This week, the Labour MP Kim Leadbeater finally put forward the much-awaited bill on assisted dying, which will likely be discussed in the coming weeks. Supporters of the bill have been campaigning on the issue for years, with legislation on the topic most recently rejected by the House of Commons in 2015. This bill, however, is little better. Above all, in its vagueness it fails to outline what drugs can legally be administered to help someone end their life.

The Terminally Ill Adults (End of Life) Bill, as it is officially known, simply states that ‘the Secretary of State must, by regulations, specify one or more drugs or other substances for the purposes of the Act’. But this is problematic: different countries where assisted dying is already legal use very different drugs regimens – and they are often far from successful. 

The practicalities involved in legalising assisted dying – such as what cocktail of drugs can legally be used – are important to consider, not least because most people are unlikely to know what such processes look like. The late Terry Pratchett once envisaged sipping a glass of brandy, sitting in his garden on a warm summer’s day, and ‘washing down whatever modern version of the Brompton cocktail [a potent mixture of painkillers] some helpful medic could supply’.

This picture-book notion of death is a far cry from the clinical reality of what legal assisted dying actually involves: sedatives, anti-sickness medications and a bitter-tasting crush of up to 80 tablets, often mixed with sweet syrup to mask its taste. In the palliative care clinic where I work as a consultant in Wales, assisted dying is sometimes brought up by patients or those close to them, but knowledge on the topic is scant. Many even think it merely involves stopping chemotherapy and just forgoing hospital visits. Throughout all the questions, there is always a baseline assumption that assisted dying will likely mean a smoother and calmer death. But does it?

Most popular

RAF Brize Norton chief’s views on patriotism revealed

Studies looking at practices in different countries such as Switzerland, the US, Belgium and Canada, have found great disparities in the medications prescribed and their ability to smoothly and effectively end a life. Assisted dying applicants, the studies found, are at substantial risk of distressing deaths. High doses of barbiturates, frequently either pentobarbital or secobarbital, are commonly used by clinicians to assist suicide. Such drugs are popularly used for assisted suicide in countries such as Switzerland and are recommended both by the Netherlands and Canada’s assisted dying medical guidelines.

In the US, however, such barbiturate medications have become increasingly scarce and expensive, prompting doctors to seek alternative drug combinations. According to Oregon’s 2020 Death with Dignity Act report, pentobarbital has been unavailable for assisted deaths since 2015, and secobarbital since 2019. 

As such, in states where assisted deaths are legal, doctors have started prescribing combinations of diazepam, digoxin, morphine sulphate and amitriptyline (DDMA) or diazepam, digoxin, morphine sulphate and propranolol (DDMP) for assisted dying instead. DDMA, for example, is most frequently used in New Jersey and Oregon, while DDMP predominates in Colorado and Hawaii.

But this is just a record of regulated usage: in the majority of US states where assisted suicide is legal – Washington, California, Washington DC, Maine and Vermont – there is no record of the drugs a patient uses to help end their own life. In Oregon, patients typically take the lethal drugs behind closed doors and without a healthcare professional present to make note of any complications they experience. According to the Death with Dignity Act report, health care professionals were reportedly present in only one in five such deaths, while assisted suicide complications are ‘unknown’ in 71 per cent of cases.

Drugs such as the DDMA and DDMP combinations are used with the intention to shutting down the breathing system and stopping the heart. But that doesn’t mean they trigger death immediately: it can often take hours or even days to occur.

The trouble is that the time to death after ingesting these lethal drugs seems highly unpredictable. From available data for Oregon in 2023, for example, the time from drug ingestion to death has ranged from three minutes (too short for the cause to have been oral drugs) to 137 hours (over five and a half days). More than a third of assisted suicide deaths to take place in the state with recorded data have taken over an hour, and 7.6 per cent over six hours. Time to death has become longer since the introduction of experimental DDMA and DDMP drug cocktails, with approximately half of patients given either combination experiencing a prolonged death lasting more than an hour. Knowing this, no proponent of assisted suicide can honestly guarantee a death free from any distress when such a lethal cocktail is given in massive doses.

These are the big unknowns about assisted dying that no one seems to mention. And of course, after death has occurred, its impossible to ask for feedback. Leadbeater’s bill includes includes no requirements to record the duration of death, nor any complications, so under the legislation we would never know for certain if a patient had suffered.

A study published in the journal Anaesthesia found that in the Netherlands, for example, patients usually lost consciousness within five minutes after ingesting lethal drugs orally. However, their deaths took considerably longer. Although for two thirds of patients their hearts stopped beating within 90 minutes, in a third of cases death could take up to 30 hours. Other complications included difficulty in swallowing the prescribed dose in up to 9 per cent of cases, while one in ten vomited after taking the drugs (both of which prevented suitable dosing). Alarmingly, in up to 2 per cent of cases, patients even re-emerged from their comas. For this reason, legislation on euthanasia (where a doctor can legally kill a patient) will probably need to be looked at in addition to that on assisted suicide, to ensure that botched assisted suicides don’t result in prolonged agony.

This is reflected in data published in Oregon, where annual complication rates have been as high as 14.8 per cent and patients are reported to have experienced difficulty swallowing, or medication regurgitation or seizures. Some have even regained consciousness after ingesting the ‘lethal’ drugs. 

One reason for such difficulties during the assisted dying process may be that ingesting sufficiently toxic dosages of the prescribed drugs can prove a significant, and often distressing, challenge. In order to achieve an ‘assisted’ death, patients in the US have been required to ingest 90 to 100 barbiturate pills by crushing them and mixing them into a sweet solvent. The bitterness and the potential for the drugs to induce vomiting requires anti-sickness tablets prior to taking the barbituates to prevent this.

One woman described the painful experience of assisting her aunt’s suicide in 2016: 

The mountain of powder we poured into more sugar syrup created a half-cup of sludge so bitter it literally burned my tongue. And my aunt, who could barely swallow water, had to drink all of it in under five minutes to ‘ensure success.’… When we sat back down at the kitchen table, white powder everywhere, we all had to wonder, ‘Who the hell wrote this law?’ We had been forced to assist in the most bizarre fashion, jumping through seemingly random legal hoops and meeting arbitrary deadlines while my aunt suffered, and finally emptying capsules, making an elixir so vile I cried when I knew she had to drink it. This was death with dignity?

We need unbiased research on whether assisted deaths are indeed safe. But here lies yet another problem: which assisted dying clinic would be content for such research, which may expose huge concerns, to go ahead on their premises? Simple EEG studies looking at the brain activity of individuals who die an assisted suicide, to capture the moments before death, and comparing them to ordinary deaths, could be a start. This would be an obvious way to collect evidence on the effects of assisted dying – rather than open up a Pandora’s box with no evidence base, and only the anecdotal reports of bystanders and clinicians supplying the medication to go off.