Contents Preface Chapter 1 - Introduction

Chapter 2 - Suicide & the Law Chapter 3 - The Peaceful Pill

18 34 42

Chapter 4 - The Exit ‘Reliability-Peacefulness’ Test 50 Chapter 5 - Hypoxic Death & the Exit Bag Chapter 6 - Carbon Monoxide Chapter 7 - Cyanide

58 Chapter 8 - Detergent Death

Chapter 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

Chapter 15 - Drug Options - Chloral Hydrate Chapter 16 - Drug Options - Nembutal Chapter 17A - Availability of Nembutal Chapter 17B - Nembutal Scams

Chapter 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

About the Authors References

Support Exit International

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About The Peaceful Pill Handbook Series

The 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.

The 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.

The 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.

For more information about The Peaceful Pill Handbook series, please visit:

http://www.peacefulpill.com

or email: [email protected] Phone:

+31 (0)6 30 966 992 (NL) +1 360 961 1333 (USA) +61 (0)407 189 339 (Australia)

Media inquiries: +31 (0) 630 966 992

Content Revised: 20 October 2016

For Derek Humphry for his courage and compassion in showing the way

‘Freedom takes a lot of effort’ Anna Stepanovna Politkovskaya

The

Peaceful Pill eHandbook

Dr Philip Nitschke &

Dr Fiona Stewart EXIT INTERNATIONAL

Published by Exit International USA Postbus 283 2000 AG Haarlem NL

[email protected] (+1) 360 961 1333 (USA) +31 (0)6 30 966 992 (NL)

THE PEACEFUL PILL EHANDBOOK, 2016 Copyright © Dr Philip Nitschke and Dr Fiona Stewart 2016

The moral right of the authors has been asserted.

All 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.

First published by Exit International USA, 2006 Cover design by Branden Barber, Twin Lizards

The Peaceful Pill eHandbook

First published by Exit International US Ltd, 2008 Technology supplied by www.Yudu.com

Nitschke, Philip Haig Stewart, Fiona Joy

The peaceful pill handbook.

ISBN 978-0-9788788-4-9 www.peacefulpill.com

Disclaimer

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

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Video: The Peaceful Pill eHandbook

Preface

The 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.

In 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.

I 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.

On each separate occasion, the computer presented a short series of questions:

1. 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?

2. Are you certain you understand that if you proceed and press the ‘yes’ button on the next screen you will die?

3. In 15 seconds you will be given a lethal injection … press ‘yes’ to proceed.

Preface

The Deliverance Machine is now display at the British Science Museum

The Peaceful Pill eHandbook

After 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.

My 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.

In 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!

In 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.

The 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

Preface

where freedom of speech is enshrined in the United States Bill of Rights. Of course, the eHandbook covers some grey areas of the law.

Finally, 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.

Acknowledgements

The 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.

Secondly, our staff at Exit International we thank very sincerely for all they do day in, day out.

Outside 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.

Finally, we’d like to thank our publisher, Richard West, for his continued support and without whom none of this would have been possible.

Dr Philip Nitschke & Dr Fiona Stewart

It is the Constitutional protections offered by the Bill of Rights that allows these issues to be canvassed at all.

The Peaceful Pill eHandbook A Word of Caution

This 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.

The 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.

Rather, 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.

Preface

As 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.

It 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.

If you feel you need counselling, please contact the following organisations:

USA: UK

Australia

Suicide Prevention Hotline - 1 800 273 8255 The Samaritans on - 08457 90 90 90 Lifeline on - 13 11 14

New Zealand Lifeline on - 0508 828 865 Canada

The Life Line on - 1-800-668-6868

Other countries hotlines can be found at: http://www.suicide.org/international-suicide-hotlines.html

The Peaceful Pill eHandbook Tips for Use

Navigation 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.

Notepad 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.

Bookmarks A bookmark feature can also be found in the top menu bar. This allows pages to be marked for future reference.

Index

The 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.

Magnification

If 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.

Multimedia

Because this is an online eBook, by its nature users can enjoy a full multi-media experience via hyperlinks and videos.

Preface Access for all Devices

The 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.

Printing The eHandbook can be printed page by page or as groups of pages.

As they now say in the world of online books - READ IT, WATCH IT!

Cashback Offer

Purchasers 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.

Once 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.

1 Introduction Developing an End of Life Plan

People 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.’

The 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.

The 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.

Introduction The Wonders of Modern Medicine

In 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.

A 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.

Our Ageing Population

A 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.

The Peaceful Pill eHandbook

In 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.

This 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.

Just 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.

The Question of Suicide

Anyone 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.

Introduction

People 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.

A Brief History of Suicide

Over 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.

With 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’.

It 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.

The Peaceful Pill eHandbook

With 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).

At 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.

For 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.

In 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.

This is why some studies continue to find a sadness associated with a serious illness. You don’t need to be a psychiatrist

Introduction

to 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.

Suicide & Depression

The 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.

There 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.

This 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.

The Peaceful Pill eHandbook End of Life Decisions & the Role of Palliative Care

Critics 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.

Palliative 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.

To 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.

No 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.

As 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

Introduction

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

ovaries. 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.

As 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.

Angelique 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.

The Peaceful Pill eHandbook

Video: Angelique’s Letter to the Prime Minister

Video: Angelique’s Plea for Nembutal on YouTube

Introduction

This 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.

Shortly 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.

See: https://www.youtube.com/watch?v=5DqXGLwmJsc

At 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.

Some 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.

The Peaceful Pill eHandbook

One 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.

Palliative 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.

Rather, 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.

The Tired of Life Phenomenon

In 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.

Introduction

In 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.

The Crofts did not need to write this note yet they wanted us to understand. And in return they asked for our respect.

To Whom it May Concern Please don’t condemn us, or feel badly of us for what we have done.

We have thought clearly of this for a long time and it has taken a long time to get the drugs needed.

We 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?

In 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.

We have no children and no one to consider.

We have left instructions that we be cremated and that our ashes be mixed together. We feel that way, we will be together forever.

Please don’t feel sad, or grieve for us. But feel glad in your heart as we do.

Sidney and Marjorie Croft

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The 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.

Another 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.

Lisette 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.

In 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:

‘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.

Perhaps 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’.

Introduction

When 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.

At 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.

Mademoiselle Lisette Nigot Conclusion

If 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.

People 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.

The Peaceful Pill eHandbook Video: Introduction

Video: The role of providing information

Introduction Video: ‘Going Together’ The suicide note of Syd & Margorie Croft

Video: ‘Mademoiselle and the Doctor’ Film Trailer

2

Voluntary Euthanasia, Assisted Suicide, Suicide & the Law

In 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.

Think 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.

Legal Definitions & Penalties

Technically 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.

By 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.

Suicide and the Law The Law of Suicide & Assisted Suicide

The Anomaly of Suicide and Assisting

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Finally, the term Assisted Suicide describes the situation in Switzerland where the provision of lethal drugs to people who are suffering has long been decriminalized.

Generally 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.

In

The 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.

See:http://www.cps.gov.uk/news/press_releases/144_09/

In 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.

In 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.

The 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.

Suicide and the Law

Defining Assisted Suicide So what is assisted suicide?

At 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.

The 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?

When 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.

See: http://www.bbc.com/news/world-europe-32499331

And 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?

On 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.

The Peaceful Pill eHandbook Legislation: What Type of Law is Needed?

Over 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.

To 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.

Laws 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.

However, 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.

Besides, 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.

In Australia in 1996, a terminally ill person had to obtain two medical opinions, a palliative care review and a psychiatric

Suicide and the Law

consultation 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.

In 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.

Why 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.

While 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.

(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)

Now available at: http://bit.ly/1eVogzs

This 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.

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Laws Around the World

Suicide and the Law

Conclusion

There 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.

Rather, 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.

By 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.

This book is intended to restore

3 What is a Peaceful Pill? Introduction

The 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.

Dr Philip Nitschke

It 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.

Drion 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.

Fig 3.1: Professor Huib Drion

What is a ‘Peaceful Pill’?

Elderly 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)

Following 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.

Drion 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.

The History of the Suicide Pill

The 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.

In 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.

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In 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.

For 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.

Hermann 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.

The Best Peaceful Pill

Half 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.

In 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.

What is a ‘Peaceful Pill’?

Over 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.

Perceived Benefits of a Peaceful Pill

While there are any number of ways by which a seriously ill person can end their life, few of these methods meet our criteria of:

• reliable

• peaceful •

dignified.

In most western countries, hanging and gun shot remain the most common methods of suicide.

Yet 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.’

Fig 3.2: Survey of Exit Members Methods of Self Deliverance

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In 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.’

A ‘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.

The 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.

A 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.

In this way, the Peaceful Pill was seen as a method that was accessible and usable, even by the most frail.

What is a ‘Peaceful Pill’? Conclusion

Exit’s survey revealed a strong preference for a reliable and effective Peaceful Pill.

This was seen as the best means of providing the option of a peaceful death at the time of one’s choosing.

The remainder of this book focuses on the various forms a Peaceful Pill might take.

In providing this information we are following the agenda set by long-standing members of Exit International.

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The Single Shot Peaceful Pill Project: Background

What is a ‘Peaceful Pill’?

4 The Exit RP Test

Many 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’.

Primary Criteria

The ‘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.’

