ‘Single Shot’ process has been adapted from a coffee pot. This method has since been modified as problems with the process were realized. The equipment now used consists of:
4338
4339• a stainless steel pressure reactor vessel with pressure and temperature monitor and stirring facility
4340
4341• a stainless condenser used for reflux and solvent extraction • a stainless receiving container fitted with calcium chloride guard tubes
4342
4343The Peaceful Pill eHandbook Stages in Barbiturate Synthesis
4344
4345There are three basic steps in the synthesis of a barbiturate Peaceful Pill:
4346
4347• Step 1: Attaching the first sidechain to the di-ethyl malonate • Step 2: Attaching the second sidechain to the product of step 1
4348
4349• Step 3: Condensing the di-substituted malonate with urea to form the required barbiturate
4350
4351Looking at these steps in more detail
4352
4353Step 1 In the case of the target barbiturates, Nembutal or Amytal, the first sidechain to be attached to the di-ethyl malonate is an ethyl halide, usually ethyl bromide is used. To form the mono-sustituted malonic ester, ethyl bromide is heated with the di-ethyl malonate in the presence of the required catalyst - the base, sodium ethoxide.
4354
4355The catalyst may be purchased or made as part of the process. To make the required ethoxide add 5.7g of metallic sodium that has been cleaned by passing through a press - see ‘Betty cooks with Sodium’ - and 125ml of very dry alcohol.
4356
4357Into this mixture of dry alcohol and sodium ethoxide add 38ml of di-ethyl malonate and 26g of bromoethane. Heat is applied and the mixture stirred using a magnetic stirrer. In an open system a reflux condenser must be fitted and a calcium chloride guard tube used to ensure no contamination by atmospheric moisture.
4358
4359The Peaceful Pill Project
4360
4361Note: Super Dry Alcohol Alcohol (ethanol) of the required dryness can be made using methylated spirits as the starting point (95.6% alcohol). Absolute ethanol (>99.5%) is obtained by heating this under reflux with dry (recently fired) calcium oxide. To significantly improve the yield in the synthesis of barbiturates, even dryer alcohol is required. To remove more of the water, thereby converting the 99.5% ethanol to ‘super dry’ alcohol (>99.8%), use 5gm of magnesium turnings with 0.5gm of iodine in a boiling vessel. Let the magnesium react with ~50ml of the 99.5% ethanol producing hydrogen and magnesium ethanolate. When all of the magnesium has been consumed, the remainder of the absolute alcohol is added, refluxed for 30 minutes, and distilled directly into the planned storage vessel. The resulting ethanol should be better than 99.95%. See the Video ‘Making super dry alcohol’.
4362
4363Step 2 Sodium ethoxide catalyst is again needed in the reaction vessel, and this time 47g of the monosubstituted ester from Step 1 is converted to a di-substituted ester by reflux (or reaction in an autoclave) with the second side chain. For the synthesis of Amytal, this second sidechain is 1-bromo-3 methylbutane. In the case of Nembutal, it is 2-bromopentane, in each case 38g is required.
4364
4365At the end of this stage the di-substituted malonate is removed again by vacuum distillation. This is 3-methyl-butyl-ethyl malonic ester in the case of Amytal synthesis; 1-methyl butyl- ethyl malonic ester if Nembutal is being manufactured.
4366
4367The Peaceful Pill eHandbook
4368
4369Step 3 Sodium ethoxide is again needed in the reaction vessel. For this final step 58g of the di-substituted malonate from step 2 is allowed to react with 15g of dry urea that has been dissolved in hot dry alcohol. The mixture is stirred and heated under reflux. After 4 hours, the excess alcohol is boiled off and the residue dissolved in water and acidified (with dilute hydrochloric acid) to precipitate the insoluble barbiturate crystals which can be washed and dried.
4370
4371Testing the Product
4372
4373As with any home-made product, careful testing is necessary. Full reassurance can only come from detailed, quantitative analysis using gas chromatography and mass spectroscopy (GC-MS).
4374
4375Exit took possession of this necessary equipment in 2008. Apart from the ability to test the products of home synthesis, the equipment is useful in verifying the veracity of old stocks of prescribed barbiturate sleeping tablets, or samples of veterinary Nembutal that have been purchased from dubious sources or have long past their quoted shelf life.
4376
4377Finally, the Exit Barbiturate Test Kit can be used to demonstrate the presence of synthesized barbiturate. In addition, the purity of dried barbiturate crystals can be tested using a glass capillary in an oil bath. For Nembutal, the melting point should be 1290
4378
4379C.
4380
4381Detailed instructions on the use of the Nembutal melting point test will be provided in future editions of the eHandbook.
4382
4383The Peaceful Pill Project
4384
4385Fig 20.7: Vials of barbiturate solution for assay using gas chromotography
4386
438721 Swiss Options (a) Dignitas - Zurich
4388
4389(b) Lifecircle/Eternal Spirit - Basel (c) EX International - Bern
4390
4391Introduction
4392
4393There is only a handful of places in the world where Voluntary Euthanasia and/ or Assisted Suicide is currently legal.
4394
4395In the US, for example, terminally ill citizens of the states of Oregon, Washington, Vermont and California can obtain a prescription for the lethal drug, Nembutal. The state of Montana is slated to have similar legislation in the future. Canada too has now enacted right to die legislation.
4396
4397In each of these places, however, a doctor cannot provide more assistance than this. Voluntary euthanasia - a lethal voluntary injection - is illegal. See Killing Me Softly: VE and the Road to the Peaceful Pill for a detailed discussion of the difference between Voluntary Euthanasia, Physician
4398
4399Assisted Dying, Physician Assisted Suicide. ‘Medical Aid in Dying’ or simply ‘Aid in Dying’ are the latest terms in this battle of semantics).
4400
4401Swiss Options
4402
4403However, in each US state where assisted dying is lawful, (as well as under the Canadian model), there are strict residency requirements. To use California’s new ‘Death with Dignity’ law, a person must be a resident of that State. It is not enough to be a Texan. You cannot fly in and get help to die.
4404
4405Similarly, in the Netherlands, the Termination of Life on Request and Assisted Suicide Act 2002 has strict residential requirements. In this country, a person wanting an assisted death must satisfy strict medical requirements and have a long- standing relationship with a Dutch doctor. This ensures that the Netherland’s euthanasia law is only for the Dutch (amd ex-pats), thereby avoiding Dutch ‘death tourism’.
4406
4407In Belgium and Luxemburg, where voluntary euthanasia was legalized in 2002 and 2009 respectively, similar residential requirements apply.
4408
4409Switzerland – Laws & Loopholes
4410
4411In Switzerland, assisted suicide is allowed by law as long as the person providing the assistance has no selfish motive. The Swiss Penal Code states that ‘a person who, for selfish motives, persuades or assists another person to commit suicide will be punished with imprisonment up to five years.’ People other than the ‘selfish’, commit no crime in assisting others to suicide.
4412
4413One important aspect about Swiss law is that the person receiving the assistance does not need to be a Swiss citizen. This opens the way for foreigners to come to Switzerland to die.
4414
4415The Peaceful Pill eHandbook Video: Dignitas in Switzerland
4416
4417Video: Flight to Zurich
4418
4419Swiss Options
4420
4421In terms of the manner of assistance, the drugs may be delivered orally (by way of a small drink) or by lethal injection that is controlled by the person. It is the person him/herself who must flick the switch and start the drugs flowing. Swiss law has allowed assisted suicide since the early 1940s.
4422
4423Given the legal environment of Switzerland, it is not surprising to find that the country is home to several right to die organizations each of which accepts foreigners as clients. These groups include the well known, ‘Dignitas’ organisation in Zurich (established in 1998), ‘Lifecircle/ Eternal Spirit’ in Basel (established in 2012) and little-known ‘Ex International’ in Berne (established in 1997).
4424
4425Dignitas
4426
4427Zurich-based Dignitas is a non-profit member society founded by lawyer, Ludwig Minelli.
4428
4429Recognizing the limitations of organizations such as ‘Exit Deutsche Schweiz’ (which only provide their services to Swiss Nationals) Minelli created a organisation that caters for those from many different countries. Dignitas’ guidelines state that they assist people who have been diagnosed with a terminal illness, an incurable disease, or who are in a medically hopeless state. Such people may have intolerable pain or
4430
4431Fig 21.1: Dignitas Director, Ludwig Minelli
4432
4433The Peaceful Pill eHandbook
4434
4435an unreasonable handicap. A person does not need to have a terminal illness to be accepted as a client by Dignitas.
