X-Message-Number: 24245
From:
Date: Mon, 14 Jun 2004 23:42:11 EDT
Subject: Oreg'n, Asst'd Suic'de & Hypoth'rmia
Content-Language: en
Hello all:
A couple of weeks ago I wrote about the possibility of a dying cryonocist
going to Oregon and using their Assisted Suicide law to end life a little early,
possibly using a blood cooling machine or a timer valve with a bathtub. This
posting got some published praise and many people seemed interested.
However, there are some, probably professionals concerned about their
professional reputation, who seldom post to Cryonet because it is public --
Google
searches will find it. Two of these wrote me with agonized pleas *not* to
pursue this. They feared that any machine connected with cryonics and assisted
suicide would remind the public of Dr Kervorkian. Then politicians would go mad
and both assisted suicide and cryonics would be outlawed.
I disagreed but tried to find a way acceptable to both sides. We
corresponded. One critic grew angry and sarcastic and we stopped mailing, but
the other
was patient and restrained (as I'd like to think I was) and eventually I made
a suggestion that was agreeable. (My correspondent emphasizes he or she is
*not* making this suggestion.) The idea is presented fully below.
Although it looks legal to me from my reading of the law, I am not a lawyer,
not giving legal or any other advice, and we'd want to get a lawyer to check
it out before acting in any way. Discussion, of course, is fine.
BTW, there was *a lot* of agony here, and the outcome says a lot for patience
in these matters.
(If this post is too long for Cryonet I'll send the missing section(s) over
the next day or two.)
Alan Mole
A Promising Method of Transition
Summary: For a dying person, to avoid terminal agonies and deterioration of
body and brain, and to die at a known time so cryo procedures can start
promptly, and to die of hypothermia so brain deterioration is delayed for 45
minutes
or even several hours, Oregon's Assisted Suicide Law may provide a solution.
The person would go to Oregon, meet the requirements of the law, and fill out
a form for assisted suicide. A 15 day waiting period would pass. The doctor
would provide the drugs and stand by. The patient would slip into a
comfortable warm bath, take the drugs -- *and open the cold tap moderately*.
Within
three minutes he or she would lose consciousness and never notice the increasing
coldness of the water. Within a half hour the water would be cold, and within
an hour or two he'd die of hypothermia, perhaps with a core temperature as low
20 C. When his heart stopped the doctor would immediately pronounce death
and the cryo team begin its work. There would be minimal delay from heart
stoppage to cryonics stabilization procedures, and plenty of time to work before
brain deterioration began.
Details:
Too many cryo patients die, then lie around for hours before they are
discovered to be dead, a doctor is summoned and pronounces them so, the rescue
team
arrives and work starts at last. And since they die at normal body
temperature, the brain deteriorates beyond recovery by conventional medical
technology in
as little as four minutes. This is not promising.
Far better to die at a prearranged time and place with everyone present, and
to die cold so brain deterioration is delayed for a long time.
Oregon allows assisted suicide. One goes to a doctor and proves he is a
resident of Oregon, The doctor examines him and affirms he is within six months
of death. A second, doctor confirms this independently. A psychiatrist may
have to examine him and pronounce him sane. He affirms his wish to die in front
of two witnesses. Forms are filled out and submitted. (Maybe not submitted
until after death; this part is not clear to me.) A fifteen day waiting period
elapses. The doctor prescribes a lethal dose of drugs, and either provides
them or the patient gets the prescription filled. The patient takes the drugs
and
becomes unconscious in about three minutes. And dies in one to three hours,
usually.
The above fills all requirements except cold. For that we modify the
scenario: The patient gets into a bath of pleasantly hot water. (The law says
nothing about location except that it not be a public place.) He puts a support
under his armpits so he won't slip into the water and drown.
He takes the drugs and turns on the cold tap. He goes to sleep while the
water is still nice and warm, so he never feels it as the water grows colder and
colder. The tub does not overflow because bathtubs have overflow drains near
the top. But gradually the water becomes colder and colder. So does the
patient. His core temperature could go as low as 20C before his heart stops.
(Recoveries from as low as 9C have been reported, but the heart had stopped at
20C
or above.) This takes an hour or so, while death from the drugs now used
usually takes one to four hours. (Barbiturates are now out; there are newer,
better ones.)