In 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.

The Exit RP Test

Video: The RP Test What it is and How does it Work?

Video: RP Test: Hanging

The Peaceful Pill eHandbook Reliability (R - 10)

Reliability 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.

Peacefulness (P - 10)

Peacefulness 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.

The most commonly expressed wish by seriously ill and elderly people is that they be able to die in their sleep.

Secondary Criteria

There are a number of lesser, but nevertheless highly-desired, characteristics for a method of dying. Six additional secondary factors are listed below:

Availability (A) Preparation and Administration (Pr) Undetectability (U) Speed of Effect (Sp) Safety to Others (Sa) Storage - Shelf Life (St)

In the RP test, a score of 1-5 is given for each of these secondary characteristics.

The Exit RP Test Availability (A - 5)

To 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)

Simplicity 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.

Undetectability (U - 5)

Methods 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.

In this situation, the question of suicide Speed of Effect (Sp - 5)

Speed of death is a further significant factor. Speed limits the likelihood of discovery and any possible interference (resuscitation).

Safety to Others (Sa - 5)

Most seriously ill people do not want to die alone. Methods that present a danger to others are unpopular for this reason.

Storage - Shelf life (St - 5)

There 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

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the 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.

Take the example of the Exit Bag when used in conjunction with Helium (see Chapter 5).

Test Factor Reliability:

This is good, but technique is important Peacefulness:

There is some short term awareness and alarm Availability:

Necessary items are readily available Preparation:

Items require assembly and coordination Undetectability:

If items removed, totally undetectable, even in the event of an autopsy

Speed:

Unconsciousness and death occur quickly Safety:

The 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

The Exit RP Test Storage: Equipment does not deteriorate and testing

readily available Total for Helium and an Exit Bag

St=5/5 is 41 (82%)

Now compare the RP Test result for the Exit Bag + Helium with the Use of Sodium Cyanide (see Chapter 7).

Test Factor Reliability: This is very high

Peacefulness: Patchy reports, hard to assess Availability: Difficult to obtain or manufacture Preparation: This is straightforward Undetectability: Some clinical changes

may be noted, certainly noted on autopsy Speed: Produces a rapid death

Safety: There may be some slight risk to

those present from possible HCN gas production Storage: Well packaged, shelf life indefinite

Total for Sodium Cyanide Score

R=10/10 P=5/10 A=2/5 Pr=5/5 U=3/5

Sp=5/5 Sa=3/5

St=5/5 38 (76%)

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A Note of Caution The RP Test score serves only as a guide.

Individual

circumstances 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.

This 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.

Similarly, the ‘availability’ of a particular method can differ from individual to individual. The comparison above suggests that helium would be preferred above cyanide.

However, 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.

See the Table towards the end of the eHandbook which provides the overall RP Test scores for the six approaches described in this book.

The Exit RP Test

Video: RP Test : Nembutal

5 Hypoxic Death & the Exit Bag

• 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

Introduction

The 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.

There 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.

Hypoxic Death & the Exit Bag

Suffocation 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.

When 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.

And 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.

The Hypoxic Death

Hypoxia 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

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used by those seeking a peaceful death is to suddenly immerse oneself in a non-oxygen environment.

The 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.

In 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.

This 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.

When 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.

It 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

Hypoxic Death & the Exit Bag Video: Introduction to the Exit Bag

Video: The Problem of Carbon Dioxide

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investigate) say that it often appears as though everyone on board has just gone to sleep.

Pneumonia 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.

The presence of an inert gas like Nitrogen or Helium in the Exit Bag will dramatically speed the hypoxic process. When

Fig 5.1: 380 litre ‘Max Dog’ Nitrogen cylinder

Hypoxic Death & the Exit Bag

a 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).

For 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.)

It 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).

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The Role of Carbon Dioxide (CO2

)

In 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.

When 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.

Hyperventilating to Minimise the Alarm Response

reduces any liklehood of an alarm response when the bag is pulled down.

To 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

level in the blood, and greatly

Hypoxic Death & the Exit Bag Video: Application of the Exit Bag (Helium)

Video: Suicide and the Death Certificate

The Peaceful Pill eHandbook Aesthetic and Other Concerns

The 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.

A Peaceful Death using Inert Gas

Whereas 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.

The 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.

Let 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

Hypoxic Death & the Exit Bag

be 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.

Note: 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.

Most 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.

An 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.

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Low 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).

The Optimal Gas Flow Rate

A 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.

Fig 5.2: Exit Bag CO2

& O2

concentration lvels for the first 5 minutes

Hypoxic Death & the Exit Bag

To 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.

The 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

For 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.

For 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).

For 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

Using the Exit flow control kit on a standard 420 litre helium cylinder gives a useful operating time of ~20 minutes.

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The Gas Source (Nitrogen or Helium) 1. Nitrogen & the Max Dog Brewing Delivery System

Nitrogen 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).

Since 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.

Regulating the Flow of Nitrogen

Max 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.

Fig 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)

Hypoxic Death & the Exit Bag The Max Dog Brewing Beer Nitrogen System

Max 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).

The 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

One 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.

Max Dog in the USA

In the US, MDB provides a unique American Kit consisting of an adjustable flow, soft-nose regulator, pressure gauge and connecting hose.

Full 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).

See: http://store.cyberweld.com/shielgascyl22.html

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Fig 5.4 (a) Australian 400 litre Max Dog Brewing cylinder

Fig 5.4 (b) American CyberWeld 20cu ft Nitrogen cylinder

Hypoxic Death & the Exit Bag 2. Helium

Balloon 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).

In Nth America, Balloon Time canisters have been available at websites such as Walmart and Amazon.

http://bit.ly/1EjGzTj http://amzn.to/1350XZi

In Australia and New Zealand, Balloon Time cylinders have been available at Spotlight stores.

In the UK, Balloon Time (and its equivalents) have been available on websites such as Party Delights, Argos and Tescos.

http://bit.ly/1dkq8B9 http://bit.ly/1FB9KZb http://bit.ly/1ElUdYx

As 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.

Note: 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.

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Fig 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)

Hypoxic Death & the Exit Bag

Fig 5.6: Top: Tesco - BOC Disposable Helium Cylinders (UK) Below: - Argos-branded Balloon Cylinder (UK)

The Peaceful Pill eHandbook Testing Gas Purity

For 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.

For 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.

In 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.

Fig 5.7: Testing for oxygen contamination in a Tescos/ BOC (UK) disposable helium cylinder

It 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-

Hypoxic Death & the Exit Bag

year old Wellington man, recom- mended mandatory oxygen con- tamination. Both men had died using Balloon Time helium.

In 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.

Fig 5.8: Meter used to detect oxygen contamination

Whether 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.

It is interesting to note that the British Tesco/ BOC equivalent of Balloon Time has not followed Worthington’s lead in oxy- gen contamination.

To 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.

The Peaceful Pill eHandbook Testing a Disposable Helium Cylinder

1. Obtain an accurate oxygen sensor eg the Detector CY-12C Oxygen Analyzer, cost ~US$100 - click HERE (see Fig 5.8)

2. 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).

4. Let the gas flow until a steady reading is obtained on the most sensitive gauge setting.

The reading should be < 2% (ie. <10% of the oxygen present in room air) if the gas is to be used.

At the end of the test, record the cylinder pressure to ensure that there is still an adequate supply left for a hypoxic death.

NOTE: The issue of oxygen contamination does not affect Max Dog Brewing Nitrogen cylinders because they contain 100% nitrogen.

Fig 5.9: Flow Rate, Pressure and Volume of Helium with Time for 420 & 250 litre Cylinders using the Exit Gas Control Jet Assembly

Hypoxic Death & the Exit Bag

If, 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.

The 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).

Gas Flow Control

No 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.

• 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.

• 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

The Peaceful Pill eHandbook Ensuring a Cylinder is Full

When 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.

If 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).

For 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).

Fig 5.10: The Exit Helium flow control fitting

Fig 5.11: Pressure

gauge used to check if gas cylinder is full

Hypoxic Death & the Exit Bag

Fig 5.12 Max Dog website www.maxdogbrewing.com

Fig 5.13 Helium flow fittings at the Exit Store

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Fig 5.14:

(a) Checking the pressure of a full max Dog nitrogen cylinder. Flow 0 l/min, Pres- sure 13MPa

(b) Helium cylinder with pressure gauge attached to flow control assembly. Full pressure 250psi or 1.7MPa

Hypoxic Death & the Exit Bag Video: Why the Exit Bag will not suit all People

Video: Do it Yourself with Betty

The Peaceful Pill eHandbook The Exit Bag

To download detailed instruc- tions on making your Exit Bag

Click HERE

The 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.

1. Making an Exit Bag

While different people make slightly different bags, the standard Exit Bag involves a plastic bag of:

• 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

The 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:

•

Plastic bag - PVC 35cm x 50cm x 50 micron PVC is a good size. Or a large polyester ‘oven bag’ see ‘A & B’

• 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

Fig 5.15 Items used to construct an Exit Bag

Hypoxic Death & the Exit Bag Construction (See Fig 5.16 & Do it with Betty video)

1. Lay the bag out on a flat surface and folded back ~ 25mm (1”) around the open end (A-B)

2. 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

4. Tape completely along the folded edge of the plastic with the sticky tape

5. Place a cut in a ~ 60mm piece of duct tape and fold this over the exiting elastic to strengthen this part of the bag

6. 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.