4436
4437Interestingly, Mr Minelli has recently gone further suggesting that people with mental illness should not be automatically excluded from the Dignitas service as their suffering is real and deserves to be addressed as such.
4438
4439A Word of Warning
4440
4441While the theory of allowing a dementia sufferer to decide on his or her own suicide is one thing, the reality of doing this is quite different. Suicide for the mentally ill, not simply those affected by diseases such as Alzheimer’s Disease, can be fraught with danger. There is no better example of what can go wrong than the 2008 case of Australians Shirley Justins and Caren Jenning.
4442
4443In October 2005, a former Qantas pilot, Graeme Wylie, who was suffering from dementia applied to use the Dignitas service. Dignitas contacted Philip Nitschke to assist with a review of Graeme’s current medical state. In his report Philip made clear that although Graeme suffered from ‘significant dementia, he retained insight into his condition’. One month later, on receipt of the report, Dignitas rejected Graeme’s application, stating that they had concerns about his mental capacity. While the organization sympathized with Graeme’s wish to put an end to his suffering, they were unconvinced that he had the ability to make a clear and consistent decision in this regard.
4444
4445Upon his rejection by Dignitas, Graeme’s friend of 30 years - Caren Jenning - travelled to Mexico in search of Nembutal for him. Upon her return to Australia, Caren Jenning gave Graeme’s partner of 20 years, Shirley Justins, the precious bottle of Nembutal. Later the same week, Shirley Justins gave the bottle
4446
4447Swiss Options
4448
4449of Nembutal to Graeme, saying ‘if you drink this Graeme you will die.’ Graeme drank his Nembutal and he died.
4450
4451After an investigation of some 18 months, and a Supreme Court case lasting seven weeks, the women were respectively found guilty of the manslaughter and accessory-before-the fact of manslaughter, of Graeme Wylie. This was in June 2008.
4452
4453The Court determined that because of his dementia, Graeme Wylie lacked the capacity to make the decision to die. He did not therefore suicide. Rather, he was murdered. Shirley Justins went on to appeal both the verdict and the sentence. Both were quashed. In 2011, the Public Prosecutor decided against a retrial. In the intervening months, Shirley served her entire custodial sentence (18 months of weekend detention). Such is the way of the law. Caren Jenning, herself suffering from breast cancer, took a Nembutal overdose before her sentencing in September 2008. She was adamant that she was ‘not going to die in jail’.
4454
4455The lesson here is that if Dignitas (or another Swiss service) rejects a person on the basis of a lack of mental capacity, that person and their family need to be very careful about alternative strategies.
4456
4457Fig 21.2: The Dignitas Doorbell
4458
4459The Peaceful Pill eHandbook The Dignitas Process
4460
4461As those who have used the Dignitas service have discovered, nothing happens quickly. The Swiss are very particular. Each Canton has an exhaustive list of requirements that the organisation must take special note to comply with. This is why it is best to approach Dignitas well ahead of a perceived need. The application process for Dignitas can be lengthy and drawn out. Dignitas say the average application takes 3 - 4 months, however a six month plus approval period is not unheard of.
4462
4463The first step to using the Dignitas service is to join the organization. For a one-off joining fee of 50 Euros and a yearly membership fee of 25 Euros, a person can become a member. From there, the person can apply to make use of the service at some time in the future, when/ if the need should arise.
4464
4465You can join Dignitas by writing to them, emailing or phoning (contact details are given in this Chapter). While a proficiency in German is not mandatory, it will help when dealing with more complex questions. The Dignitas phone reception does have an English language option, but this can lead to an answering
4466
4467Fig 21.3: The Dignitas House in Zurich
4468
4469Swiss Options
4470
4471machine, depending on the time of day that you call. And call- backs in English may take longer.
4472
4473More than this, though, there is the issue of cultural differences. The authors are regularly approached by people who have contacted Dignitas (and the other groups) and who are frustrated that they get nowhere fast. Some things inevitably get ‘lost in translation’. This serves to make an already complex process more difficult. This is a note of warning.
4474
4475To make an application to Dignitas, there is a formidable list of documents required. Firstly, you must have your illness fully investigated, diagnosed and recorded and an official medical case history compiled in your home country. required by Dignitas upon application include:
4476
4477Documents
4478
4479• Birth certificate (issued in past 6 months) • Passport
4480
4481• Marriage certificate (issued in past 6 months) • Medical records (tests and results) • Medical specialist reports • General Practitioner medical reports
4482
4483• Current local government rates notice (to prove place of residency)
4484
4485• Current drivers license • Statements from family members (children, grandchildren)
4486
4487To apply to use the Dignitas service, a person needs to complete the application form and forward this, along with copies/ and originals to the Dignitas office in Zurich.
4488
4489Note – Swiss authorities insist that at least some of these documents are certified extracts not more than 6 months old, and some may need to be verified by a Public Notary. Be prepared to do a fair bit of running around to gather the paperwork together.
4490
4491The Peaceful Pill eHandbook
4492
4493Upon receipt of the application, Dignitas reviews each applicant’s situation. If deemed suitable, a provisional letter of acceptance will be mailed to the client. This is called the ‘green light’. can be made.
4494
4495It is at this point that plans for travel to Zurich
4496
4497Upon Arrival in Zurich Upon arrival in Zurich, an appointment is made with one of a number of consulting physicians who work in conjunction with the organization. These medical doctors are independent of Dignitas and work from their own rooms.
4498
4499There is a detailed meeting with the consulting doctor and the medical records are re-examined (by a second doctor). If relatives or loved ones have accompanied the person to Dignitas, the doctor will likely interview the family members and/ or friends. Don’t be surprised if you are interviewed together, then individually, then together again.
4500
4501Once the medical consultation has taken place and if the doctor is satisfied, a prescription for pentobarbital will be written. However, the drug is not handed over to the person at the time of the consultation with the doctor. Rather, approval at this stage means that a final appointment can be made. This appointment is when the person will die. The doctor’s approval means that the drug will be available for consumption by the person at the Dignitas house on the chosen day.
4502
4503The Final Appointment
4504
4505The final appointment is held at the Dignitas house in the outer Zurich neighbourhood of Forch. This appointment can take
4506
4507Swiss Options
4508
4509place quite quickly after the medical review, sometimes the following day. A third member of the Dignitas team may arrive during the appointment and deliver the drugs that will be used. Two Dignitas staff will be present at the death. The death will be filmed.
4510
4511The Drugs
4512
4513As is the case in all places where assisted dying is legal, the drug that is used at Dignitas is Nembutal (pentobarbital natrium). There is no argument that this is the best end of life drug. A prescription will have been written out for this drug by the consulting doctor who saw the client. The prescription will be filled by Dignitas staff on the person’s behalf.
4514
4515Fig 21.4: One of two rooms at the Dignitas House
4516
4517The Peaceful Pill eHandbook
4518
4519It is the Dignitas staff who produce the Nembutal at the final appointment. At the pending death, Dignitas staff will dissolve the pentobarbital powder in a small glass water to form a drink. This is done when the person indicates for a final time that it is their wish to go ahead with their death.
4520
4521The Pentobarbital used by Dignitas is the soluble sodium salt and 15gm are dissolved in ~50ml of water just before use. The concentration of Nembutal in the liquid consumed is 300mg/ml. The amount consumed is ~50 mls which is no more than a few mouthfuls. Note: This dose differs significantly in concentration from the sterile veterinary anaesthetic Nembutal. Anaesthetic Nembutal has a concentration of 60mg/ml, about 5x weaker than that used by Dignitas.
4522
4523Dying at Dignitas
4524
4525Once the client and their family and friends arrive at the Dignitas house for the final appointment, a few further tasks must be attended to.
4526
4527Firstly, additional legal paperwork is completed
4528
4529concerning informed consent, power of attorney and forms to release the body. This final hurdle clears the way for the death to take place.
4530
4531At this time, the person (Dignitas client) reads, approves and once more signs papers indicating that they know what they are about to do and indicating that they are acting of their own free will. Their signature is witnessed by those present. After the completion of the paperwork, the Dignitas staff explain again that the person can opt out at any time. The client is asked if they’d prefer to stay seated around the table or if they’d like to lie down. Either way, it is the person who determines what happens next and how it happens.
