**9. What can be done to shorten life? Using one's own resources**

#### **9.1 Ending life without a doctor**

#### *9.1.1 Why we die*

Man is an obligate aerobe [13]. Every cell in our bodies depends on oxygen for the metabolic processes that sustain life. Although some cells such as skeletal muscles can function anaerobically (without oxygen) for a short time, accumulating an oxygen debt by forming lactic acid to be broken down when oxygen is available again, the brain cannot. The brain requires a continuing and largely uninterrupted supply of oxygen, and therefore of the blood that carries oxygen. All methods of producing death that we discuss as methods of suicide or euthanasia interrupt oxygen to the brain. Lethal doses of sedatives may stop breathing, may allow the airway to obstruct so air exchange ceases, and may themselves stop the heart. Major trauma (e.g., gunshot, car crash, and fall from a height) may destroy the brain or heart, or more likely will lead to blood loss that eventually leaves the heart running on empty, with no

oxygenated blood to send to the brain. Hanging or strangulation stops blood flow to the brain. Poisons may stop the heart. Inhaling an inert gas displaces oxygen from the lungs, leading to oxygen lack, rapid unconsciousness, and rapid death of brain and then heart.

#### **9.2 Suicide in the USA: grading the methods**

Suicide without physician assistance accounts for about 1.5% of deaths worldwide [14]. Rates vary by country, from as high as 53 deaths per 100,000 population in Greenland to as few as 3 per 100,000 in Peru [15]. In the USA, rates vary by state from a high of 29.6 per 100,000 in Montana to a low of 6.1 per 100,000 in the District of Columbia [16].

"lostallhope.com" has an extensive listing of methods of killing oneself, evaluated according to lethality (99% for shotgun to head, 6% for cutting wrists), time required (1.4 min for shotgun to chest, 456 min for overdose of nonprescription drugs), and agony (3.75 for explosives, 95 for setting fire to self). Those seriously evaluating methods for ending their own lives may want to examine this list of options, none of which require assistance from a physician.

Not included in this list is any accounting of the effect on bystanders, on those who find the person who has accomplished suicide, and on families. In general, some of the most effective and available methods are those frequently used, with lifelong effects on survivors and those left to clean up after a violent death.

#### **9.3 Less easily available methods**

Several methods of ending life are less violent.

#### *9.3.1 Medications*

Medications are extensively dealt with in the three references above. In general, non-prescription overdoses have a high risk of failure. However, prescription overdoses not officially provided by assisted suicide programs also fail at a high rate. Opioids (narcotics) are often used by those who want to bypass physician consultation and use materials available at home. Some cancer patients will have massive doses of opioids at home, and some will be encouraged to take huge doses of these medications as a method of inducing respiratory arrest and death. Be warned! Patients who have been taking opioids for pain relief will be refractory to the respiratory effects of even massive doses of drugs and will very likely commit themselves to several days of deep sleep and a distressing wake-up in the midst of continuing life. Worse, many will have communicated their plans to family, who may panic on discovering that the intended lethal dose is not working, taking actions to bring death to their loved one that will lead to their having committed homicide, whether charged with it or not.

Poisons, such as insecticides, are also extensively dealt with in the references. All such methods have a high risk of failure and continued life with injury and cannot be recommended for consideration.

#### *9.3.2 Inert gas inhalation*

Inhaling inert gas (helium, argon, or nitrogen) is a painless, effective, and very accessible means of dying. Both books cited above describe technique and equipment in detail. Although doctors could recommend this setup as more effective than the medications they prescribe, they do not. Doctors prescribe medication, for the most part, and do not think of inhalation. Anesthesiologists think of inhalation but are generally not involved in assisting suicides.

"Painless" dying occurs when the brain stops functioning first, and then the heart. This can happen with drugs that abolish consciousness first, then stop breathing, then stop the heart. Eliminating oxygen from the air being breathed can also abolish consciousness first and then lead to rapid death of brain and heart, all with no poison or toxin at all. How can that happen?

In normal breathing we inhale air containing 21% oxygen, 78% nitrogen, 1% other gases, and very little carbon dioxide (0.04%). Since the body uses oxygen and produces carbon dioxide in its metabolic processes, the exhaled air after exchange in the lungs contains less oxygen (17%) and much more carbon dioxide (4%, about 100 times as much). Nitrogen is still there unchanged, but exhaled water vapor has diluted it a bit.

Breathing is automatic, generally. Our respiratory control center notices that carbon dioxide is rising and triggers a breath. Our body's breathing control mechanism is very sensitive to little rises in carbon dioxide. Too much carbon dioxide sends a loud alarm signal to the brain to defend the airway at any expense, because if carbon dioxide is rising something has gone frightfully wrong with breathing. Anybody who has breathed for even a short time into a paper bag, rebreathing carbon dioxide as it builds up, knows the desperate feeling of suffocation that shortly makes us take the bag away and breathe fresh air again.