7. The toggle (D) (or other fastener) is then threaded onto the two ends of the elastic to complete the bag (Fig 5.15)

Connecting the Cylinder to the Exit Bag

To 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.

The Peaceful Pill eHandbook Fig 5.16: Exit Bag Manufacture

Fig 5.17: The completed Exit Bag

Fig 5.18: Positioning, inflating & Using the Exit Bag with Nitrogen

Hypoxic Death & the Exit Bag Video: Betty does Max Dog Nitrogen

Video: Betty & the Exit Bag

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The use of Lung Function Screening (Spirometry) for those with respiratory disease

For 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.

Lung 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.

For 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

Fig 5.19: Spirometry to assess lung function before using an Exit Bag

Hypoxic Death & the Exit Bag

nitrogen (ie not have significant restrictive disease). Spirometry offers a quick effective screening test to exclude significant lung pathology that may interfere with the method.

The 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.

Three 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%.

To 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

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reduce 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.

The 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.

To 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.

Note: 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.

Hypoxic Death & the Exit Bag After the Death - The Affect of Inert Gas on the Body

The 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.

In 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’.

If, 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.

The Peaceful Pill eHandbook Nitrogen Method Summary Supplement

Fig 5.17: MaxDog gas regulator (with plastic dust cap) Preparation of the Regulator and Tubing

Identify 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)

Fig 5.18: Connecting the hose

Take 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.

Hypoxic Death & the Exit Bag

Dip 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 )

Make 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.

Test 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.

An 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.

An 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).

Note – ensure that it is impossible to pull the hose off the barbed nip- ple on the regulator.

Fig 5.19: 6mm PVC tubing attached toMaxDog gas regulator

The Peaceful Pill eHandbook Connecting the Exit Bag to the Cylinder

There 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).

Insert 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.

Tape 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.

Fig 5.21:Taping gas hose to inside of Exit Bag

Fig 5.20: Adhesive tape to attach tube to Exit bag

Hypoxic Death & the Exit Bag Ensure the Cylinder is Vertical

It 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

Fig 5.22:Positionin the nitrogen cylinder

An 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.

Another 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.

Attaching the Regulator to the Gas Cylinder

In some countries the cylinder ships with a dust cap. Re- move the dust cap from the cylinder. (See fig 5.23, right)

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Now 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).

To 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.

To 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).

Hold 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.

Fig 5.24 Atatching the regulator to the cylinder:

If you cannot fasten the regula- tor tightly to the cylinder by hand, you can use a wrench but do not over-tighten.

The 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).

Hypoxic Death & the Exit Bag Turning on the Gas & Checking for Leaks

1. Set the flow control on the regulator to zero (fig 5.25a).

2. 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).

3. 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).

4. Listen for the sound of any gas leaking and watch the pres- sure gauge. If there is a leak, the pressure gauge will fall.

3 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.

Fig 5.25:Checking gas pressure

The Peaceful Pill eHandbook Checking Gas Cylinder Pressure

Max 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.

To 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).

If 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).

Preparing for a Peaceful, Hypoxic Death

There 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.

1. Make sure the gas cylinder is stable and ensure that it will not roll over.

2. Ensure the tube will not be dislodged if it is pulled after the person becomes unconscious.

3. 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.

Hypoxic Death & the Exit Bag Things to Remember

Remember, 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.

Fig 5.26:Gas flow @ 15l/min

1. 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.

2. The nitrogen displaces the oxygen in the Exit Bag. It is the low oxygen environment that causes death.

3. The Exit Bag should be filled with nitrogen before one exhales and pulls the bag down.

4. Once a deep breath is taken, loss of consciousness is almost immediate and death follows soon after.

5. 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.

7. The loose fit allows the Nitrogen to flow continuously from the Exit Bag taking any exhaled carbon dioxide with it.

The Peaceful Pill eHandbook The Process

1. Place the Exit Bag collar around the head, above the ears and scrumple up the bag so there is no air inside.

2. 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.

5. 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).

6. 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.

8. With the Bag fully over the head and take a deep breath (see fig 5.28).

Fig 5.27:Filling the Exit Bag

Fig 5.278The Exit Bag over the head

Hypoxic Death & the Exit Bag Changing Your Mind

Remember, 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:

1. 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.

4. Undo the brass hexagonal nut on the regulator and dis- connect from the cylinder.

5. Put the dust caps (if available) back on the regulator and cylinder.

6. 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.

Concluding Comments

The 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.

Nevertheless, 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.

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Is it necessary to have more than one cylinder to ensure sufficient gas is available?

No. 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.

Using 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.

Can a face-mask be used instead of the Exit Bag?

Common, 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.

The 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.

Hypoxic Death & the Exit Bag

THE RP TEST SCORE – Exit Bag + Inert gas Reliability Peacefulness

Considered “peaceful” partly because the loss of consciousness comes quickly. There is the sensation of “air hunger” and alarm

Availability

All components are readily available Preparation

(A = 5/5) (Pr = 1/5)

Considerable assembly and “setting up” of equipment Undetectability

Speed

Loss of consciousness comes quickly Safety

The method presents no danger to others Storage

Total RP Score (U = 5/5)

If all equipment is removed detection is rare. If Nitrogen is the gas used the method is totally undetectable.

(Sp = 5/5) (Sa = 5/5) (St = 5/5)

Components do not deteriorate with time. Pressure testing can readily establish that the cylinder is full

41/50 (82%) (R = 8/10)

The method is reliable but technique is important and a degree of coordination and dexterity is required

(P = 7/10)

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THE RP TEST SCORE – Exit Bag + Inert gas Criteria

Reliability

Peacefulness Availability Preparation

Undetectability Speed

Storage Total

Score 8/10 7/10 5/5 1/5 5/5 5/5 5/5

41 (82%)

Hypoxic Death & the Exit Bag

6 Carbon Monoxide (CO)

• 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

Introduction

Carbon 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.

Death 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.

Carbon Monoxide

PPM [CO]

35

200 400

800

1600 3200

6400 12,800 Time 8 hours

2-3 hours 1-2 hours

Symptoms

Maximum exposure allowed by OSHA in the workplace over an eight hour period.

Mild headache, fatigue, nausea and dizziness.

Serious headache-other symptoms intensify. Life threatening after 3 hours.

45 minutes Dizziness, nausea and convulsions. Unconscious within 2 hours. Death within 2-3 hours.

20 minutes 5-10

minutes 1-2

minutes 1-3

minutes Table 6.1 Effect of carbon monoxide exposure

It 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.

There 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.

Headache, dizziness and nausea. Death within 1 hour. Headache, dizziness and nausea. Death within 1 hour.

Headache, dizziness and nausea. Death within 25-30 minutes. Rapid Death

The Peaceful Pill eHandbook Testing the Concentration of Carbon Monoxide

To 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.

Exit 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.

Fig 6.2

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

Carbon Monoxide

Gauges 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.

Gauges 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.

Sources of Carbon Monoxide From Commercial Gas Suppliers:

Cylinders 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/

Cylinders 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

slab laser). See: http://www.praxair.com/gases/buy-carbon-monoxide-gas

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Table 6.3. Compressed CO cylinder sizes Vehicle Exhaust Gas

Carbon 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.

Formic Acid

Carbon Monoxide is produced by a chemical reaction that occurs when the formic acid (HCOOH) is broken down into water (H2

O) and carbon monoxide (CO). The catalyst for this

breakdown is concentrated sulphuric acid. The sulphuric acid remains chemically unchanged but is diluted by the water released.

Monoxide 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.

The chemical equation is: HCOOH a H2 O + CO

Carbon Monoxide Oxalic Acid

Concentrate 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.

The chemical equation is: HO2CCO2H aH2 Carbon (charcoal)

0 + CO2 + CO

The 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.

The chemical equation is: 2C + O2 a 2CO

Zinc 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).

The chemical equation is: Zn + CaCO3 → ZnO + CaO + CO Vehicle Exhaust Gas as a Source of Carbon Monoxide

Internal 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.

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Older 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.

Despite 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.

This 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.

Carbon Monoxide

Fig 6.4. The car as a carbon monoxide source

This 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.

In 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.

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Fig 6.5 The early CoGen

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

Carbon Monoxide

Video: The Exit COGen

The Peaceful Pill eHandbook Making Carbon Monoxide (the COGen)

For 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.

In 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.

Since 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.

How the COGen Works

The 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’.

150 ml of 85% formic acid is placed in chamber (‘A’) with the control-valve shut.

Carbon Monoxide

Fig 6.7 The COGen & acids

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250ml of concentrated sulphuric acid (98%) is placed in the outer chamber ‘D’ and the COGen assembled.

Opening 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’.

The 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.

Sourcing the Acids

Concentrated 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.

Formic 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.

Oxalic acid is used as rust and stain cleaner and can be purchased from hardware stores.

Carbon Monoxide Safety Note

Concentrated 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.

Generating Carbon Monoxide using a Charcoal Burner

This 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.

If 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.

Table 6.8 CO concentration with time using COGen in a vehicle

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In 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.

Other 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.