4532
4533Swiss Options
4534
4535The Dignitas rooms are bright and airy. They are decorated in warm light colors. There is a coffee machine and CD player for those who wish to have music. And in case you forget to bring your own music, there is even a Dignitas CD compilation of well known relaxing popular music, in case you feel that music might be a valuable last minute addition.
4536
4537Once the person indicates that they wish to go ahead, the staff set up a video recorder on a tripod in the corner of the room. All proceedings from this point are recorded. This is done to provide evidence about the death if questions are asked as to its voluntary nature.
4538
4539After the death, the Swiss police may view the tape to ensure that no pressure or coercion took place. With the camera rolling the person is then given access to the first of a two-step drug protocol. The first drug is an anti-emetic (anti-vomiting drug) and is taken in the form of a small drink. The drug provided is metoclopramide. This drug is taken as a ‘stat dose’ meaning in a large quantity all at once.
4540
4541The Dignitas staff place the glass on the table. It is for the person to reach for the glass and take the drug if they wish. After this drug is swallowed, a half an hour is needed for it to take effect before proceeding. This time can be very stressful and the Dignitas staff are skilled in providing a calm environment for the person and their family/ friends.
4542
4543When the time has passed, the person is then given access to the Nembutal. Once again, the Dignitas staff ask if the person wishes to proceed and reminds them that they can opt out or change their mind at any time. If the client says ‘yes’, a staff member will place the small glass of the dissolved pentobarbital sodium solution on the table.
4544
4545The Peaceful Pill eHandbook
4546
4547In January 2007, the authors accompanied US-born former physician, Dr John Elliott, to the Dignitas clinic. Dying of Multiple Myeloma (a cancer of the bone marrow), this 79-year old man’s last weeks had been a nightmare of untreatable pain. John desperately wanted release from his suffering.
4548
4549Fig 21.5: Dr John Elliott and his wife Angelika in Switzer- land shortly before his death
4550
4551When staff presented John with the glass
4552
4553of Nembutal at the Dignitas apartment, he reached for it quickly. However, John had a problem with gastric reflux, a condition associated with the palliative radiation therapy he had undergone some weeks earlier.
4554
4555Afraid that he would vomit, John needed significant reassurance that he could manage the small drink. He was pleased when he was able to consume the 50ml drink with little difficulty. Prepared for the much talked about bitter after-taste, John finished the Nembutal, saying ‘that didn’t taste too bad.’
4556
4557Because John’s favourite drink was cognac, everyone shared his final moments with a toast to his ‘exit’. Not only did the cognac take away the drug’s after-taste, it made the Nembutal work faster.
4558
4559Swiss Options
4560
4561We clinked glasses while John’s wife Angelika held him. John nodded peacefully off to sleep.
4562
4563hour. John’s journey has been captured in a short film called ‘Flight to Zurich.’
4564
4565See: http://www.youtube.com/watch?v=1j4c6aVFfUk After it’s Over
4566
4567About an hour after John died, a Dignitas staff member performed several simple tests to confirm death. Once this was established, the staff called the police who arrived with a medical doctor and an officer from the Coroner’s department. The funeral home was also contacted at this time.
4568
4569In all deaths, those present are asked to leave the room while the doctor examines the body, The police may view the video tape of the death and interview those present about the nature
4570
4571John Elliott died within the
4572
4573Fig 21.6: John Elliott on arrival at Zurich Airport
4574
4575The Peaceful Pill eHandbook
4576
4577of the death. Was the death peaceful? Was it voluntary? Did it go according to the person’s wishes?
4578
4579Once all questions are answered and the officials are comfortable, the family and friends of the deceased person can leave. The body is then removed to the funeral home, in preparation for either cremation or transportation back to the person’s country of origin.
4580
4581Dignitas and the Swiss Law
4582
4583While the statistics tend to vary, Dignitas say that around 500 people use their assisted suicide service each year. Although there have been a handful of situations where a person’s family has become disgruntled with Dignitas (these cases have been reported at length in the international media), most people would be grateful to the compassionate team of workers at Dignitas who make this choice possible.
4584
4585If you are thinking about using the Dignitas service, there are several points to note. Firstly, it is important to understand that Dignitas does not provide lethal injections. At Dignitas, the client must be able to act for themselves and consume the lethal drug unassisted. This means that unless a person is able move their arms to lift the glass to their lips, or suck on a straw, or swallow, or empty the drug into their own stomach ‘peg’, then Dignitas is not the service for them. At both Lifecircle/Eternal Spirit or Ex International a lethal injection is possible although the person themselves must be able to activate the flow of drugs into the vein.
4586
4587Swiss Options
4588
4589Remember, at Dignitas there is no doctor present at the death. Once a person has been accepted by Dignitas, this is very much a DIY model of operation. Interestingly, Dignitas Founder, Ludwig Minelli, has a background in law not medicine. Dignitas provides a relatively de-medicalized model of dying.
4590
4591In the authors’ opinion, the popularity of the Dignitas service is likely to continue. Although for west coast Americans, Australians, New Zealanders and South Africans the sheer distance involved means that Dignitas is unlikely to be first choice because of the logistics involved.
4592
4593Dignitas: Looking Forward
4594
4595In March 2011, the good people of the Canton of Zurich went to a referendum to decide if the Dignitas service should continue to accept foreigners as clients. Despite grave fears, the population voted overwhelmingly (78%) to maintain the status quo allowing foreigners access to Switzerland’s assisted suicide services.
4596
4597Media reports about this positive development can be found at:
4598
4599http://www.bbc.co.uk/news/world-europe-13405376 http://bit.ly/lcpjpb
4600
4601What does Dignitas cost?
4602
4603At the current time, the Dignitas organization charges a one- off joining fee of approximately €50 and an annual member contribution of at least €25. The current cost of the Dignitas service is just over €10,000.
4604
4605The Peaceful Pill eHandbook
4606
4607Dignitas Contact Details Address:
4608
4609PO Box 9, CH 8127 Forch, Switzerland
4610
4611Telephone: 0011 41 44 980 44 59 Fax: 0011 41 44 980 14 21 Email: dignitas@dignitas.ch Website: http://www.dignitas.ch
4612
4613Fig 21.7: Drs Philip Nitschke & John Elliott take a walk in the countryside outside of Zurich shortly before John’s death in January 2007.
4614
4615Swiss Options
4616
4617The Lifecircle/Eternal Spirit Process (contributed by Sophie Haesen)
4618
4619In recent years, a second assisted suicide service that caters for foreigners has emerged. The association ‘Lifecircle’ was created in the Basel region of Switzerland in 2011 and is thus the newest right-to-die organization in Switzerland. Its founder is Dr Erika Preisig, a general practitioner and former consultant physician for Dignitas.
4620
4621Lifecircle is an association established under Swiss law. Its philosophy involves a commitment to human and self- determination in the often difficult circumstances that surround the end of life. Membership is open to any person over 18 years, and can be obtained via the website or by sending a letter/email requesting membership and indicating name, date and place of birth, address and nationality. A yearly membership fee of 50 CHF (Swiss Francs) is payable or 1000 CHF for life membership.
4622
4623Upon joining Lifecircle, members are invited to send a copy of their living will. This is then stored in the association’s archive and is accessible via the internet in case of need.
4624
4625The Peaceful Pill eHandbook The Lifecircle Process
4626
4627Members of Lifecircle can apply for an assisted death as provided by the group’s sister foundation, Eternal Spirit. The following conditions must be met:
4628
4629• The main diagnosis must be physical (not psychiatric) • The member must be of sound judgement AND • either terminally ill OR • suffering unbearable and uncontrollable pain or have an unacceptably incapacitating disability.
4630
4631Family members must be informed although, unlike Dignitas in Zurich, they are not required to give their consent to the assisted suicide. This is an important diffference to note!
4632
4633The application must also include:
4634
4635• a detailed motivation letter and biographical brief, signed and dated,
4636
4637• at least two medical reports containing all diagnoses, one of which should be recent,
4638
4639• a recent confirmation of sound judgment written by a doctor, which is eminently important for (early) dementia sufferers,
4640
4641• valid passport or identity card of member and member’s spouse if married,
4642
4643•
4644
4645birth certificate (multilingual CIEC/ICCS format, for more information see www.ciec1.org) of member and member’s spouse if married,
4646
4647• depending upon civil status: marriage certificate, spouse’s death certificate (multilingual CIEC/ICCS format), divorce certificate.
