Talvikki
Elementalist
- Nov 18, 2021
- 822
An euthanasia that does not succeed immediately is rare but can be traumatic for the doctor and those involved. Recently, a Dutch general practitioner shared a highly intense euthanasia experience in a medical journal for Dutch doctors, where his patient only passed away after the administration of four sets of euthanasia drugs, four hours after the procedure began.
The Euthanasia That Didn't Work
As always with euthanasia, my hand trembled as I pressed the doorbell. I always have to take three deep breaths first, knowing that inside, everyone is waiting in tense anticipation, and the bell sounds to them like death announcing itself. The greeting always feels awkward—what do you say? The trick is to take charge without stealing the spotlight. It's the patient's and family's moment, not yours.
The atmosphere was remarkable. Soft piano music played, not from a recording but from someone actually at the keys. The scent of delicious appetizers wafted from beautiful platters being passed around. About twelve people were there, all dressed elegantly, which felt unexpectedly pleasant. It wasn't even unenjoyable. The woman at the center of it all had a heavy smoker's voice that cut through the murmur of the others, making me think once again that she'd have been better off not smoking.
Her lung cancer had spread, and she had resolutely chosen to end her life on her terms. It struck me, as it often does, that people who opt for euthanasia don't shy away when the moment arrives. "Better today than tomorrow," she said.
The transition from greetings to the actual procedure is a strange moment. You don't say, "Well, shall we get started?" But whatever words you choose, that's exactly what they mean. When the time comes to administer, amid those who start crying, there's always one who says something funny, like, "Hey, Pa, remember when that old rustbucket of yours wouldn't start?" and everyone laughs through their tears about something I don't understand but know why it's said.
When the moment arrives, a deep emotion fills the room as the eyes slowly close and life seems to gently drift away.
"Is something supposed to happen, or what?"
That's what I thought was happening with this woman, too. Her eyes were closed. Everyone was silent. Only the pianist played softly on. Her breathing grew shallower—or so I thought. I waited for life to slip quietly from the room, for the end to be final. But something felt off. Her life was still there; I saw her breathing softly. The family saw it too. And they saw that I saw it. The syringes were empty. It's utterly impossible to still be breathing after both have been administered, yet she was. I waited, pretending I had everything under control. The room was deathly silent.
Then, out of nowhere, her loud, gravelly smoker's voice rang out: "Is something supposed to happen, or what?" People clapped hands over their mouths, looked at each other, and started crying. Sweat broke out on my forehead, my heart raced to 180, and all I could think was: this can't be. She opened her eyes, and we locked gazes. Clear as day, she said, "I expected something very different from this." I felt awful for her and thought: this is impossible. The IV went in perfectly, no swelling, it was smooth, no issues, the medication was correct. How can this be?
It was the only time in my adult life I genuinely wanted to call for my mother. Twelve tense, expectant people, trays of appetizers, champagne, piano music. All the emotions and anticipation of the past weeks had converged on this one profound moment everyone had prepared for. And that serene atmosphere was shattered in the most absurd way by the voice of the woman who was supposed to be gone. Is something supposed to happen, or what.
I pulled myself together and calmly addressed the patient and her family. Something went wrong; I'd get the backup set and try again. With shaking knees, I walked to the car, thinking: how, how, how can this be? I returned, performed the procedure again, checked everything. It went technically perfect, yet she stayed awake. Nothing happened.
Realizing I'd ruined an incredibly important moment for these people and both my euthanasia kits were used up, I called the hospital's anesthesiologist: how do I fix this? He launched into a technical spiel about the patient's body weight and whether the dosage was correct. I snapped, "Correct dosage? Normally, 1 milliliter is enough to end it. I've given fifty times that, and nothing's happening—don't talk to me about dosages." This was no help.
Eventually, the ambulance service arrived. I fetched a third and fourth emergency kit from the pharmacy. We administered them intravenously in the groin. Still no result—she kept talking. Recovering from the shock, the others cautiously resumed talking, and the pianist started playing softly again. But the room now held a sobered, disenchanted atmosphere. It would never be what it was meant to be. Meanwhile, we desperately accessed the femoral artery—something you'd normally never consider. That was the fourth kit. Only half an hour later—by which point I was arranging to move her to the hospital—did she finally pass away at home. It was six o'clock.