Fig 6.9 Test vehicle with BBQ charcoal burner

Carbon Monoxide

Fig 6.10. Charcoal burner.brazier and test shipping container

Table 6.11. CO concentration with time in test shipping container

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The Destiny Euthanasia Machine

In 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

Tony 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

Table 6.12. Destiny CO Machine

Carbon Monoxide

voice 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:

The 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

Design Considerations

Following 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.

The 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.

As 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.

The Peaceful Pill eHandbook Construction of Destiny

Construction 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.

• 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?

• Are you certain you understand that if you proceed and press the ‘yes’ button to go to the next screen that you will die?

• If you press this button in 15 seconds you will die

Table 6.13. Destiny screenshot

Carbon Monoxide

The 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.

Testing & Use of Destiny

At 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.

The 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.

Warning

It 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.

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Conclusion

Carbon 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.

Most 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).

Exit RP Test for Carbon Monoxide

The method loses points in the subcategories of Preparation, Undetectability and Safety.

Preparation 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.

Carbon Monoxide

This 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

RP test result 31 (62%), for Destiny RP is 35 (70%)

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 8/10 7/10 3/5 1/5 1/5 5/5 1/5 4/5

31 (62%)

7 Cyanide

The 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.

Sampedro, 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’.

Ramon San Pedro

Cyanide

Background to Cyanide

In 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.

With 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.

In 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.

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Hydrogen 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.

Today, 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.

Can Cyanide provide a peaceful and reliable death?

Those 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?

Most 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.

On 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

Cyanide

Liberties 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.

Eyewitness 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).

Toxicology 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).

In 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.

Nevertheless, 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.

The Peaceful Pill eHandbook The Availability of Cyanide

Soluble 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. .

The 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.

NOTE: 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.

Cyanide over the Internet

In 2013 Exit became aware of an internet supplier of sodium cyanide from Thailand.

Contact: Napat Chorphantha, 4/596 Moo4 Klongkum, Bunglim, Bangkok, Thailand 10240 Email: [email protected]

However 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.

Cyanide

Fig7.1: Quantofix quantitative cyanide test kit

Testing Cyanide

As 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.

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Using Cyanide for a Peaceful & Reliable Passing

Only 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.

Alternatively, 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,

The effect is greatest when the salt reaches the acid environment of the stomach, so ensure that your stomach is empty before taking the cyanide.

A 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.’

Cyanide

Fig7.2: Lethal quantity (1gm) of KCN

Fig7.3: ‘0’& ‘00’ gelatine capsules

The Peaceful Pill eHandbook What about hydrogen cyanide gas?

Potassium cyanide is not the only form of cyanide that is lethal. There is also the gas, hydrogen cyanide.

The 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.

Hydrogen 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.

Concentrated 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.

Warning

Be 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.

Cyanide The Manufacture of Sodium Cyanide

They 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.

Sodium 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.

In 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.

The 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.

A 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.

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Fig7.4: Forge reduces sodium cyanate with carbon

Fig 7.5: Filtering and weighing the sodium cyanide

Cyanide

The 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).

It 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.

As 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.

The 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.

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Cyanide - RP Test

For 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.

Reliability 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.

There 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.

In 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.

The 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.

An 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).

Taken in this manner the likelihood of a peaceful cyanide death is increased significantly. (P= 5)

Cyanide

Looking at the Minor Criteria:

Availability (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.

Preparation (5/5) - Cyanide salts are consumed as a drink or in a gelatin capsule.

Undetectability (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..

Speed (5/5) - a very quick death.

Safety (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.

Storage (5/5). With proper storage, the sodium and potassium soluble cyanide salts have an almost indefinite shelf life.

Exit RP Score for Sodium Cyanide: 39 (78%)

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Exit RP Test

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 10/10 5/10 3/5 5/5 3/5 5/5 3/5 5/5

39 (78%)

Cyanide

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. 8 Detergent Death

Since 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.

This 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.

Detergent Death

The Method

The method makes use of the toxic nature of the gas hydrogen sulfide (H2

S) and it’s ease of generation from readily available

(unrestricted) household chemicals. Hydrogen Sulfide (commonly known as ‘rotten egg gas’) is extremely toxic when inhaled.

The 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.

Concentrations 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.

Fig 8.1 Simple ingredients used in Detergent Suicide

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Production 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.

2HCl + CaS 4 H2 S + CaCl

The 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

) in aqueous solution. is used in vehicle lead acid batteries.

The 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

SO4 ) (See Chapter 6) which

Detergent Death

Problems with the method

While 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.

Clearly 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.

While 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.

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The Exit RP Test

The method scores poorly for Peacefulness (P=2), but high on Reliability (R=10).

Considering the minor criteria:

Availability & Speed score well at 5/5, Preparation & Storage at 4/5.

However on Safety and Detectability, only the lowest score would be appropriate, giving a total score of only 30 (60%).

The method therefore scores only slightly better than hanging which says it all (28, 56%).

Detergent Death

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 10/10 2/10 5/5 4/5 0/5 5/5 0/5 4/5

30 (60%)

9 Introduction to Drugs Introduction

For 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’.

For 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).

However, 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.

Introduction to Drugs The Role of the Drug Overdose

Generally 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’.

While 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.

The 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.

The 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.

The Peaceful Pill eHandbook Drugs, Swallowing & Taste

A 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.

To 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.

The 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.

Introduction to Drugs

By 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).

Drugs and Vomiting

Any 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.

To 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.

Anti-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.

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If 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.

Unless 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.

If 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.

Fig 9.1: The common antiemetic metoclopramide

Introduction to Drugs Drugs & Alcohol

Alcohol 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.

Secondly, 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.

Thirdly, 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.

Note 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.

The Peaceful Pill eHandbook Drug Tolerance

Exposure 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.’

Some 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.

After 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).

Tolerance 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.

Introduction to Drugs Slow Release (SR) & Enteric Coated (EC) Drugs

Some 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.

Drugs 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.

This 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.

Enteric 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.

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Alternative Routes of Administration of Drugs Stomach PEGs & Nasogastric (NG) Tubes

People 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’.

The 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.

Nasogastric 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.

Fig 9.2: Intravenous drug administration

Introduction to Drugs Intravenous Drugs

Many 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.

The 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.

To 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.

One 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.

Rectal Administration

Drugs 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.

The Peaceful Pill eHandbook Resuscitation

The 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.

Some 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.

People 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.

Other 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

Introduction to Drugs

prefer 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.

It 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.

If 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.)

Alternatively, 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.

The Peaceful Pill eHandbook The Shelf Life of Drugs

Most 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.

To 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.

Research 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.

Also, 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.

Introduction to Drugs

Video: Packaging & Shelf Life of Veterinary Nembutal

Video: What is the Shelf Life of Nembutal?

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To determine if a drug has deteriorated, there are some common sense guidelines.

In 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.

If 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.

Of 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.

Introduction to Drugs Conclusion

This 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.

Specific 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.

10 Morphine & Slow Euthanasia Introduction - The Doctor’s Loophole

‘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.

Known 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.

It 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.

While 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.

Others know exactly what their ‘prime

intention’ is, but wisely decide to keep quiet about it. Others just prefer not to think about it too closely.

Morphine & Slow Euthanasia

It 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.

How Slow Euthanasia Works in Practice

A 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.

If 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.

It 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.

If, 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.

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Another 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).

By blurring this link, a doctor can help a patient die and escape the legal consequences.

Problems 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.

They 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.

Another 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.

Morphine & Slow Euthanasia

A 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.

This 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.

And 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.

Coupled 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.’

The 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.

The 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.

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In 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.

Also 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.

For 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.

Those 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.’

It 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.

That is slow euthanasia!

Morphine & Slow Euthanasia Asking for Slow Euthanasia

The 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.

When 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.

A patient might even imagine that the doctor is saying that ‘when things deteriorate I will give you access to lethal drugs.’

In

reality, 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.

Exit 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?

If 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.

The Peaceful Pill eHandbook The Role of Opiates & Opioids

Opiates 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.

While 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.

The 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.

A small dose of morphine may have almost no effect on one person, while that same dose could kill another.

Predicting

the 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.

Another 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.

Morphine & Slow Euthanasia

To 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.

It 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.

Opioids

Natural Opium Morphine Heroin Codeine

Semi Synthetic Heroin

Synthetic Pethadine Methadone Fentanyl

Fig 10.1: Liquid morphine

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Morphine 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).

Many 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?

A 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.

For 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.

The 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.

Morphine & Slow Euthanasia The Use of Heroin

Exit 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.

As 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.

Note: 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.

One 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.

The Peaceful Pill eHandbook Conclusion

In 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.

This 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.

This 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.

Finally, 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.

While 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.

Morphine & Slow Euthanasia The Exit RP Test for Morphine

Morphine (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).

Minor 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).

Exit RP Test - Morphine

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 4/10

10/10 3/5 5/5 2/5 2/5 5/5 3/5

34 (68%)

11 Propoxyphene Introduction

A 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.

Fig 11.1 Propoxphene capsules (Doloxene)

Propoxyphene The Various Forms of Propoxyphene

Propoxyphene is marketed under a number of names, exam- ples include Darvon, Doloxene, and Depronal.

Regardless 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.

Propoxyphene capsules have only one active ingredient (dex- tropropoxyphene napsylate).