4648
4649• The certificate of residence issued by civil registry office of residence (phone bill or driver’s license is not sufficient).
4650
4651Swiss Options
4652
4653The medical and administrative documents can be sent as copies, the originals can be brought in person to Switzerland.
4654
4655As the compilation of all these documents may take some time, it is best to start this process several months ahead. For example, the requested information may need to be resent in a revised format acceptable by Swiss law. Medical records can also often take some time to obtain and collate.
4656
4657After receipt of the request to die, and payment of an initial fee of 3000 Swiss Francs (CHF), the member’s file will be given to a Swiss physician who will decide upon the ‘provisional green light’.
4658
4659In the course of the acceptance process, phone calls or Skype conversations may be required to supplement the information contained in the written documents. If the application is not accepted (for whatever reason), a refund of 1000 CHF will be made. This excludes costs such as doctors’ fees which need to be covered, irrespective of the outcome.
4660
4661Fig 21.8: The house of the Eternal Spirit Foundation in Basel.
4662
4663The Peaceful Pill eHandbook
4664
4665After the ‘provisional green light’, a date for the assisted death can be fixed. Before coming to Switzerland, the member will be required to pay a second installment of 7000 CHF. Members who are in a difficult financial situation can apply for a partial or total exemption but will need to send financial statements as justification. The board of Eternal Spirit will then decide on a case-per-case basis.
4666
4667Upon arriving in Basel in Switzerland, the person attends two consultations with two different doctors. These consultations are organized by Eternal Spirit and are required by Swiss law. The second consultation needs to occur at least two days after the first consultation to ensure that the member has not changed their mind in the interim. It is normal for the member and family to book in to a Basel hotel for two or three nights’ minimum.
4668
4669The medical consultations usually take place in the doctor’s own rooms in the Basel region. In exceptional circumstances, the consultations can be arranged at the place where the member is staying.
4670
4671During the consultations, the person’s medical records and current situation will be reviewed. If the second consultation is deemed satisfactory by the consulting doctor, a prescription for a lethal dose of pentobarbital sodium (NAP) will be provided to Eternal Spirity. The drug will then available for the ‘accompaniment’ (assisted death).
4672
4673Swiss Options
4674
4675At Eternal Spirit, the death will take place in a house belonging to the organisation. Upon arrival, a final round of paperwork will need to be completed. This is required by Swiss law. After this is completed, the member and his/her loved ones can spend some time in the room, talking or listening to music, drinking tea, coffee or even champagne.
4676
4677The death will usually take place on the morning following the second medical consultation. It is normal for a doctor and at least one other Eternal Spirit staff to be present. The member must be accompanied by at least one friend and/or family member; any of whom can choose to be present at the moment of dying, or leave the room immediately prior. Once the person has died this person will need to identify the body.
4678
4679Eternal Spirit recommends the intravenous administration of pentobarbital. This avoids the need for anti-emetic (anti- vomiting) medication. This method allows a very fast death to take place, normally within a few minutes. This sets Lifecircle apart from Dignitas which insists on oral administration. (ExInternational prefers oral administration but does consider intravenous when absolutely necessary (ie if the person cannot swallow).
4680
4681However, if the member prefers to take the Nembutal orally by mouth, this is also possible but is not preferred. In all cases, the important point is that the person must administer the drug him or herself. This can be done by opening the valve on the intravenous drip. For quadriplegics, the valve can be activated via a special interface.
4682
4683When the person is ready to die, he/she will lie down on the bed. The doctor will insert the IV cannula (with a saline solution). The member will then be instructed on how to open the valve. Once
4684
4685The Peaceful Pill eHandbook
4686
4687this process is fully understood by the person, the Nembutal will be added to the saline solution.
4688
4689A camera will be set up in order to record the following procedure in which the person will be:
4690
4691• asked to state his/her name. • asked for the reason why he/she has come to Eternal Spirit • asked what will happen once the valve is opened.
4692
4693By recording these preliminary steps, Lifecircle/ Eternal Spirit seeks to ensure that the death will be deemed voluntary; that is, it has been carried out by the person themselves, and that he/ she has been fully cognizant of the consequences. The video will be shown to the police after the death.
4694
4695An hour after the person’s death, Eternal Spirit staff will inform the local Swiss police that a non-natural death that has occurred. This is required by Swiss law. Police will then arrive along with a representative of the Public Prosecutor’s office and a forensic doctor. At this point, family/ friends will be asked to leave the room, while the forensic doctor examines the body.
4696
4697Once the police leave, a funeral home will be contacted and the body will be collected soon after. The body is then disposed of as per the member’s wishes. This includes cremation with the ashes to be sent to a nominated person. Alternatively, the person’s ashes can be scattered in a peaceful forest in Switzerland. While the body can be transported back to the person’s home country this process will incur significant additional costs which should be costed for well in advance.
4698
4699Swiss Options
4700
4701Other practical considerations for those coming to Basel to die at Lifecircle/Eternal Spirit is that the organisation is not able to organize travel tickets or book hotel rooms.
4702
4703These tasks
4704
4705remain the responsibility of the person and their family/firends. However, the addresses of hotels close to Lifecircle/Eternal Spirit can be provided.
4706
4707The Lifecircle website provides information about the service in German, English and French. Staff speak at least two of these languages. This enables communication with those from countries such as the US, the UK, Canada, Australia and New Zealand. As Lifecircle/Eternal Spirit is a small organization, it is best that initial contact is via email. Only then can communication take place via phone or Skype.
4708
4709Lifecircle/ Eternal Spirit Costs
4710
4711As with Dignitas, an assisted death at Lifecircle/Eternal Spirit is around 10,000 euro. Exit understands that this was the deliberate intention by the Founder not to undercut Dignitas in price.
4712
4713Lifecircle/ Eternal Spirit Contact Details
4714
4715http://www.lifecircle.ch http://www.lifecircle.ch/pdf/lifecircle_Interview_EN.pdf
4716
4717The Peaceful Pill eHandbook
4718
4719EX International
4720
4721EX International is a third assisted dying organisation to cater for foreigners. EX International was established in 1996. In September 2016, the authors met with EX International to discover more of each organisation’s activities. The authors were then invited to tour the premises in Bern, Switzerland.
4722
4723The following review of the organisation is based on both publicly available information and first person communications. The organisation is extremely sensitive to any type of publicity of who they are and what they do. This exists to the extent that the group has a rather rambling landing page (exclusively in German) as the totality of their website. Persevering with this first impression, however, reveals an organization with its heart in the right place and who may well be able to provide a caring and helpful environment for an assisted suicide.
4724
4725Fig 21.9: ExInternational Website
4726
4727Swiss Options
4728
4729Membership of EX International
4730
4731On application for membership (there is a one off joining fee of €100), the applicant will be sent a ‘brochure’ which details the philosophy of the group along with the procedure for membership, required patient information, waiting periods and of course the cost.
4732
4733The group understands that membership might be requested for the following reasons:
4734
4735• A person may not wish to endure a ‘painful illness through to its bitter end’;
4736
4737• A person may not wish to become ‘dependent on others’; and • A person may not wish to be ‘subjected to extreme medical technology’.
4738
4739Assisted suicide is defined by EX International as the person acting autonomously to take the ‘medical drug’ (Nembutal). ‘Active euthanasia’ (where a lethal injection is administered by another person) is not provided. While the group does not exclude assistance for psychiatric suffering, there is the proviso that the person must be ‘capable of judgement’ and ‘not in the care of the health services’ (presumably mental health services).
4740
4741To join EX International, one sends a recent passport photo, along with the registration form and payment. The person will in turn be requested to complete a ‘disposition in contemplation of suicide’ form. This is to establish a history of consideration in regards to an assisted suicide. EX International advise that this form should be reviewed periodically for the purpose of creating and maintaining this history. A living will is also strongly recommended.
4742
4743The Peaceful Pill eHandbook
4744
4745In the authors’ opinions, EX International sets itself apart from Dignitas and Life Circle in a number of ways.
4746
4747Firstly, EX International say they can act quickly and be reactive to the individual needs of a dying person. While the Dignitas ‘green light’ can take many months to acquire, at EX International the process is claimed to be quicker. This might be particularly useful for those with little time left. At EX International there is no designated ‘waiting period’ between joining the group and receiving an assisted suicide. What is required is that the decision to take one’s own life must be a long-held sentiment.