Unlike too much carbon dioxide, the body has very weak alarms for too little oxygen. Rather, low oxygen produces primarily sleepiness and then unconsciousness. A pilot whose oxygen supply has been interrupted, or a shipyard worker who has unknowingly entered a chamber flushed with nitrogen that has displaced all the oxygen, feels no distress but keeps on breathing normally until unconsciousness sets in. Breathing is perfectly normal, even when there is no oxygen in the air, so the carbon dioxide level stays normal and the carbon dioxide alarm is never set off. A single lungful of an inert gas, such as helium, can produce rapid hypoxia (oxygen shortage) and rapid unconsciousness with no sensation of being short of breath. Anybody who has inhaled the entire content of a helium balloon and held their breath can attest to the rapid onset of light-headedness and impending loss of consciousness. Usually, the person breathing from the balloon would lose consciousness, drop the balloon, and be restored by breathing oxygen-containing room air, since breathing would not stop. If, however, an entire balloon of helium surrounded the person's head so that breathing pure helium would continue, death would rapidly follow, and the person who dies would only have been aware of falling peacefully asleep, breathing normally.

This phenomenon is the basis of a suicide technique known as "inert gas inhalation." An inert gas is one that has no toxic or anesthetic properties of its own but simply displaces oxygen in pure gas breathing. Nitrogen, argon, and helium are the commonest examples of inert gases. Breathing from a large plastic bag (think turkey bag) filled with one of these gases placed around the head and face, sealed loosely at the neck, will produce unconsciousness within one to three breaths, and death within minutes. All inert gases can be purchased or rented from gas suppliers, welding shops, or even toy stores that carry balloon supplies (though helium that has been blended with 20% oxygen would not work for this purpose). Inert gas inhalation requires some preparation and some purchase of supplies but does not require the presence of another (though recommended). Most importantly, it does not require a prescription or the participation of a doctor. It leaves no telltale signs, creates no distressing mess,

and (especially in the case of nitrogen) is generally undetectable on autopsy. These features make it the technique of choice for those looking for a painless, low-stress approach to suicide that does not require requesting a physician's participation.

#### *9.3.3 Voluntarily stopping eating and drinking (VSED)*

Since eating and drinking are essential to life, one way to control life is to control eating and drinking. Stopping eating and drinking, it can be argued, is ethically permissible in the same way that foregoing life-sustaining treatment is permissible. In fact, failing to honor a competent patient's refusal of food and drink could lead to an attempt at force feedings, with a nasogastric tube and restraints, a complete violation of a patient's dignity and autonomy. The Supreme Court of the United States of America has affirmed the right of a capable individual to refuse any unwanted treatment [17], even if that refusal results in death. Dr. Timothy Quill has written an up-todate and complete book with answers to virtually all questions about VSED [18].

Death usually occurs within 1–3 weeks of starting a fast, depending on the patient's physical condition. Dehydrated, cachectic patients decline in a shorter time than obese, well-hydrated patients. This is not a process for a solo individual—as the fasting person declines, round-the-clock attention becomes necessary. Further, general agreement of family and caregivers gives peace and support for a process that is not easy every minute.

The first few days of fasting may find the patient awake and responsive, able to reminisce and to examine in detail the course chosen. As dehydration progresses, the patient becomes sleepier and more lethargic, eventually becoming completely unresponsive before death. Though pain and discomfort are not common, good palliative support is invaluable.

Once committed, most patients want the process to move as quickly as possible. The number one bit of advice is to take no fluids at all, including fluids taken with medication. Even a little bit of water every day may prolong the dying process by days. Most patients will complete their fasting journey in several days to a week [19]. Those who take longer are almost always taking some sort of fluids. In a Dutch study of the VSED experience of patients of 708 family physicians median time to death was 7 days; 8% had a prolonged process of 14 days or more [20].

VSED is particularly well suited to patients with gastrointestinal obstruction or difficulty swallowing, or those with sufficient control to deal with discomfort in early stages. For some, VSED has the appeal of being an entirely natural process that needs no medication or instrumentation. It is also legal and effective even in states where assisted suicide is not protected. Although patient experience is better if those in the environment are supportive, the process depends entirely on an individual decision. VSED is supported by most hospices and is an extension of the end-of-life process that many experience, with stopping eating and drinking as death approaches.

## **10. Get your financial house in order**

Do not forget about getting your financial house in order—will, living will, POA selection, accounts in order, insurances discovered, etc. Having all the details of your accounts, beneficiaries, funeral wishes and such in one place will make things easier for your heirs and those who are tasked with planning and executing your wishes. Use a simple book where you can fill in the essential information, or you can provide your attorney's information if your trust and/or will is there.

*Leaving Early: The Reality of Assisted Suicide and Euthanasia in 2022 DOI: http://dx.doi.org/10.5772/intechopen.105989*