However, the drug propoxy-

phene is often marketed in combination with other common analgesics such as paracetemol (acetaminophen) and marketed as Di-Gesic (Darvocet).

These 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.

Note: 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.

The Peaceful Pill eHandbook When is Propoxyphene Prescribed?

Propoxyphene (dextropropoxyphene napsylate) is almost al- ways available from a doctor on prescription, where it is used for pain management.

Propoxyphene is usually prescribed

when 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.

Propoxyphene 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)

How Lethal is Propoxyphene?

Propoxyphene 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.

When 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.

As 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.

Propoxyphene

If 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.

Propoxyphene 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.

The Role of Oxazepam

Oxazepam (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.

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

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Note: Duration of action of the benzodiazepine is important - shorter acting drugs like temazepam are not recommended.

When is Oxazepam Prescribed?

Well 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.

People using propoxyphene, often take a full packet of 30mg oxazepam tablets as the supplement.

Using Propoxyphene

The 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.

It 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.

Video: Using Propoxyphene Propoxyphene

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Fig 11.3: 100mg pink Propoxyphene Capsules

Fig 11.4: Doloxene packaging

Propoxyphene

Alcohol 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.

Shelf Life of Doloxene

Propoxyphene 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).

The Future of Propoxyphene

Propoxyphene 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.

See: http://nyti.ms/9iPzgD

At the time of press, propoxyphene is still available on pre- scription in Australia, Mexico and a range of South American and Asian countries.

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Fig 11.5: Propoxyphene powder ready for mixing with water

Fig 11.6: 10gm propoxyphene ready to drink

Propoxyphene

Video: The Preparation of Propoxyphene (Doloxene)

Video: What is the Shelf Life of Doloxene?

The Peaceful Pill eHandbook RP Test for Propoxyphene

Propoxyphene 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).

In 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%

RP Test for Propoxyphene

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 9/10 7/10 4/5 3/5 3/5 2/5 5/5 3/5

36 (72%)

12 Amytriptyline Introduction

Amitriptyline 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.

The 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.

Their 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.

Since this time the TCAs have undergone something of a resur- gence for the treatment of intractable neuropathic pain (such as trigeminal neuralgia) and migraine.

Amitriptyline

Using Tricylics for a Peaceful Death

The 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.

The 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.

Fig 12.1 The tricyclic antidepressant amitriptyline

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Amitriptyline 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.

Preparation of Amitriptyline

The 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.

For 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.

Fig 12.2 Amitriptyline with metocloptamide, oxazepam and Gin

Amitriptyline Video: Preparing Amitriptyline

The Peaceful Pill Handbook

Take 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.

Note: 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.

Once 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)

Amitriptyline How does Amitriptyline score on the RP test?

Exit 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).

In 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.

There 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).

The 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).

Total 34 or 68%

The Peaceful Pill eHandbook

RP Test for Amitriptyline

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 9/10 7/10 2/5 3/5 3/5 2/5 5/5 3/5

34 (68%)

Amitriptyline

13 Chloroquine Introduction

This 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.

First 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.

Chloroquine

Packaging & Availability

The 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.

Fig 13.1: Blister pack 250mg Avloclor (chloroquine phosphate) tablets

The Peaceful Pill eHandbook Dosage

Quantities 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.

Administration

The 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.

Note: 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).

The 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.

The Use of Potentiating Drugs

The 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

Chloroquine

subject 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.

This 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.

Fig 13.2: Chloroquine Phosphate Tablets

The Peaceful Pill eHandbook The RP Test for Chloroquine

The drug scores well on reliability, speed and availability, but relatively poorly on peacefulness.

RP Test for Chloroquine

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 8/10 5/10 5/5 4/5 3/5 4/5 5/5 3/5

37 (74%)

Chloroquine

14 Insulin Introduction

There 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.

What is Insulin & is it effective?

Insulin 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.

Insulin

However, if an overdose of this drug is taken, the blood sugar can be pushed dangerously low, and diabetic hypoglycemic coma and death result.

A 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.

Significant problems using Insulin

The 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

Fig 14.1: Typical subcutaneous Insullin administration

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insulin 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.

The 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.

In 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.

Fig 14.2: ‘NovoRapid’ rapid acting insulin ampoule, 1000U in 10ml with 0.5ml syringe for subcutaneous administration

NOTE: 20 full syringes would need to be quickly injected to administer 1000U

Insulin Conclusion

In summary, Insulin is not reliable enough to recommend if sub- cutaneous injection is the only method of administration avail- able.

The RP Test for Insulin

Insulin 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.

RP Test for Insulin

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 5/10 5/10 3/5 2/5 2/5 5/5 5/5 3/5

30 (60%)

15 Chloral Hydrate Introduction

One 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.

The 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.

Chloral 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

Chloral Hydrate

In 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.

The 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).

The 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.

Note 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.

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Conclusion

There 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.

Fig 15.1: 200ml bottle of Chloral Hydrate syrup (1gm/10ml)

Chloral Hydrate

The RP Test for Chloral Hydrate

Chloral Hydrate has a questionable reputation in the mjor indices of reliability and peacefulness, and scores poorly at 60%. Criteria

Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total

Score 5/10 5/10 3/5 3/5 2/5 3/5 5/5 4/5

30 (60%)

16 Drug Options - Nembutal

I 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

Introduction

The 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.

A Short History of Barbiturates

Sodium 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.

All 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.

Nembutal

Fig 16.1 Nembutal women’s magazine advertisment from 1950’s

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Video: A Short History of Nembutal

Video: What Everyone Should Know about Sleeping Tablets

Nembutal

Other 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.

The 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.

Barbiturate Sleeping Pills

In 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.

Fig 16.2: Pentobarbital (Nembutal) sleeping tablets

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Along with the original Veronal, there was Barbital, Amytal, Seconal, Soneryl, Nembutal and several others.

While 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.

Fig 16.3: Amylobarbital (Amytal) sleeping tablets

Barbiturates as Drugs of Abuse

In 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).

Nembutal

With 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.

The Advent of Non-barbiturate Sleeping Pills

The 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.

By 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.

Barbiturate Use in Veterinary Practice

The 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.’

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A 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).

Nembutal in Countries where Assisted Dying is Legal

Nembutal 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

When 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.

Fig 16.4: The ‘Deliverance’ euthanasia machine

After 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.

Nembutal

The 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

While 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.

Drinking 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.

Fig 16.5:

Sterile veterinary Nembutal

The Peaceful Pill eHandbook How Barbiturates Work

Barbiturates 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.

As 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.

Available Forms of Nembutal

For 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.

Barbiturates 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.

Nembutal

The 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.

The 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.

Fig 16.6: Non-sterile coloured

Non-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.

Since 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).

Pentobarb & Phenobarb – Confusing Names

Nembutal 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.

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While 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.

Sources of Nembutal

In 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.

Let 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.

The 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!

Nembutal and Veterinarians

Veterinary 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

Nembutal

bad 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!

If 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

Fig 16.7: Non-sterile veterinary

Veterinary Board became concerned about the increasing use of veterinary

Nembutal 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).

Exit 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.

Moves 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.

The 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

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Veterinarians and Nembutal

Nembutal and the Black Market

Nembutal

a 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.

A Case Study in Nembutal

When 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.

I 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.

After 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!’

A 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

The Peaceful Pill eHandbook

reassured 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.

The 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.’

Nembutal and the Black Market

Exit 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.

The 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.

If the seal and labelling of a Nembutal bottle is intact and the expiry date not exceeded, the drug is likely to be effective.

Nembutal

Nevertheless, 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

The Exit Test Kit enables people who have acquired liquid Nembutal to self-test the drug.

Note: 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) .

The Shelf Life of Liquid Nembutal

Event 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.

If stored in a cool place and kept

in its sterile, sealed bottle, liquid Nembutal can be expected to have a shelf-life of many years.

A detailed discussion of the shelf life of both liquid and powdered Nembutal can be found in the following Chapters.

Conclusion

The 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.

The Peaceful Pill eHandbook

Yet 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.

However, 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.

The RP Test for Nembutal

Nembutal 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.

Nembutal

Exit RP Test - Nembutal

Criteria Reliability

Peacefulness Availability Preparation

Undetectability Speed Safety

Storage Total Score

Score 10/10 10/10 2/5 5/5 4/5 4/5 5/5 4/5

44 (88%)

17A Availability of Nembutal Introduction

For 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.

Where 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.

In this chapter the following issues are covered:

• 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

Since 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.

The availability of Nembutal can and does

change without warning. Old stores close and new stores open. Websites appear and disappear, seemingly overnight. Scammers operate in a relentless manner.

Historically, 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:

what 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 ...

Another US tourist to Mexico was more specific.

Mexican 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!

In 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.

The Peaceful Pill eHandbook Types of Nembutal on Sale

Nembutal (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.

Liquid 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).

A 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.

White 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.

Drug Labelling

The 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.

Mail-order Chinese powder Nembutal is sold as reagent grade ‘Sodium Pentobarbital’, CAS No. 57-33-0.

Availability of Nembutal Legal Considerations

If 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.

The 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.

In 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.

Any 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.