4748
4749Another important factor about EX International is that while the involvement and support of family and friends is considered important, the Ex International brochure states that it is the ‘autonomy of the patient wishing to die [that] takes precedence!’ This suggests that it is not necessary for extended family to be supportive of the person’s decision to seek assistance.
4750
4751The process for using the group to die is much the same as for the other two services (although there is some suggestion that one may travel to Bern without prior to the organization giving the official ‘green light’ of prior approval. Instead the approval may be organised on arrival). The death takes place at the organisation’s designated rooms in Bern. These are similar to those at Dignitas. There is the same white leather furniture, the same bright walls, the same floral soft furnishings.
4752
4753As with Dignitas and Life Circle, one should also expect much to-ing and fro-ing in communication (email, phone, skype video) in the lead up to the planned death. Once in Switzerland the person will visit one of the doctors linked to the group. A volunteer from EX International will accompany the person on this visit. The visit is critical to confirm the person’s medical condition, the constancy of their request for assistance to die and
4754
4755Swiss Options
4756
4757Fig 21.10: Dr Philip Nitschke & Professor Avril Henry at her home in Devon,UK
4758
4759their mental capacity to make the decision. The outcome of the visit will be a prescription for Nembutal. This will be provided to the volunteer for later use by the patient.
4760
4761EX International came to the authors’ close attention after former Professor of English medieval culture, Avril Henry, asked Dr Philip Nitschke for assistance with her application. At this time 81-year old Professor Henry was toying with two decisions as her health and quality of life were rapidly deteriorating. Professor Henry was needing to decide if she would go to Bern for an assisted suicide, or if she would try to import illegal drugs into the UK. Professor Henry was desperate to die in her own home and to be buried in her orchard. As history tells it, Avril opted for the latter. The UK media carried significant coverage of her death. See below.
4762
4763See: http://bit.ly/2dbW5em
4764
4765Before Avril made the decision to abandon the Swiss option, however, she was involved in a backwards and forwards communication with the volunteers at EX International.
4766
4767Professor Henry sought Dr Nitschke’s help because she was ‘frustrated’ at the lack of clarity surrounding the required
4768
4769The Peaceful Pill eHandbook
4770
4771paperwork. For example, was or was not the signature of a British GP on a medical record required? This type of to-ing and fro-ing can be especially problematic when the conversation is delicate and one does not wish to offend. And given it is across languages and cultures. As Professor Henry put it:
4772
4773I was reluctant to let her know how fractured her English is (especially as my German is not fractured because I haven’t any!)
4774
4775Professor Henry was also uncomfortable with the offer from EX International that she pay a sum that suited her. The arbitrariness of this amount left Avril feeling anxious and confused. On the one hand she was happy to pay whatever it took, she simply needed clear guidance. Given that Avril’s quality of life was fast deteriorating (as a result of poly-pathology rather than terminal illness) and the sheer effort of daily life was fast-zapping her energy and concentration, this ‘lost in translation’ was especially unwelcome. It should be noted that this phenomenon is not unique to EX International. Others have reported similar confusion when dealing with the other organisations.
4776
4777EX International Costs
4778
4779Another feature of EX International is that they are significantly cheaper in price compared to the other two organizations. While EX International is keen that their actual fees not be published in the eHandbook, it is safe to say that they are 25 - 30 percent cheaper than their ‘competitors’.
4780
4781In addition, EX International has established an ‘Aid fund for the less well-off’ on the grounds that ‘no member should have to
4782
4783Swiss Options
4784
4785renounce to [sic] a dignified death due to lack of money’. This is commendable and may mean that EX International is a real option for those who would not otherwise have the resources for an assisted suicide in Switzerland.
4786
4787That said, for most people a trip to Switzerland will never be a cheap option. In some ways the Swiss realise this and are prepared to work with small budgets to accommodate those who are less well off. Then again, it is not a good look to be making money out of helping people to die. From the authors’ perspective the ongoing criticism of all Swiss assisted suicide organizations is unfair given what is being offered; not to mention the legal and ethical minefield that surrounds such activities.
4788
4789In Summary
4790
4791While, on the one hand, EX International is a rather secretive organisation operating on the outskirts of Bern, on the other hand their politics concerning a person’s ‘right to choose’ cannot be faulted. In this respect the group openly states that they seek to provide ‘a new freedom of choice’ through choice itself. This means that by merely knowing that choice exists a person may relax, feel less anxious and ultimately die a natural death. This seeming irony is close to the authors’ own hearts. Access to information and choice over one’s death can help us live longer and happier lives.
4792
4793EX International Contact Details EX International CH-3000 Bern 23
4794
4795Postfach 1042
4796
4797Tel. 0041 (0)31 311 71 23 Fax 0041 (0)31 311 71 24 info@exinternational.ch
4798
4799The Peaceful Pill eHandbook
4800
4801Conclusion
4802
4803Switzerland remains the only place in the world where a non- resident person who is terminally ill or suffering unbearably can travel to get help to die. Fortunately, the Swiss show no signs of changing this act of international largesse. For this they are to be congratulated.
4804
4805However, dying in Switzerland is never going to be everybody’s first option. Not only is an arduous trip to a foreign country required. But one must time one’s run. The person must be sick enough to qualify for these organisations’ requirements, but not so sick that they cannot make the trip.
4806
4807This process also locks the person into a specific day or set of days on which to die. And if the person changes their mind, they must make an expensive and stressful trip back home to the other side of the world.
4808
4809This dilemma of timing was evidenced in the experience of 35 year old Jay Franklin from Melbourne. Suffering from Hirschsprung’s Disease, Jay has experienced over 100 operations. The doctors have said there is nothing else that can be done for him. Jay lives in extreme daily pain. He receives food from an IV tube, such is the poor state of his bowel and other organs.
4810
4811In 2013, Exit International raised over $25,000 to enable Jay and his mother Bertha to travel to Switzerland for an assisted death for Jay. At the time, this is what Jay wanted. Yet the more he thought about the idea, the less he liked it. Jay did not like the idea of locking himself into a set plan. He knows his quality of life is not much but he is not ready to die.
4812
4813Swiss Options
4814
4815For Jay, Switzerland was always going to be a one way trip. He did not have the money to go and then come back to Melbourne. So great was this dilemma that Jay has since returned all the money raised for him for his trip.Today he is taking his chances with obtaining Nembutal illegally, because at least this way he can stay at home and he does not lock himself into dying prematurely.
4816
4817Jay’s story has been extensively reported and can be viewed at these links:
4818
4819The Age ‘Jay Franklin is pleading for help’ http://bit.ly/2ci8xMm
4820
4821ABC 4 Corners ‘My own choice’ http://ab.co/2cKcps1
4822
4823Fig 21.11: Jay & Bertha Franklin campaigning in Melbourne for the Voluntary Euthanasia Party, 2016
4824
482522 Final Considerations Introduction
4826
4827Even if The Peaceful Pill eHandbook fulfills its intended purpose of making the process of dying peaceful and reliable, this does not mean that planning for death is not complicated. It can be very complex and things can go wrong or smoothly, depending upon the plans put in place in the days, weeks and months beforehand. Of course, once the person concerned has passed away, they will not be worried. But for those left behind, the aftermath of a death is almost inevitably sad and can be very stressful.
4828
4829This Chapter seeks to provide a few pointers of what to do and what not to do in the event of a rational suicide - your own or a loved one’s. To this end, we discuss issues such as cleaning equipment away (and the legal issues involved), suicide notes, death certificates, autopsies and coronial inquiries. This Chapter is not intended as legal advice. For that readers must visit a professionally qualified solicitor or attorney in their local area. Rather, this Chapter offers some common sense advice on how to safeguard your elected death and make its aftermath as least stressful for all concerned.
4830
4831Do You have the Capacity to Die?
4832
4833The bio-medical literature has long argued that if a person elects to suicide, then they must have been depressed or otherwise psychiatrically impaired. Over recent decades, medical studies have consistently reported that less than 10 percent of all suicides are ‘rational’. That is, they are deaths which reflect an ‘informed decision’, in the ‘absence of cognitive impairment that would prevent realistic assessments from being made.’ The third criteria in determining if a suicide is rational is that the decision to die has been one of ‘free choice without external pressure’ (Worth & Cobia, 1995). Some studies report as few as one percent of all suicides as fulfilling this criteria.
