Euthanasia,What is the euthanasia referendum and what are you voting for? The End of Life Choice Act explained.nembutal
The discussion about assisted dying often centres around people who are suffering being given the choice to die when they want, on their terms – but what do those final moments actually entail?
On September 19, New Zealanders will get to vote on a piece of legislation which would allow eligible terminally ill adults the option to request medication that would end their life, through assisted dying.
This September, New Zealanders can vote on whether they support the End of Life Choice Act coming into force.
Here we analyse the medical ins and outs of assisted dying: what drugs are given, whether anyone can overrule it and if a person can still become an organ donor afterwards.
READ MORE:* Euthanasia referendum: What is assisted dying? The End of Life vote explained* Euthanasia referendum: The arguments for and against legalising assisted dying* Euthanasia referendum: How assisted dying laws work around the world* Euthanasia referendum: Will you support the End of Life Choice Act?
WHAT IS BEING PROPOSED IN NEW ZEALAND’S EUTHANASIA REFERENDUM?
Assisted dying is defined in the End of Life Choice Act as a doctor or nurse practitioner giving a person medication to relieve their suffering by bringing on death, or, the taking of medication by a person to relieve their suffering by bringing on death.
In the Act, “medication” means a lethal dose of the drugs used for assisted dying.
To be eligible, an adult must be suffering from a terminal illness likely to end their life within six months. They must have significant and ongoing decline in physical capability, and experience unbearable suffering that cannot be eased “in a manner he or she considers tolerable”.
A person would not be eligible if the only reason they give is that they are suffering from a mental disorder or mental illness; have a disability of any kind; or because of their advanced age.
WHAT HAPPENS DURING THE PROCESS?
If the End of Life Choice Act came into law following the referendum, it would allow eligible people to choose a method, date and time for taking the lethal dose of medication.
At the time the person has chosen, the doctor or nurse practitioner must ask the person if they still choose to take the medication before it is given. The doctor or nurse practitioner must remain with them until they die.
Should they change their mind – which they can at any stage – the medication is taken away.
There are four methods in which the lethal medication can be administered under the Act: ingestion, trigged by the person; intravenous delivery, triggered by the person; ingestion through a tube, triggered by the doctor or nurse practitioner; or injection, administered by the doctor or nurse practitioner.
A person would need to be suffering from a terminal illness that would end their life within six months to be eligible for assisted dying under the proposed Act.
Dr Cameron McLaren is an oncologist in the Australian state of Victoria.
Since Victoria’s assisted dying law came into force on June 19, 2019, McLaren has assisted more than 80 patients in their applications to access assisted dying, and has been present at least 20 deaths.
In these deaths, patients take a lethal dose of medication which suppresses the central nervous system – the brain and spinal cord, controlling most functions of the body and mind – to essentially cause brain death, McLaren says.
They are profoundly unconscious when this happens, and their heart and lungs shut down some time afterwards, he says.
WHAT DRUGS ARE GIVEN AND HOW DO THEY WORK?
Stuff asked the Ministry of Health what specific medications would be used in New Zealand if the law was to pass, but it stated it was “not engaging on discussion around the referendums”.
The End of Life Choice Act also does not refer to any specific medications. This is, in essence, because the law cannot be too precise in mentioning medicines by name in case these change over time.
However, the group of drugs most commonly used to end life are called barbiturates – which act as nervous system depressants.
A large dose will effectively make the brain slow down to a point where it stops telling the body to keep the respiratory system working, and breathing ceases.
Dr Cameron McLaren, an oncologist in Victoria, has been present at the assisted deaths of more than 20 people. He says the common word used to sum up the experience is ‘beautiful’.
Pentobarbital (usually known by its brand name, Nembutal) is the drug most commonly used in voluntary assisted dying in many other jurisdictions which allow it.
In Australia, most people will ingest the lethal dose of pentobarbital as a drink – a white powder mixed with about 30 millilitres of a liquid suspension.
The drink is bitter, so McLaren recommends patients have their favourite drink on hand – whisky, red wine, cordial and Coke have been popular choices – to wash their mouth out afterwards.
However, in cases where the person is too ill to ingest the medication themselves, a doctor or nurse practitioner could administer the dose, under the proposed Act.
In Victoria, this involves a series of injections, similar to putting someone off to sleep for surgery.
This starts with midazolam – a benzodiazepine often used for anaesthesia, sedation and anxiety. Patients are then given lignocaine (lidocaine) as a local anaesthetic, as some injections can be painful to the vein, McLaren says.
Patients are then administered a “really large dose” of propofol, used to induce and maintain general anaesthesia in surgery to render a patient unconscious.
Pentobarbital is the most commonly used drug in the assisted dying process in Victoria, and other jurisdictions with similar laws overseas.