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Video: Laredo, Mexico

Availability of Nembutal

Fig 17.1: Mexican veterinary sterile Nembutal: Anestesal

Fig 17.2: Mexican veterinary sterile Nembutal: Sedal-Vet

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Fig 17.3: Mexican veterinary sterile Nembutal: Pentobarbital Injectible

Fig 17.4: Mexican veterinary sterile Nembutal: Sedalphorte

Availability of Nembutal

Fig 17.5: Mexican veterinary sterile Nembutal: Barbithal

Fig 17.6: Mexican veterinary sterile Nembutal: Sedalpharma

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Fig 17.7: Mexican veterinary sterile Nembutal: Pentovet NRV

Availability of Nembutal

Fig 17.8: Mexican veterinary sterile Nembutal: Sedalpharma

Fig 17.9: Mexican veterinary sterile Nembutal: Pentomax

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Fig 17.10: Mexican veterinary sterile Nembutal: Pisabental

Availability of Nembutal

Fig 17.11: Mexican veterinary sterile Nembutal: Dolethal

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Video: Buying Nembutal in Mexico

Availability of Nembutal

Fig 17.12 Australian Government publication March 2011

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Note: 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.

Despite 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.

http://www.customs.gov.au/webdata/resources/files/ImportingBarbiturates.PDF

Exit 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.

What happens to those charged with importing Nembutal?

To 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) .

Availability of Nembutal

At 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.

See: http://bit.ly/bECnzG

A 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.

See: http://bit.ly/1r9q78v

The 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.

See: http://ab.co/1wMPY6L

In 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.

Note: 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.

The Peaceful Pill eHandbook Nembutal Over the Internet: Mexico

In 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.

Web: http://www.fotolog.com/pindolonsilver/ & http:// www.silverpindolon.com Email: [email protected] Email: [email protected] (encrypted) or

Email: <[email protected]> (encrypted)

A 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’.

Web: http://www.pisaagropecuaria.com.mx/pisabental/ Email: [email protected] Email: <[email protected]> (encrypted)

The 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.

Some offers include the anti-emetic drug, metoclopramide for an extra $50.

Note - both these suppliers have encrypted (Protonmail) addresses.

Note - in Mexico metoclopramide is available over-the-counter for a few dollars.

Availability of Nembutal A Note on Interpol

In 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.

At 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.

As one of these readers wrote to Exit:

I believe the Mexican supplier gave Interpol details of his customers.

My purchase was 18 months ago, so unlikely any email exchange was picked up randomly.

All police visits have followed open online communication between the person visited and the person known as Alejandro Vasquez. This seems more than mere coincidence.

Needless 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.

The Peaceful Pill eHandbook Legal Recap

In 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.

While 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.

Clearly, 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.

It 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.

Furthermore, 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.

Availability of Nembutal Reader Feedback

Over 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.

To 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.

Some scammers purport to be associated with Exit. Some purport to represent Exit International. What needs to be made clear is the following:

• Exit has no relationship with any source listed in the Peaceful Pill eHandbook

• 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

• Exit does caution that legal advice is recommended before using the Internet to obtain Nembutal.

The Peaceful Pill eHandbook Chinese Powder Nembutal

Since 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.

Nembutal 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).

Sources of Chinese Nembutal Powder

Johnson 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: [email protected] or <[email protected]> (encrypted) Payment by Bitcoin, Western Union, or direct bank transfer.

Testing of Sources of Chinese Nembutal Powder

Random samples from the suppliers listed below have provided results showing 99% purity.

• Rundong Chemical, Quzhou • Haihang Industry Co • David Zhang • Cherry Chemical, Hangzhou • Johnson

Availability of Nembutal

With the exception of the last name listed above (Johnson), none of above sources of Nembutal are operating. Indeed, some may now be scammers.

Fig 17.13: Powder Nembutal as shipped from China

Fig 17.14: Nembutal from 3B Scientific International

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Fig 17.15: gms powder from China

Fig 17.16: Sample 1: Flat-packed powder from China

Availability of Nembutal

Fig 17.17: Sample 2: Envelope of flat-packed powder from China

Fig 17.18: Sample 3: Package of flat-packed powder from China

The Peaceful Pill eHandbook Using the TOR Browser to access the ‘dark web’

TOR is free software that allows anonymity in searching the internet, and access to the ‘dark web’, areas of the internet inaccessible by normal browsers.

In 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.

See the New York Times report at: http://nyti.ms/19qbnWc

In 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.

The Guardian newspaper provides an excellent portal on the rise and fall of the Silk Road market place.

See: http://www.theguardian.com/technology/silk-road

Replacement 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.

One market place, AlphaBay, accessible by TOR, is reported to be offering the sale of the drug.

For further discussion see: http://www.peacefulpillhandbook.com/forums/

Availability of Nembutal Using Bitcoin Virtual Currency for Payment

While 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.

Bitcoin 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.

To use Bitcoins, you will first need to choose an online ‘wallet’ to install on your computer or mobile phone.

Upon installation, your wallet will generate a Bitcoin address, and allow you to purchase (and spend) your Bitcoins in an anonymous way.

In mid 2016, Mexican and Chinese providers of internet Nembutal indicated that they accept payment using Bitcoins.

For general information on Bitcoins see: http://bitcoin.org/en/

To create a Bitcoins Wallet go to: https://www.bitcoin.com/

For further discussion see: http://www.peacefulpillhandbook.com/forums/

The Peaceful Pill eHandbook

Legal 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.

The Politics of Buying Nembutal over the Internet

As 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.

One 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.

One 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.

Availability of Nembutal

On 2 May 2016, Australian Dr Craig Wright claimed he was the founder of Bitcoin. His claim is disputed.

Read Wired Magazine’s report at: http://bit.ly/1rrjKyw

Fig 17.18a: Bitcoin Founder - Dr CraigWright

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Video: Crossing the US Border

Video: Disguising a Bottle of Nembutal?

Availability of Nembutal

Purchasing Nembutal in Person: Mexico

Over 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.

Mazatlan

In 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.

His 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:

Ejercito Mexicano No. 5 (near Playa Norte) area of Mazatlan

Bob 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’.

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Playa del Carmen

In 2010, Exit received its first report of the availability of Nembutal in the tourist resort town of Playa del Carmen. Sandy wrote:

On 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.

I 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.

I 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.

I 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.

By December 2015, another traveller, Ted, had a more unproductive time in this tourist town.

I 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.

Availability of Nembutal

Video: Up Close: A Bottle of Anestesal (Nembutal)

Video: The dangers of bringing Nembutal home

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Fig 17.19: Playa Norte in Mazatlan, Mexico Puerto Vallarta

In 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.

Valladolid

Valladolid 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.

Nembutal 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.

Availability of Nembutal

One store where Nembutal is available is Farmacia Veterinaria Los Potrillos at:

Calle 41 177-I Col Valladolid Centro Yucatan

At 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.

Fig 17.20: Farmacia Veterinaria Los Potrillos

The Peaceful Pill eHandbook Tijuana

Exit 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.

Ten 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.

Another 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.

One 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:

I 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.

John, USA, 8 April 2016

Availability of Nembutal

Fig 17.21: Farmacia Veterinaria on El Travieso, Zona Centro Tijuana

Fig 17.22: Map featuring Farmacia Veterinaria on El Travieso

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John’s April 2016 feedback contrasts with that of Gary who wrote in December 2015:

I 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.

In a similar manner, Steve from Australia reported to Exit that in January 2016 he purchased Nembutal over-the-counter at ‘Granero Los Alazanes’.

Exit 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.

The veterinary pharmacy can be found at:

Calle Benito Juárez 2da 8557 Zona Centro, Tijuana

Fig 17.23: Granero Los Alazanes Business Card

Availability of Nembutal

Fig 17.24: Granero Los Alazanes

Fig 17.25: Map featuring Granero Los Alazanes

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A 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.

This outlet is extremely close to the pedestrian footbridge into Tijuana.

Jael’s street address is: Ave Negrete # 727-4 Zona Centro Tijuana

Prescription Request for Purchase in Mexico

For many years, the legal status of purchasing Nemb- utal

over-the-counter has been unclear. In some cas- es and locations a script is needed, in others it is not.

For 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’.

Legal Recap

The 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.

Availability of Nembutal

Fig 17.26: Farmacia Veterinaria Jael

Fig 17.27: Map featuring Jael Farmacia

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Fig 17.28: Vetson Clinic

Fig 17.29: ab Clinic

Fig 17.30: Centro Cambiario

Availability of Nembutal Nogales

The 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.

For bus services see: http://www.mexicandoctorsdir.com/sahuaro_shuttle.htm

Once 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.

These are:

Clinica Veterinaria Vetson Cnr Ingenieros, no 321 Nogales Centro Tel 312 22 10

ab Medicina Veternaria Calle Ana Gabriela Guevara, no 74 Nogales Tel 631-304-3312

Imelda Lopez Centro Cambiario (ask for Jose) Tel 631-129-7556

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Video: Juarez, Mexico

Availability of Nembutal

SOUTH AMERICA Purchasing Nembutal in Person: Peru

For 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.

In 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.

Fig 17.31: Suni Agro in Lima - Peru

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Lima - Peru

As 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.

Located at the intersection Santa Beatriz in central Lima, Zoo Farma is an Agro Veterinaria which takes 20-30 minutes by

Fig 17.32: Zoo Farma Agro Veterinaria

Availability of Nembutal

taxi 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.

This 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.

I 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).

Neither 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.