This was an unbelievable event. We later concluded it was due to her extremely low blood pressure and high blood viscosity, causing the injected bolus to stay where it was. Only when it was administered arterially did it reach where it needed to, and even then, it took time.
Later, the daughter and I embraced, and she comforted me, seeing how hard it was for me, while I felt for her. "You know what's beautiful?" she said. "Mom always said she wanted euthanasia at six in the evening, because her mother went that way at six. When you could only do two in the afternoon and not five-thirty, she was disappointed. But now, she passed at six after all."
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The described scenario seems like a nightmare for any well-intentioned euthanasia-performing physician and is something a healthcare provider hopes never to encounter. According to current guidelines, the 2-gram dose of thiopental administered intravenously is so extremely high that a patient would normally be guaranteed to fall into a deep coma and often die immediately. The most logical explanation for the unusual course of this case is not the dose itself, but a lack of circulation of the medication to the brain, despite the patient remaining fully responsive. The additional three bolus injections were merely a "push" to get the barbiturate to the brain so it could do its job.
We don't know all the details, but it's possible that the patient's condition caused circulation to be centralized at an extremely low output (peripheral vasoconstriction), leaving the bolus largely stagnant in the peripheral vessels and acting like a "slow-release" preparation with minimal delivery. A spastic vascular reaction to the drug during the initial administration could also have contributed to or caused a "lock-up" of the bolus in the peripheral vessels. Finally, thrombosis of the subclavian vein or superior vena cava syndrome could have played a role, impeding the flow of medication to the superior vena cava and right atrium.
Intravenously administered medication in the presence of potential "obstructions" to the heart or with very slow circulation is best managed with a carrier infusion or an alternative venous access, such as through the other arm, foot, or, if necessary, the groin. However, in an acute phase without additional tools, this is harder to achieve and may fail. Moreover, it can be potentially traumatizing for bystanders.
The intensity of this experience raises questions about the need for adjustments to the official euthanasia guideline and the derived guidelines. Especially if this could be prevented with relatively simple procedural changes.
One proposal could be to make the choice between bolus and a modified infusion administration less discretionary. Pre-inserting a well-functioning infusion with a relatively high flow rate, continued after the thiopental bolus, might have improved the procedure's outcome. This ongoing infusion would also be maintained after the coma check and rocuronium administration until the patient's death.
The Euthanasia That Didn't Work
As always with euthanasia, my hand trembled as I pressed the doorbell. I always have to take three deep breaths first, knowing that inside, everyone is waiting in tense anticipation, and the bell sounds to them like death announcing itself. The greeting always feels awkward—what do you say? The trick is to take charge without stealing the spotlight. It's the patient's and family's moment, not yours.
The atmosphere was remarkable. Soft piano music played, not from a recording but from someone actually at the keys. The scent of delicious appetizers wafted from beautiful platters being passed around. About twelve people were there, all dressed elegantly, which felt unexpectedly pleasant. It wasn't even unenjoyable. The woman at the center of it all had a heavy smoker's voice that cut through the murmur of the others, making me think once again that she'd have been better off not smoking.
Her lung cancer had spread, and she had resolutely chosen to end her life on her terms. It struck me, as it often does, that people who opt for euthanasia don't shy away when the moment arrives. "Better today than tomorrow," she said.
The transition from greetings to the actual procedure is a strange moment. You don't say, "Well, shall we get started?" But whatever words you choose, that's exactly what they mean. When the time comes to administer, amid those who start crying, there's always one who says something funny, like, "Hey, Pa, remember when that old rustbucket of yours wouldn't start?" and everyone laughs through their tears about something I don't understand but know why it's said.
When the moment arrives, a deep emotion fills the room as the eyes slowly close and life seems to gently drift away.
"Is something supposed to happen, or what?"
That's what I thought was happening with this woman, too. Her eyes were closed. Everyone was silent. Only the pianist played softly on. Her breathing grew shallower—or so I thought. I waited for life to slip quietly from the room, for the end to be final. But something felt off. Her life was still there; I saw her breathing softly. The family saw it too. And they saw that I saw it. The syringes were empty. It's utterly impossible to still be breathing after both have been administered, yet she was. I waited, pretending I had everything under control. The room was deathly silent.