4834
4835At Exit we clearly disagree with many studies undertaken within the discipline of psychiatry and which take as their starting point the premise that suicide is always the result of mental illness. While we are not suggesting that such authors are biased or blinkered, we do argue that their view of suicide is unnecessarily and unhelpfully narrow. We suggest that this
4836
4837narrow view of suicide is the elephant in the room, and that it is out of touch with the views of many elderly people. With a lengthening of the lifecourse, many elderly people have strong opinions against having to live longer (and for the most part sicker ) lives than those who have gone before them. As a result people, they are more likely to say that chronic ill health and frailty - two factors of old age - are not for them. Old age and wellness do not always go hand in hand.
4838
4839It is within this frame of reference that this final Chapter acts as the conclusion to the eHandbook. Anecdotal evidence shows that rational suicide is on the rise in advanced western societies. One recent Canadian study – undertaken from within the discipline of psychiatry - has dared to suggest that up to 30 percent of suicides may be the result of rational decisions of free will. Perhaps even the medical profession might be finally changing their view.
4840
4841See: http://bit.ly/1NzbUHV
4842
4843The Suicide Note Legally speaking, whether a person has the capacity to suicide is often a vexed question. This is why a suicide note can be especially useful. A statement that outlines the following points may be especially beneficial.
4844
4845• The decision was the result of careful consideration • No other person was involved in this decision • The decision was not influenced by outside pressures •
4846
4847If the person was suffering from a serious illness this should be mentioned
4848
4849• In short, paint a picture which any reasonable person would be able to relate to and sympathise with.
4850
4851Once the note has been signed and dated, make a few photocopies. Give or mail copies to one or two close friend s(if you have told anyone of your plans). Remember, you could also hand your friend or family member a sealed envelope and just ask them to ‘keep it safe’. That way you need not reveal the exact date and time of your plans. If you are in contact with a lawyer you could also give one to them. Leaving one hidden in a drawer in your home is another possibility.
4852
4853A well written suicide note will not only help confirm that you knew what you were doing - that you had mental capacity to die - but it will help keep others safe. It would be much more difficult for the police to charge a loved one with helping you suicide - even if they were with you when you died - if you leave this an explanatory note.
4854
4855Few people want their death to be noted as ‘suspicious’ which requires police involvement, and maybe even an autopsy. A suicide note that explains your actions will help safeguard against this. In this scenario, the suicide note will provide a very useful safeguard if loved ones find themselves implicated in the death (ie. did they incite you to suicide?). If ,on the other hand,
4856
4857Fig 22.1: A suicide note
4858
4859the person taking their life does not care that their death be a known suicide, the suicide note can be left alongside their body.
4860
4861The Process after Death
4862
4863If a death takes place outside of a hospital, hospice or other medical institution (eg. at home), it is normal practice upon ‘discovering’ the death, that a doctor / physician be called. Upon arriving at the house, the doctor will then have two options.
4864
4865If the death looks to be natural, and the patient has been seen by the doctor in the past two months (the required time period may change depending upon where you live), he/ she will certify death and issue a death certificate. The person’s underlying disease will be listed as the cause of death. There will be no red tape. The body will be ‘released’ to a funeral home, and memorial arrangements can be made.
4866
4867If, on the other hand, the doctor suspects that the death is not natural (eg. if the death is possibly a suicide or if the cause of death is unclear) the doctor can certify death, but will not sign a death certificate. In this case, the doctor will likely call the coroner’s office and the police will be involved. This is no cause for alarm and will not necessarily delay a funeral or disposal of the body.
4868
4869If there is a well-written suicide note, it is unlikely the police will do more than question anyone present about their relationship with the deceased. Questions will be asked in order to confirm that those present played no role in the person’s death. Here, a suicide note will help make a death less suspicious.
4870
4871If the deceased was known to be seriously ill and if that person has made an effort to choose a method that leaves no obvious physical signs, or if the person and/or friends and family have removed any evidence of suicide, the doctor will certify death and sign the death certificate.
4872
4873When attending a death, police are usually sensitive and respectful. However, they are there to do a job and this may involve the questioning of those who were in the house at the time. The police may also ask questions of the nature of illness of the person who has just died. If the suicide is obvious they will note the method used (if apparent). Details will then be forwarded to the Coroner’s office. That said, if there is any suspicion in the minds of the police that the person was assisted in their death, the questioning of those present may intensify. Be warned and be careful. The police are not your friend, no matter how friendly they may be to you.
4874
4875Should I say I was present when She Died?
4876
4877Exit is often asked if it is lawful for a loved one to sit with a person when they take their life (ie. drink their Nembutal). In reply we say there is ‘no clear legal answer.’ Clearly, it can be the right thing to be present with the person you love. No one should be forced to die alone unless that is their wish. However, the right thing is not always the legal thing to do.
4878
4879In countries such as the US, Australia, Canada, the UK and New Zealand there is very little case law which exists to help clarify whether being present when a person dies a) amounts to encouragement to suicide - ‘assisting a suicide’ under criminal law or b) reflects a breach of a duty of care - under civil law.
4880
4881Generally speaking a duty of care does not kick in unless the person who is about to die is known to you or is obviously mentally ill (ie. psychotic and therefore lacking in capacity).
4882
4883Generally speaking, there is little need to worry about whether you have a duty of care to stop a person suiciding. In the western, adversarial legal system, personal liberty is highly prized and is subject to strong legal safeguards.
4884
4885‘Restrictions on liberty and interference with rights, privacy, dignity and self-respect ... [should be] kept to the minimum necessary in the circumstance’ (Jervis on The Offıce and Duties of Coroners, 1957).
4886
4887Note: In most countries, the police rarely attend all deaths. They will only attend deaths that are suspicious. On a handful of occasions, police have considered a death suspicious on the grounds that the person was either a member of Exit or because they left the Peaceful Pill Handbook lying close by.
4888
4889Police discretion will always be just that. Police who operate in politically conservative areas or who are religious and for whom the idea of rational suicide is unheard of or unethical, may act
4890
4891Fig 22.2: An attractive coroner’s court entrance
4892
4893differently from those of alternate mindsets. The one take-home message is that if police do question you in a way that is clearly officious it is best to say nothing on or off the record.
4894
4895In most jurisdictions, laws require you to tell the police your name and address. But that is it. And never submit to a recorded police interview unless you have an lawyer present. Seek legal advice immediately.
4896
4897Cleaning Away and the Law
4898
4899Given that the deaths that we are talking about in The Peaceful Pill eHandbook are peaceful and dignified, any cleaning up means the removal of equipment such as an Exit Bag or empty drug packets from the death scene. In some situations, this can be done well ahead of time. Many people who suicide by drinking Nembutal will clean things away themselves. They will remove the bottle. They may even have time to rinse their glass before they nod off to sleep. If this is done, the cause of death will clearly look natural (even if it is suicide).
4900
4901In most countries, it is an offence to interfere with the ‘circumstances of a death’/ ‘interfere with a corpse’ etc. In the scheme of things, however, this is not a particularly serious crime. For example, removing an Exit bag from a loved one’s head, after they have died, is a very different matter to helping the same person put the bag on their head in the first place. It is clearly assisting a suicide to help a person position a bag on their head.
4902
4903If, by chance, the authorities do become aware that some ‘cleaning-up’ has taken place, family and friends have explained their actions by saying that they were ‘protecting their family’s reputation’. They say it would be a ‘blemish on the person’s good name’ if their suicide were ever to be made public.
4904
4905Of course, whether you fess up to this at the scene of the death or get all officious and insist on not saying anything unless you are to be charged, is always a line call. Only those present will be able to judge how to handle the situation. Generally speaking, however, the act of ‘cleaning away’ is unlikely to attract anything more than a legal slap on the wrist.
4906
4907Death Certificates
4908
4909Upon arriving at the home of the person who is now deceased, the attending physician will perform two tasks. Firstly, they will confirm death. They will do this by carrying out a number of simple tests to establish that the person is indeed dead, not simply in a catatonic or comatose state.
4910
4911Having confirmed death, the next issue is the signing of the death certificate. There is a number of requirements that must be satisfied before this can be done. Two are of particular interest.
4912
49131. The doctor must know the patient. Usually there is the requirement that the doctor has seen the patient in a professional capacity - not just to say hello at the golf club - in the past two months (the time period varies depending on the jurisdiction).
4914
49152. The doctor must be satisfied that the death is natural.
4916
4917The requirement that the patient be known to the doctor can sometimes cause difficulty. Often, very sick people have little contact with the medical profession. This means that finding a doctor who could even sign the certificate can be a problem. It may therefore be wise to visit your doctor in the days or weeks prior to your suicide; any number of reasons such as a developing fever or breathlessness would suffice.