There 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).

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First 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.

After 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.

This 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”.

http://bit.ly/1SBmOSV

One 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.

Terri, Brazil, February 2016

Availability of Nembutal

As if to verify the previous report, Bill also wrote:

I 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.

I 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.

I 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.

Bill, Germany, September 2015

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Cuzco - Peru

For 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.

The 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.

In

daylight 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.

Fig 17.33: One of the many Agro Vet- erinarias in Calle Tres Cruces de Oro in Cuzco, Peru

Some 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.

Availability of Nembutal

Stores which have been known to sell Nembutal in Calle Tres Cruces de Oro include:

• Casagroveto, El Progreso at No. 461 • Agroveterinaria Belen (Principal) at No. 496 • Progensa EIRL at No. 485 • Sucursal (Branch) at No: 421

In February 2016 Sharon wrote:

Hello , 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 .

Hearsay received at the end of 2015, however, was less posi- tive:

I 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!

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Fig 17.34: Peruvian Halatal

Fig 17.35: Peruvian veterinary sterile Nembutal

Fig 17.36: Peruvian veterinary sterile Nembutal

Availability of Nembutal

WARNING: In late 2015 Exit received reports from Peru that those seeking to purchase Ha- latal

were being sold

‘Halatal KT’ instead. The reason was that “‘Halatal’ was no longer available”. ‘Halatal KT’ was said to be an equivalent.

Both drugs are available in 50ml bottles and ap- pear to have similar la- belling, but they are DIFFERENT DRUGS!

Fig 17.37: Halatal iKT, 50ml of 10% Ketamine

Halatal KT is 10% Ketamine and contains NO Nembutal. As such it is useless as a reliable end of life drug.

Fig 17.38: Nembutal boxes on display under the counter

The Peaceful Pill eHandbook La Paz - Bolivia

La Paz in Bolivia is the highest capital city in the world and, as such, its altitude may not suit all travellers.

Like Cuzco,

Nembutal 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.

To 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.

In La Paz, one pentobarbital is commonly sourced from the veterinary outlet at:

Av. Saavedra No 1004 Zona Miraflores, La Paz

Availability of Nembutal SE ASIA

Since 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.

Bangkok - Thailand

In 2011, Nembutal could be obtained over-the-counter from veterinary pharmacies in Bangkok. This has since ceased.

The 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.

If you’d like to prove us wrong, however, here are the details:

Eieng Sew Tung Dispensary 475/9 Ratchaprarop Rd, Makkasan, Ratchatewee, Bangkok 10400 Tel : +66-2251-1482 Fax: +66-2251-7238

In 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.

The Peaceful Pill eHandbook Southern Thailand

Exit 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).

Trang Animal Hospital 184/1-3, Wisetkul Road Tambon Thap Thiang Amphoe Mueang Trang, 92000, Thailand

The liquid Nembutal on sale is labelled injectable solution, 100ml, pentobarbital sodium 5.47g. The Ceva brand is made in France.

The reported price for Nembutal from the Animal Hospital is 1,500 Thai Baht per bottle. This equates to around USD$40.

Fig 17.39: Map featuring Trang Animal Hospital

Availability of Nembutal

Fig 17.40: Sterile veterinary Nembutal as it is retailed in Thailand

Concluding Comments

Nembutal continues to be sold over-the-counter (lawful) and over the Internet (check your local laws regarding legality) from several countries around the world.

However, 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.

That 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.

17B Nembutal Scams Introduction: Proliferation of Scammers

Since 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..

In 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.

Scammers 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.

In 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.

This 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.

In this Chapter the following issues are covered:

• 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

A-Z List of Scam Sites

The following is a current listing of scam websites that DO NOT SELL Nembutal, despite what they claim/ promise etc.

Exit 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.

DO NOT have anything to do with the following list of names, websites, email addresses. They are criminals and you WILL lose your money.

The Peaceful Pill eHandbook A-Z List of Scam Sites (as of August 2016)

• Anonymous Pharm/ Meryl Pest Control <http://merylspestcontrol.com/wp-page/nembutal. php>

• •

Berlin Pharmacy <[email protected]> Cho Collins Cameroon

• Cameroon 1. El-Hazzi Jal – Saeed <[email protected]> • Cameroon 2. “Derek” <[email protected]> Tel + 273 676 1644 79 & + 1 6267 250 821

• EMS Express Mail Service (fake courier) • Export Ph <http://export.ph/offers/view/2861&#62; •

Glomedstore <[email protected]> •

• 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 <[email protected]>

• <[email protected]> tel +1 (423) 523-9563 • • • • • • •

Jonas <[email protected]> Jones from Peaceful Pill Directory <[email protected]>

Jorge Hernandez <[email protected]> <http://www.jorgehernandez.me/&#62; Jorge Ramires and Vital Finale <http://vitalfinale.com/&#62; Kapital Natalya Ukraine Malvin Castrol Marvin Castrol

• Mezam Pharmacy <http://www.mezampharmacy.com> <[email protected]> • • •

Muller Gomez Nembutal for You <[email protected]> Nembutal for Euthenesia (sic) <http://nembutalforeuthenesia.com/&#62;

• Nembutal Group USA <[email protected]> • Nembutal Group Norway <https://ukeuthanasiasolution.wordpress.com> •

• • • • • •

• •

Nembutal Online <www.nembutalonline.com>

Nembutal Online Ukraine <www.nembutalonline.com> & <[email protected]> Nembutal Peaceful Exit Solution <www.nembutalpeacefulexitsolution.com> Nembutal Supplier Group

Peaceful Exit Solutions <https://www.linkedin.com/in/ordernembutaldrug&#62;

Peaceful Pill Directory “Jones” <www.peacefulpilldirectory.com> <info@peacefulpilldirectory. com>

Perfecto Relief <http://perfectorelief.com/order-nembutal-online/&#62; Quality Nembutal Pentobarbital and Others

• <https://qualitynembutalpentobarbitalsupplyandothers.wordpress.com/el-hajjis-jal-saeed- supply-ltd-money-back-guarantee/>

• Shawn Hardy <[email protected]> •

UK Euthanasia Solution <https://ukeuthanasiasolution.wordpress.com>

• Vital Finale (see Jorge Hernandez) <http://vitalfinale.com/&#62; • Weiku.com <http://www.weiku.com/Inorganic-Chemicals/buy-nembutal-sodium- pentobarbital.html>

• And, Exit International USA Newark!

Nembutal Medication <www.nembutalmedication.com> “Derek” Claims to work for Exit International! (see Cameroon)

Nembutal Scams

How Internet Scams Work The modus operandi of scammers is generally the same.

1. 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.

2. 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.

3. 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:

Name: Xavier Paddy Address: 2804 Evergreen Ave, Baltimore MD 21214 Amount: $832 (for 300ml, concentration unspecified)

In broken English, they remind you to include:

“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. “

If your alarm bells are not going off now, they should be! Sounds too good to be true? It is too good to be true!

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But 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.

Here is an example:

1) Is the Nembutal for you or someone else? Me.

2) Why do you need Nembutal, for suicide or as an aid against pain ?

Initially 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.

3) Have you ever bought Nembutal before ? No.

4) What is your experience and what do you know about buying Nembutal online ?

I’ve done extensive research & understand there are scams out there. 5) Your age ? 43

Nembutal Scams

6) How soon do you want to buy? ASAP 7) Your order quantity?

15g powder but understand I only need 6g & want advice on the quickest/painless method.

Please make sure you answer all the above questions because your answer will determine whether we will provide you with the drug

Thank you and awaiting your reply

Dr Malvin Castrol VITAL FINALE

Email: [email protected] Website: http://www.vitalfinale.com/

The 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!

The Peaceful Pill eHandbook The Dangers of Internet Scammers

It 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.

Did 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.

Tips to Pick a Scammer

It 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.

Exit 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:

Nembutal Scams

• 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?

• Do they say they have been approved/ endorsed by The Peaceful Pill eHandbook?

• Do they say they send/ have sent samples of Nembutal to Exit International for testing?

• 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?

The 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.

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Anonymous Pharm/ Meryl Pest Control http://merylspestcontrol.com/wp-page/nembutal.php

Berlin Pharmacy <[email protected]> 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

* This scammer has scammed the person once and is now offering a discount for a second order. Talk about a con!

Cho Collins Cameroon Name used is: El-Hajjis Jal-Sawed Offer: 10 grams= US $422

Scam Website - from Cameroon?

Nembutal Scams

EMS 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.

I 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.

After 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

Export Ph http://export.ph/offers/view/2861

Glomedstore < [email protected]>

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 <[email protected]>

The Peaceful Pill eHandbook Jorge Hernandez & Vital Finale

This scammer is long-standing, having managed to evade the authorities since at least 2014. To be clear:

Jorge Hernandez = Malvin/ Marvin Castro = Vital Finale

Exit 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.

Below is a sample of the questions that Exit continues to be asked about Jorge Hernandez.

Do 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.

Reader 1

I 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?

Reader 2

This past week, I found someone online named Jorge Hernandez, promising to send me high quality Nembutal (3 bottles). I lost my $1,240.00.

Nembutal Scams Reader 3

I 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.

Reader 4

I 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.

His email is [email protected]. That’s also his website. If you have any questions I’m available.