Then, out of nowhere, her loud, gravelly smoker's voice rang out: "Is something supposed to happen, or what?" People clapped hands over their mouths, looked at each other, and started crying. Sweat broke out on my forehead, my heart raced to 180, and all I could think was: this can't be. She opened her eyes, and we locked gazes. Clear as day, she said, "I expected something very different from this." I felt awful for her and thought: this is impossible. The IV went in perfectly, no swelling, it was smooth, no issues, the medication was correct. How can this be?
It was the only time in my adult life I genuinely wanted to call for my mother. Twelve tense, expectant people, trays of appetizers, champagne, piano music. All the emotions and anticipation of the past weeks had converged on this one profound moment everyone had prepared for. And that serene atmosphere was shattered in the most absurd way by the voice of the woman who was supposed to be gone. Is something supposed to happen, or what.
I pulled myself together and calmly addressed the patient and her family. Something went wrong; I'd get the backup set and try again. With shaking knees, I walked to the car, thinking: how, how, how can this be? I returned, performed the procedure again, checked everything. It went technically perfect, yet she stayed awake. Nothing happened.
Realizing I'd ruined an incredibly important moment for these people and both my euthanasia kits were used up, I called the hospital's anesthesiologist: how do I fix this? He launched into a technical spiel about the patient's body weight and whether the dosage was correct. I snapped, "Correct dosage? Normally, 1 milliliter is enough to end it. I've given fifty times that, and nothing's happening—don't talk to me about dosages." This was no help.
Eventually, the ambulance service arrived. I fetched a third and fourth emergency kit from the pharmacy. We administered them intravenously in the groin. Still no result—she kept talking. Recovering from the shock, the others cautiously resumed talking, and the pianist started playing softly again. But the room now held a sobered, disenchanted atmosphere. It would never be what it was meant to be. Meanwhile, we desperately accessed the femoral artery—something you'd normally never consider. That was the fourth kit. Only half an hour later—by which point I was arranging to move her to the hospital—did she finally pass away at home. It was six o'clock.
This was an unbelievable event. We later concluded it was due to her extremely low blood pressure and high blood viscosity, causing the injected bolus to stay where it was. Only when it was administered arterially did it reach where it needed to, and even then, it took time.
Later, the daughter and I embraced, and she comforted me, seeing how hard it was for me, while I felt for her. "You know what's beautiful?" she said. "Mom always said she wanted euthanasia at six in the evening, because her mother went that way at six. When you could only do two in the afternoon and not five-thirty, she was disappointed. But now, she passed at six after all."
---
---
The described scenario seems like a nightmare for any well-intentioned euthanasia-performing physician and is something a healthcare provider hopes never to encounter. According to current guidelines, the 2-gram dose of thiopental administered intravenously is so extremely high that a patient would normally be guaranteed to fall into a deep coma and often die immediately. The most logical explanation for the unusual course of this case is not the dose itself, but a lack of circulation of the medication to the brain, despite the patient remaining fully responsive. The additional three bolus injections were merely a "push" to get the barbiturate to the brain so it could do its job.
We don't know all the details, but it's possible that the patient's condition caused circulation to be centralized at an extremely low output (peripheral vasoconstriction), leaving the bolus largely stagnant in the peripheral vessels and acting like a "slow-release" preparation with minimal delivery. A spastic vascular reaction to the drug during the initial administration could also have contributed to or caused a "lock-up" of the bolus in the peripheral vessels. Finally, thrombosis of the subclavian vein or superior vena cava syndrome could have played a role, impeding the flow of medication to the superior vena cava and right atrium.
Intravenously administered medication in the presence of potential "obstructions" to the heart or with very slow circulation is best managed with a carrier infusion or an alternative venous access, such as through the other arm, foot, or, if necessary, the groin. However, in an acute phase without additional tools, this is harder to achieve and may fail. Moreover, it can be potentially traumatizing for bystanders.
The intensity of this experience raises questions about the need for adjustments to the official euthanasia guideline and the derived guidelines. Especially if this could be prevented with relatively simple procedural changes.
One proposal could be to make the choice between bolus and a modified infusion administration less discretionary. Pre-inserting a well-functioning infusion with a relatively high flow rate, continued after the thiopental bolus, might have improved the procedure's outcome. This ongoing infusion would also be maintained after the coma check and rocuronium administration until the patient's death.