4918
4919Then, some days or weeks later, when you die, the doctor is called it would reasonable for them to assume that you died a natural death. They don’t call pneumonia the old person’s friend for nothing.
4920
4921At an Exit workshop, the room can generally be evenly divided into those who worry about what will be recorded on their death certificate and those who do not. Some people, understandably, fear being known as old Aunt Josie who ‘committed suicide.’ Others will have no preference, saying ‘who cares what they write, I’ll be dead anyway?’
4922
4923If a person who is about to die from a serious disease suicides, the death will be recorded as ‘suicide.’ If you do not want ‘suicide’ recorded on your death certificate, you will need to take steps to disguise the truth. A method of death that leaves no obvious signs is of course the only logical course (eg. Nitrogen). But there are some minor legal issues involved here, so beware.
4924
4925Dying without Trace
4926
4927Most drugs used to end life leave no obvious identifying signs. Death from either liquid or powder Nembutal is one example. The person will appear to have succumbed to their cancer or heart disease. However, if Lethobarb - the dyed form of the drug is used - the person’s lips will be stained green; hence the name the ‘green dream’. Green lips are a dead giveaway (pardon the pun) to a death that is not natural.
4928
4929And, remember, if an autopsy is performed, the pentobarbital will be discovered. Questions about its source could be asked. A suicide note that explains the source of the drug could be very helpful in this situation.
4930
4931The only method that leaves no trace, even at autopsy, is the Exit Bag with nitrogen (a hypoxic death with helium will be detectable at autopsy). For the death to be recorded as natural, however, the bag, tubing and the cylinder would need to be removed. This is where a possible breach of the law comes in.
4932
4933Regardless of the method, it is generally advisable that the suicide takes place in the evening. This allows family members or friends to ‘discover’ the body in the morning. The doctor can then be telephoned. Overnight the person has had the full time to complete the dying process. And it will be possible for everyone in the house to be asleep (or not) when the death took place.
4934
4935Autopsies
4936
4937If there is any doubt about the cause of death, the doctor will contact the coroner and an autopsy may be arranged. An autopsy involves the dissection of the body by a pathologist, the visual and microscopic inspection of organs, along with the biochemical testing of body fluids, stomach contents etc.
4938
4939At autopsy, the existence of any drugs (and alcohol) in the body will be discovered. If the drug is uncommon or difficult to obtain, questions will be asked about whether or not assistance was provided in obtaining, preparing or administering the substance.
4940
4941Although permission for an autopsy will be sought, and next of kin may have the right to refuse, it is as well to remember that refusal can generally be overridden (depending upon the jurisdiction). Autopsies are generally only sought if there is a legal or medical mystery associated with the death; that is, if there is uncertainty about how or why the person died. In these situations, especially if there is the possibility that the suicide was assisted in any way, the decision will be made irrespective of family wishes.
4942
4943Fig 22.3:A typical tagged body at autopsy
4944
4945In cases where the death is clearly a suicide, an autopsy is generally unlikely to be performed. Autopsies are expensive and will only be undertaken if a benefit can be established. However, they can also be undertaken for political reasons, although this is quite rare.
4946
4947Even though autopsies are becoming less frequent, they can never be totally ruled out (O’Connor, 2004). In the case of a seriously ill person who takes an overdose of prescription propoxyphene they have been prescribed, and leaves the empty packets by the bed, and a suicide note, there is little likelihood of an autopsy being performed. If an undetectable death is important to you and your family is prepared to stretch the law for you, Nitrogen is your only option.
4948
4949Safeguarding Your Will
4950
4951As discussed earlier, the medical profession has long argued that suicide is usually the outcome of a psychiatric illness. This makes rational suicide a contradiction in terms. If a person wants to die - regardless of the context - then QED they were not thinking rationally.
4952
4953Luckily, the law has never gone down the path of equating suicide with mental illness. Rather, the courts have found in a wide rang of cases where suicide is no indication of mental illness. To this end, the law refuses to see suicide as the outcome of mental illness. Indeed, some suicide notes have even been upheld as wills. Two birds with one stone as they say.
4954
4955Where the making of a will is concerned, the law will be relatively unconcerned if your death was a suicide or not. What counts in terms of making a will is that you were of ‘sound mind, memory and understanding’ at the time that you made it.
4956
4957This means that you must understand what you are doing in making you will, you must have a general overview of your assets that you intend to give away, you must be mindful to those who may have a ‘moral claim’ to your assets (eg. your blood relations) and, finally, you must be aware of the ramifications of dividing your assets in the way you have done.
4958
4959If you fulfill these legal requirements, you will be said to have ‘testamentary capacity’. So even if you then go on to suicide, your will will be relatively safe from contest on the grounds of incapacity. If safeguarding your will is important to you there are several further steps that can be taken as extra precautions. These may be particularly important if your will is contested in court and if the ‘other side’ calls hostile psychiatrists as expert witnesses.
4960
4961Fig 22.4: It is your last will after all
4962
4963As professionals trained in the pointy end of bio-medicine, it is psychiatrists who are most likely to reject the premise that your decision to end your life was a rational one. Indeed, most psychiatrists object to the concept of rational suicide. As expert witnesses - even if they have never met you - psychiatrists have the power to make your suicide seem the action of a mentally ill person. Planning head by undertaking a few simple steps can minimise the chance of this occurring in court.
4964
4965• Ask your Doctor to go witness for your will. In addition, ask them to document in their medical notes your state of health and state of mind at the time you make your will.
4966
4967• Ask your family members to write a brief statement of your mental wellness at the time you suicided. Courts will generally prefer evidence from those who knew you rather than consulting psychiatrists who never met you.
4968
4969• Give your lawyer a one-page explanation of why you are dividing your assets up in this way - thereby providing extra evidence that you knew exactly what you are doing.
4970
4971•
4972
4973If you are making a will that is substantially different from a previous version, write an explanation of why have changed your mind and give this to your lawyer.
4974
4975If you have had a diagnosis of early Alzheimer’s Disease - there will be no right or wrong answer.
4976
4977On the one hand, you could submit to an examination for the express purpose of pinpointing the degree to which you are affected, and hope that your testamentary capacity is confirmed.
4978
4979On the downside of course is that a) you may not wish to know and b) the results may be worse than you thought. There is no clear guideline for a diagnosis as devastating as Alzheimer’s Disease and Dementia.
4980
4981The above discussion is intended to provide a useful check- list for safeguarding what happens to your property after you are gone. And, more importantly, to ensue that just because you suicide, your intentions should not be compromised or overlooked. For legal advice on all aspects please consult a solicitor or attorney in your local area.
4982
4983Preserving Your Privacy with a Mail Forwarding Service
4984
4985In this era of identity theft, an increasing number of people are turning to offshore mail forwarding services in order to receive their mail in their home country. These services have sprung up partly because of the boon in online shopping but also because people are increasingly wary about revealing their true mail and street address when purchasing online.
4986
4987Fig 22.5: How mail forwarding services work
4988
4989Regardless of where you live ,there will be a mail forward service for your area. Some services only forward letters. Others take all your mail, re-parcel it into plain wrapping and send it on by either regular mail or by Fed X courier etc.
4990
4991Once you decide to go with one of these services, you will need to shop around to find the one that offers the right service for your particular needs.
4992
4993Examples of these virtual mail forward services include (in no particular order):
4994
4995http://www.mailnetwork.com/ http://www.myus.com/ http://www.my-mail-service.com http://www.manchestermailingaddress.co.uk/ http://www.my-uk-mail.co.uk
4996
4997As one website says: ‘You can use this address to give others the impression that you or your business are located in Vancouver as opposed to the city, province, state, country or continent in which you currently reside.’ They then add: ‘We can even repackage your mail for added discreetness.’
4998
4999Grief Counselling
5000
5001The rational suicide of a loved one will evoke mixed reactions in those close to that person. The broader community’s reaction may also be mixed. While most people support the concept of rational suicide there is still a significant minority who do not. It cannot be assumed that there will always be sympathy for those left behind so be careful.
5002
5003In many circumstances where a person has died of their own hand, counselling may be of assistance for those left behind. The ability to talk things through can be therapeutic and can go a long way towards easing the inevitable grief and despair.
5004
5005Private counsellors list their services in most countries’ telephone directories and of course online. Community health centres also commonly offer counselling as part of their range of health services. There are also often community telephone help lines.
