3.1.- ORAL SELF-ADMINISTRATION
3.1.1.- PROCEDURE AND RECOMMENDED MEDICATIONS
A. PREMEDICATION
A.1. Antiemetics
The first step is a preparatory step. It involves taking an antiemetic to minimize the risk of vomiting the coma-inducing medication. The
recommended medications are metoclopramide and ondansetron, which can be administered according to the following guidelines (select one):
a) Metoclopramide 30 mg taken 1 hour before administration of the coma-inducing medication.
b) Ondansetron 8-24 mg taken 1 hour before administration of the coma-inducing drug.
c) Metoclopramide 20 mg plus ondansetron 8-24 mg 1 hour before administration of the coma-inducing drug.
The guidelines listed above simplify the process, but the following guidelines could also be indicated (select one):
c) Metoclopramide 10 mg/8 hours starting 36 hours before taking the product.
d) Ondansetron 4 mg/12 hours, starting 36 hours before taking the product.
Metoclopramide can cause extrapyramidal reactions: spasms of the muscles of the face, neck, and tongue, incoordination of voluntary movements, and difficulty staying still. Although extrapyramidal effects are more common in adolescents and young adults, ondansetron is recommended for people who have experienced them.
Ondansetron is a very effective antiemetic that is recommended as an alternative to metoclopramide. Rarely, a condition called serotonergic syndrome (palpitations, flushing, and agitation) may occur, which may limit its use.
A.2. Anxiolytics
Optionally, if the patient requires it, an anxiolytic could be administered 30-45 minutes before the administration of the coma-inducing medication. It may also be considered to prescribe them 24-48 hours before euthanasia to reduce anxiety in the days leading up to it.
The recommended medications and doses are as follows:
a) Lorazepam 1-2mg orally
b) Diazepam 10-25 mg orally
c) Midazolam 7.5-15 mg orally
The dose of anxiolytic will depend on the patient's clinical condition and the dose and duration of the patient's usual intake of benzodiazepines.
B. COMA-INDUCING MEDICATION
The second step is to take a coma-inducing drug containing
pentobarbital: oral solution of pentobarbital 15g in 100ml.
The use of pentobarbital is recommended because the production of secobarbital is very limited, which could cause supply problems.
There are no drugs containing pentobarbital or secobarbital marketed for human use in the country, nor is it possible to obtain a drug registered in another country in a suitable oral form containing any of these active ingredients, so it will be necessary to prepare an oral solution.
Annex III includes the complete formula, as well as recommendations for its preparation and storage. To prepare it, Hospital Pharmacy Services must obtain the raw materials through the same channels used for the preparation of medicines. The pentobarbital solution can be prepared in advance and is stable for one month at room temperature (25ÂşC). It should not be refrigerated or frozen.
In the event of a shortage (shortage) of pentobarbital (and secobarbital), intravenous administration is recommended.
The territories may manage requests for these products centrally, organizing a hospital pharmacy service as a reference point for the entire territory.
3.1.2-. DURATION OF THE PROCESS
- The period of time between the administration of the coma-inducing drug and the moment of death varies from person to person, but in the vast majority of cases, it takes less than 30 minutes. However, it can sometimes take longer (2-3 hours).
- Prolonged periods such as these can lead to difficult situations, so it is advisable to agree on a maximum time limit of 2 hours with the patient and their family. If the patient has not died within that time, then the procedure for administering medication intravenously should be initiated.
- In anticipation of a prolonged oral process or its failure, the possibility of vascular access should be evaluated and an agreement should be made with the patient in advance to have venous access available before starting the oral process, in case it is necessary to use it.
3.1.3.- PRACTICAL RECOMMENDATIONS
- In general, an intravenous line should be available for all patients before starting the process in case it is necessary to use it.
- It is recommended to fast for 6 hours and have a light meal such as tea with toast approximately 1 hour before taking the coma-inducing medication. The likelihood of triggering the gag reflex caused by ingesting a bitter solution is reduced by having some food in the stomach. This food should not be heavy or difficult to digest, as this would slow down the absorption of the drug and, consequently, the entire process.
- While taking the medication, the patient should adopt the standard Fowler's position, in a semi-sitting position at approximately 45-60Âş with the knees extended or bent, and remain seated for at least 20 minutes, even if unconscious, to optimize absorption and prevent regurgitation.
- The patient should consume the entire medication within 4 minutes. The use of a straw should be avoided as it can slow down intake. Complete intake of the dose must be ensured. Liquids may be taken between swallows as long as they do not prolong the duration of the intake.
- If the patient is unable to hold the glass containing the solution, a healthcare professional from the care team will assist with everything necessary during the process.
- After consuming all of the medication, the patient may drink half a glass of water if they wish. The residual bitter taste of the medication can be mitigated by drinking something with a different flavor, such as chocolate, a strong liqueur, or a non-carbonated beverage at room temperature, half a glass. Liqueurs or creamy and milky beverages should be avoided.
- If the patient vomits, it is advisable to use the intravenous route.
- The medication can also be administered to patients with a nasogastric tube (it should be rinsed beforehand to ensure that it does not become blocked during administration of the medication).
- The nasogastric tube has an opening/closing mechanism that can, in most cases, be opened and closed by the patient. There are also enteral feeding pumps that connect to the patient's nasogastric tube and can be operated in the same way as intravenous administration pumps. In both cases, self-administration could be considered.