Scam Website - How to Order Nembutal Europe

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The various faces of Jorge Hernandez & Vital Finale

Nembutal Scams

Jorge 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.

The 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.

Kapitan 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.

Malvin 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.

We 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.

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All we need from you to proceed are the following delivery details:

Full names...................... Address........................... Postal zip code................. Mobile Number................ Your order...............100ml ($432 USD)- $578 Australian Dollars

As 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.

Awaiting to confirm your delivery details. Thanks

Mezam Pharmacy http://www.mezampharmacy.com <[email protected]>

Muller Gomez

The 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.

Nembutal Scams

Hunter 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.

These crooks need to be caught. They’re preying on people who are suffering, and it’s wrong.

Nembutal for You <[email protected]>

Nembutal Group USA Email: <[email protected]> Phone: +1(916)741-3687

Nembutal Group Norway https://ukeuthanasiasolution.wordpress.com

Nembutal Supplier Group https://groupeuthanasiamedication.wordpress.com/tag/ nembutal-supplier-group-ltd/

Thank 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.

I emailed [email protected], they said delivery was by [email protected]

The 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

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Nembutal Online Ukraine www.nembutalonline.com 16/2 Prorizna St, Kiev 01001 <[email protected]>

Peaceful Exit Solutions https://www.linkedin.com/in/ordernembutaldrug

Peaceful Pill Directory A new and slick site using Exit images and text, replete with fake 5 star rating on various sources!

1800 26th St S Arlington, VA 22206 USA tel: +1(469)607-0971 www.peacefulpilldirectory.com

Perfecto Relief http://perfectorelief.com/order-nembutal-online/

Quality Nembutal Pentobarbital and Others https://qualitynembutalpentobarbitalsupplyandothers. wordpress.com/el-hajjis-jal-saeed-supply-ltd-money-back- guarantee/

UK Euthanasia Solution

https://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/

Nembutal Scams

Weiku.com http://www.weiku.com/Inorganic-Chemicals/buy-nembutal-sodium-pentobarbital.html

The dynamic website of Nembutal Online Ukraine

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Peaceful Pill Directory scam website

UK Euthanasia Solutions scam website

Nembutal Scams

Previously Listed Scammers (no longer operating)

Below is an incomplete list of scammers and some screenshots of websites that have disappeared or have been closed down.

Peaceful Exit Community & Dr John Harris Email: [email protected] http://www.peacefulexit.com

Exit Foundation Facebook Page https://www.facebook.com/pages/Buy-Nembutal-online-Exit- Foundation/1418156448451388

Buy Nembutal Online Wordpress Blog See: https://euthanasiachat.wordpress.com/

Lonely End http://www.lonelyend.com

Speedy Express Int (fake courier site) http://www.speedyexpressint.com

This was a fake courier site that allowed purchasers to enter their fake tracking number and get false updates (since replaced with fake EMS courier).

Ekow Anderson Western Union details show the following address: Address:122, Florya Metro, Istanbul, 34000, Turkey

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Chi Germain Akenji Western Union details show the following address: Address:1213 Alexandria Ave, Bitola, 7000, Macedonia

Philip Force Western Union details show the following address: Address: 325 Lanham Rd, Laurel, 20708, MD, USA

Pristupa Yuliya Western Union details show the following address: Address: 03 Oktyabrskaya St, Poltava, 21000, Ukraine

A previous scam website - Exit Foundation

Nembutal Scams

“Lonely End” scam Site

‘Peaceful Exit Community’ scam website no longer operating

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Fake Facebook pages offering Nembutal

Nembutal Scams

Neighbourhood Watch for Scammers

As 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.

To 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.

That said, we return time and time again to the cliché.

‘If it sounds too good to be true, it likely is too good to be true.’

Caveat Emptor!

18

Testing and Storing your Nembutal Sample

• 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

Taking a Sample for Testing

The 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).

A sample of veterinary liquid Nembutal for testing can be obtained as follows:

The 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.

Testing & Storing Nembutal

The 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.

To 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.

Fig 18.1: Removing a sample of Nembutal

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When 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.

The Difference between Qualitative vs Quantitative Testing?

Qualitative 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.

NOTE: 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.

In 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).

Quantitative 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.

Fig 18.2: Weighing out Nembutal powder for testing

Testing & Storing Nembutal The Qualitative ‘Spot’ Test

The 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.

The 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.

For veterinary liquid Nembutal, the steps are as follows:

1. 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’.

2. 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.

3. At ~5 minutes, read the results of the test off the dip-card. After 10 minutes the results cannot be relied upon.

To use the Exit Spot Test for powdered Nembutal, the steps are as follows:

1. Use a clean knife to separate out a small sample of the powder (see Fig 18.2).

2. 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.

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Reading the Qualitative Test Results Positive Result

One 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

Two 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).

Fig 18.3: A positive ‘Spot’ Test

Testing & Storing Nembutal Video: Testing Nembutal: Obtaining the Sample

Video: Exit Triple Test Acid Conversion Test (ACT)

The Peaceful Pill eHandbook The Max Bromson Quantitative Test

There 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.

The Max Bromson Quantitative Test Kit can be obtained at: http://www.exitinternationalstore.com Each Exit Max Bromson Quantitative Test Kit contains:

• Digital scales with accuracy of +/- 0.001gm • Glass Melting Point capillary tube (x2) • Digital probe thermometer (00

C to 2500

• Spot test cassettes (x6) • 2ml micro-pipettes (x6) • 3ml syringes (x6) • 25G hypodermic needles (x4)

C)

Fig 18.4: Exit ‘Max Bromson Triple Test’Kit (Spot test cassettes not shown)

Testing & Storing Nembutal Video: Melting Point Test (MPT)

Video: Dilution Purity Test (DPT)

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Note: In May 2016 the consumables provided in the Max Bromson Kit were doubled, so that more than one sample could be tested.

The 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.

The 3 Tests are:

a) The Acid Conversion Test (ACT) b) The Melting Point Test (MPT) c) Dilution Purity Testing (DPT)

a) The Acid Conversion Test (ACT)

Nembutal (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.

Conversion into the insoluble crystalline form can be achieved by acidifying the solution and driving the pH down, so that an insoluble precipitate is formed.

If 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.

Testing & Storing Nembutal

Method: 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)

Weigh out approximately 500mg (1/2 gram) of powder for testing. Record the accurate weight and dissolve the sample in approximately 50ml of distilled water.

When 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.

Weigh 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.

Repeat 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.

Place the filter paper in an oven set at low heat (~1000 C), and

allow the filter paper to dry. Re-weigh the filter paper plus the dried precipitate.

Calculate the weight of the total precipitate by subtracting the weight of the filter paper.

The % purity of the original sample is obtained by: (Weight of salt/ Weight of precipitate) x 90

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Note: 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.

Note: 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.

Set aside the dried pentobarbital crystals for use in the melting point test (MPT).

The ACT Test is shown in the video ‘Purity Testing for Nembutal Powder’.

Note: 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.

b) The Melting Point Test (MPT)

A 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).

For 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

C, and a glass container of cooking oil that can be heated slowly on the stove.

Testing & Storing Nembutal

Regardless of whether one has the powdered salt (from China), or a bottle of liquid solution of the salt, the process is as follows:

Place 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

C +/- 10 C.

A video of the MPT is shown: ‘The Melting Point Test for Nembutal’.

Note: In the video a magnetic laboratory stirrer is used to ensure a uniform temperature of the cooking oil being heated.

c) The Dilution Purity Test (DPT)

The 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.

Accurately 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.

Return 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.

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Re-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).

Use 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.

Reseal 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%.

Note: 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.

A video of the DPT is shown: ‘The DIY Home Nembutal Purity Test’.

Max Bromson Quantitative Test Results

Home 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.

A spurious or unexplained result from one test can then reasonably be disregarded if the other two tests return an adequate result.

Testing & Storing Nembutal

For example, a good purity result on the ACT (ie. better than 70%), with a MPT of 1300

C would give confidence that

ingestion 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.

If, however, a sample fails all three tests, it would be wise to source an alternative sample, or seek a laboratory assay.

Additional Home Quantitative Tests Water Content Test (WCT)

The 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.

To 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

C. After

30 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%

Acid Titration Testing (ATT)

Reliable 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.

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This method involves accurately weighing out a small sample of powder (~200mg +/- 0.5mg), drying it in an oven at 1000

C

to 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.

A 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

Exit 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.

Laboratory Quantitative Testing Using Gas Chromatography

The 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.

Over 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).

Testing & Storing Nembutal

Fig 18.5: Exit Laboratory GC Machine Mobile Nembutal Testing

The 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.

In 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.

The Peaceful Pill eHandbook Storage & Shelf Life of the Barbiturates

The 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.

In 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.

The Storage of Powder Nembutal Method 1

Obtain 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

C is fine). Method 2 (Courtesy of Alan Davies)

An 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/

Testing & Storing Nembutal Fig 18.6

10gm of powder in foil

Powder wrapped in foil

Place in Mylar storage bag

Silica Gel moisture absorbing sachet

O2

absorbing sachet

Place the vacuum sealed Mylar bag inside a PE ‘Food Saver’ bag

Above: Vacuum seal the Mylar bag inside a plastic PE bag along with moisture and oxygen absorbing sachets

Right: The finished package ready for storage