5006
5007Fig 22.6: Angelika Elliott with her husband John on the morning of his assisted suicide in Zurich in 2007
5008
5009Telling Your Story Publicly
5010
5011Some people who choose rational suicide resent the fact that they are made to act like criminals in order to die with dignity. While some travel overseas to acquire prohibited drugs, others lie to their doctors and deceive those they love. Most of us are acutely aware that this cloak of darkness has to change.
5012
5013This is why some people want their deaths to mean something publicly. Telling your story in the media is one way to push the debate forward. If you think you would like to contribute to public debate and encourage legislators to act, there are several options available. As trite as it might sound, as a rule of thumb, most media are keen on personal stories that involve suffering and heroism.
5014
5015Take the story of Australian grandmother, Nancy Crick, as an example. Nancy went public with her plans to invite 21 end of life choices campaigners to be with her on the night she took her Nembutal. In telling her story Nancy wanted to force the authorities to clarify whether it was a breach of the law to be with someone when they die. Nancy died peacefully, sipping on Baileys and smoking her last cigarette. The Australian Police never did decide to charge those present. This grey area of the law prevails to this day.
5016
5017Over the years, Exit has found that an alternative approach is for the person to film their story, or provide an interview, on the condition that it be published only after their death. This was the case with 31-year-old Angelique Flowers. Angelique’s Internet plea to the Australian Prime Minister was front page news in The Sydney Morning Herald.
5018
5019See: http://bit.ly/1JzVOQB
5020
5021Her YouTube plea is still publicly available at: http://www.youtube.com/watch?v=jdxd_EFDd4s
5022
5023A documentary about her death titled ‘35 Letters’ won the 2014 Sydney Film Festival.
5024
5025The trailer can be viewed at: http://www.youtube.com/watch?v=5DqXGLwmJsc
5026
5027One possible downside of ‘going public’, however, is that the tapes and records can be used as evidence in a court room. If you do want to prepare a farewell message, be sure to be careful what you say about the involvement of loved ones. After all, it was the airing on 60 Minutes of a video tape of Dr Kevorkian assisting his patient, Thomas Youk, that saw Kevorkian spend his next decade in prison.
5028
5029A third possible way to tell your story publicly is for your family and those closest to you to speak for you after you have gone. This is a very safe option. However, without the imagery and direct quotes from you, there will be much less media interest
5030
5031Fig 22.7: Angelique Flowers’ Youtube video
5032
5033and likely less impact. That said, getting people’s stories out to the broader public domain is an essential part of initiating political change.
5034
5035Concluding Comments
5036
5037The Peaceful Pill eHandbook was first published in 2008. Since this time the book has been regularly updated to include new and changed information. This is essential to keep up with the debate about end of life choices.
5038
5039The online format of the eHandbook has allowed updating when and as it is required. At the current time, the eHandbook is updated around six times each year. The online eHandbook contains over 50 pieces of video, providing hands-on instruction and critical detail on a diverse range of issues. And it can now be accessed on laptops, PCs, Androids and iPads and iPhones.
5040
5041The Peaceful Pill eHandbook is made available in the philosophical belief that knowledge equals empowerment. An an end-of-life plan makes for longer and happier life in one’s later years. Far from pushing people towards suicide, establishing one’s options helps people to stop worrying, and get on with living better.
5042
5043For those with terminal illness, being back in control can be pretty satisfying given the adversity which surrounds.
5044
5045Freedom shouldn’t take this much effort.
5046
5047But for the time being it does.
5048
5049Exit appreciates reader feedback on the facts and the feelings that come with reading our books. Thank you.
5050
5051About Philip Nitschke
5052
5053Dr Philip Nitschke PhD, MBBS, BSc (Hons) is the Founder and Direc- tor of Exit International. As the first doctor in the world to administer a legal, lethal, voluntary injection under Australia’s short-lived Rights of the Terminally Ill Act, Philip is a pioneer of the modern right to die movement globally.
5054
5055Philip was awarded his doctorate in applied physics. He later became a graduate of Sydney Medical School.
5056
5057With Fiona Stewart, Philip is author of Killing Me Softly: Voluntary Euthanasia and the Road to the Peaceful Pill (Penguin 2005, now republished). His autobiography, Damned If I Do (with Peter Corris) was published by Melbourne University Press in 2013.
5058
5059Philip is the recipient of many rewards and honours including nine- time nominee for Australian of the Year. He lives in the Netherlands.
5060
5061About Fiona Stewart
5062
5063Dr Fiona Stewart PhD, MPolLaw, LLB, BA is a public health sociolo- gist and lawyer. Fiona has worked in a variety of fields including over a decade in academia. Fiona has also been a consultant to World Health Organization, a journalist, newspaper columnist, dot-com founder and media strategist. Fiona lives in the Netherlands.
5064
5065Fiona Stewart & Philip Nitschke
5066
5067The Peaceful Pill eHandbook References
5068
5069Australian Bureau of Statistics (2000) Suicide Trends, Aus- tralia, 1921-1998. Cat. No. 3309.0, Canberra, ABS.
5070
5071Australian Veterinary Association (2006) ‘AVA rejects Nitschke advice as unethical’ Media Release 24 July, 2006.
5072
5073Batlle, J. C. (2003) ‘Legal status of physician-assisted sui- cide’, JAMA, Vol. 289, No. 17, p. 2279-81.
5074
5075Commonwealth of Australia (2005) Criminal Code Amend- ment (Suicide Related Material Offences) Act 2005 NO. 92 at: http://www.austlii.edu.au/au/legis/cth/num_act/ccar- moa2005n922005479/
5076
5077Drug Misuse and Trafficking Act 1985 (NSW) at: http:// www.austlii.edu.au/au/legis/nsw/consol_act/dmata1985256/ index.html
5078
5079Furniss, B., Hannaford, A. Smith, P. W. G. & A. Tatchell (1989) Vogels’s Textbook of Practical Organic Chemistry, Harlow, Prentice Hall.
5080
5081Hancock, D. (2005) ‘Deaths Cocktail’, The Bulletin, 8 Nov at: http://www.exitinternational.net/documents/exit45.pdf
5082
5083Humphry, D. (1996) Final Exit. New York, Dell, p. 30.
5084
5085Liebermann, L. (2003) Leaving You – The Cultural Meaning of Suicide. Chicago, Ivan R. Dee.
5086
5087Mendelson, W. B. (1980) The Use and Misuse of Sleeping Pills - a Clinical Guide, New York, Plenum Medical Book Company.
5088
5089References
5090
5091National Prescribing Centre (2006) ‘The withdrawal of co- proxamol: alternative analgesics for mild to moderate pain’ MeReC Bulletin, Vol. 16, No. 4.
5092
5093Nitschke, P. & Stewart, F. (2005) Killing Me Softly: VE and the Road to the Peaceful Pill. Melbourne, Penguin.
5094
5095O’Connor, A. (2004) ‘Deaths go unexamined and the living pay the price’, New York Times, 2 March.
5096
5097Public Citizen (2006) ‘Petition to the FDA to ban all pro- poxyphene (Darvon) products at: http://www.citizen.org/ publications/release.cfm?ID=7420
5098
5099Routley, V. & Ozanne-Smith, J. (1998) ‘The impact of catalytic converters on motor vehicle exhaust gas suicides’, Medical Journal of Australia. Vol. 168, p. 65-67.
5100
5101Ryan, C. J. (1996) ‘Depression, decisions and the desire to die’, Medical Journal of Australia, Vol. 165, p. 411.
5102
5103Shanahan, D. (2001) ‘Mail order suicide kit’, The Austral- ian. 20 August.
5104
5105Solomons, T. W. B. & Fryhle, C. B. (2004) Organic Chemis- try (8th ed.), New Jersey, John Wiley & Sons.
5106
5107Stone, G. (2001) Suicide and Attempted Suicide: Methods and Consequences, New York, Carroll and Graf.
5108
5109Veterinary Surgeons Board of the ACT (2003) Newsletter June 2003
5110
5111Join Exit International Membership of Exit International provides:
5112
5113• Exit meetings, workshops, Viva seminars (free for members) • Exit R&D results • Local Chapters (inc local coffee & chat) • Peaceful Pill Online Forums (free & exclusive for members on approval) • Exit Newsletter Deliverance • Exit Supporter lapel badge & card
5114
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5118
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5120
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5126
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5128
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