This large quantity of propofol ensures the person is in a “very deep medical coma”, before an injection of the paralytic drug rocuronium is given, which stops the person’s breathing, McLaren says.
HOW LONG DOES IT TAKE?
In McLaren’s experience, people fall asleep within between three and seven minutes after drinking the liquid.
Twenty to 30 minutes after falling asleep, the person stops breathing and their pulse (heartbeat) stops.
The vast majority of patients will die within an hour, and almost everyone within two hours.
In essence, from the time they fall asleep, the person goes into a “profoundly deeper and deeper state of medically-induced coma” until they die.
McLaren says he always reassures patients that it is a “definitive dose… no-one has ever woken up from that dose of that medication”.
“It’s an odd sort of reassurance, but [the medication] works.”
IS IT PAINFUL?
“Absolutely not,” McLaren says.
There is no chemical reason why a person taking these medications would feel any pain, as they are simply sedatives, he says.
When a person is put into that level of medically-induced coma, there is no reason to have pain.
Even if there was pain, the body would be unlikely to register it because of the profound nature of the coma, he says.
McLaren says of all the deaths he has been present at, the word which keeps coming up is ‘beautiful’.
WHO CARRIES OUT THE PROCESS?
Under the proposed End of Life Choice Act, a medical practitioner or nurse practitioner can be involved in administering a lethal dose of medication to an eligible patient in New Zealand.
To qualify, a health practitioner – or doctor – must be registered with the Medical Council of New Zealand, and must hold a current practising certificate.
Dr McLaren says the process is painless and similar in essence to putting a person to sleep for surgery.
Nurse practitioners are also permitted to carry out the process under the Act.
A nurse practitioner has a slightly different role than a registered nurse: they are able to diagnose you, prescribe you medication and order and interpret test results – which a registered nurse cannot.
This is because they have completed additional training over and above that of a registered nurse.
Under the Act, nurse practitioners must be registered with the Nursing Council of New Zealand and hold a current practising certificate.
There are currently about 370 nurse practitioners registered in New Zealand.
CAN ANYONE OVERRULE IT?
If a person has been deemed eligible and has chosen to take the medication, they cannot be forced to stop by any external parties.
They are able to change their mind at any time. No particular statement is needed to be written or said by the person to show they have changed their mind, and the person can use gestures to communicate if needed.
Under the Act, a person who chooses to receive assisted dying does not have to discuss that wish with anyone if they don’t want to.
However, their doctor must encourage the person to have this discussion with their family, friends and counsellors, and must ensure the person has the opportunity to do so.
The decision to access assisted dying is entirely up to the individual. A doctor cannot suggest it, and family cannot overrule it.
A welfare guardian – a person appointed by the Court to make decisions about the care and welfare of a person unable to do that for themselves – does not have the power to make any decision, or take any action, about assisted dying for the protected person.
Similarly, advance directives – a statement signed by a person setting out ahead of time that a treatment is wanted, or not wanted, in the future – are not permitted under the Act.
WILL IT IMPACT A PERSON’S LIFE INSURANCE?
A person who dies as a result of assisted dying is taken to have died from the terminal illness from which they suffered, as if assisted dying had not been provided.
CAN YOU STILL BECOME AN ORGAN DONOR?
This depends on individual circumstances, but is possible and is happening overseas in countries where similar laws have been passed, such as Belgium and the Netherlands.
Organ Donation New Zealand was unable to comment on what this could look like in New Zealand.
However, in the Netherlands, for example, assisted dying followed by organ donation is legal and endorsed by Eurotransplant, the non-profit responsible for allocating donor organs.
Assisted dying is typically done at home, but organ donation needs to be facilitated in a hospital because of the limited time permitted after circulatory arrest and when organs are harvested.
In some cases this has meant the person has not gone ahead with organ donation as it has meant having to die in hospital, research about the Netherlands’ MAID (medical assistance in dying) process published in the Canadian Medication Association Journal found.
A procedure was developed in the Netherlands which would allow people who access assisted dying the ability to donate their organs with “minimal disruption to the dignity of dying in their own home”.
This involves using an ‘anaesthesia bridge’ to separate the experiencing of dying at home with subsequent biological death and organ donation in hospital.nembutal
Once a patient is given the anaesthetic and is unresponsive, and the family has said their final farewells, they are taken to hospital by ambulance. The drugs for the assisted dying procedure are given in hospital, and, after death, regular organ removal procedures are followed, the journal article states.
Another study, published in JAMA (the Journal of the American Medical Association) found an estimated 10 per cent of all patients undergoing euthanasia in Belgium could potentially donate at least one organ.nembutal
In New Zealand, very few medical conditions prevent people from being organ or tissue donors, according to Organ Donation New Zealand.
Some organs may not be suitable if a person has cancer, for example, but some tissues may be.nembutal
For more Stuff coverage on the euthanasia referendum