(Actual time to die of hypothermia depends on water temperature, body shape
(fat insulates), robustness of subject etc. In some cases the heart might stop
before the core temperature was this low -- also because the drugs might kill
faster. And vasodilators -- drugs that open the blood vessels beneath the
skin and allow faster cooling -- may be used to hasten this. Alcohol is one,
but
if it interacted unfavorably with other drugs, then the physician might be
able to administer vasodilator drugs. And the water should be as cold as
possible -- i.e. a town with cold tap water is best. All this could use some
more
research. Though even if the core temperature were a little high, it should
still be well below normal.)
If there is a danger that the drugs could kill him before he is very cold,
then he could take a large but nonfatal dose so as to sleep deeply without dying
of the drugs. This would force death to be by hypothermia, as desired. (The
doctor can hardly be expected to see whether he takes all the drugs or just
half of them.)
(This too should be discussed. In case hypothermia does *not* kill the
subject, he does not want to linger for weeks in a coma from an inadequate drug
dose .)
I spoke with an Oregon counselor for Compassion in Dying. She said there is
never an autopsy -- they are rare to begin with, and in the case of a person
known to be dying, and attended by a physician, they are unheard of.
She also said there is no reporting requirement as to where the patient died
-- that's private between him and his family. If there were, one could
honestly say "He said he wanted to die in a bath. He slipped into a nice
comforting
warm tub, took the pills and slept." There is no more need to tell the water
temperature when he died than to tell, if he died in bed, whether the blanket
was pink or blue. Thus the public need never know about this choice, and if
they somehow learned, well, most people find baths warm and fuzzy, not at all
like Dr. Kervorkian and "those terrible suicide machines."
Note in the law below, the reports filed are NOT public.
The colder the tap water the better. Someone could find a location getting
water from the mountains where the water is quite cold.
Residency requirements:
I found the actual Oregon statute at
http://www.leg.state.or.us/ors/127.html
Here is the residency requirement:
127.860 3.10. Residency requirement. Only requests made by Oregon residents
under ORS 127.800 to 127.897 shall be granted. Factors demonstrating Oregon
residency include but are not limited to:
(1) Possession of an Oregon driver license;
(2) Registration to vote in Oregon;
(3) Evidence that the person owns or leases property in Oregon; or
(4) Filing of an Oregon tax return for the most recent tax year. [1995
c.3 3.10; 1999 c.423 8]
I think if you rent an apartment or stay with a friend so you have a legal
address, you can get a driver's license on day one. In fact the law usually
demands it. Length of residence to register to vote I don't know (James, could
you call and find out?) Obviously if you rent the merest apartment you'll get a
copy of a lease and be able to show it. With enough advanced warning you could
even file a tax return, using a friend's address as "home". But the tax
return should not be necessary. Note that not all the above (1, 2, and 3) could
be required and any one is probably enough. Consider an old woman who does not
drive, is not registered to vote, and lives in her daughter's house. Neither
1, 2,3 and probably not 4 apply to her, yet she in undeniably a resident. So
if you did 1, maybe 2, and 3, surely you'd be OK. Thus, although indeed the
Oregonians do not *want* people coming from all over to use their law, I think
residency is a paper tiger and would prove to be no obstacle.
You could quite honestly say: "Here is my lease to show I live here now. And
I plan to live here for the rest of my life!"
Hypothermia:
http://www.tc.gc.ca/marinesafety\TP\Tp13822\chapter-1.htm
1. Initial immersion or cold shock ^
On initial immersion, there is a large inspiratory gasp followed by a
four-fold increase in pulmonary ventilation, i.e. severe hyperventilation. This
on
its own can cause small muscle spasms and drowning. Along with this, there is a
massive increase in heart rate and blood pressure. These latter cardiac
responses may cause death, particularly in older, less healthy people. These
effects
last for the first two to three minutes, just at the critical stage of ship
abandonment.
2.. Short-term immersion or swimming failure (Of no interest here)
3. Long-term immersion or hypothermia ^
After thirty minutes or more of immersion, death may occur from hypothermia.
The reason for this is that water has a specific heat 1000 times that of air
and a thermal conductivity of about 25 times that of air. Thus, when a body is
immersed in water below body temperature (37 C), it will inevitably cool to
hypothermic levels at a rate dependent on:
Temperature differential
Clothing insulation
Rate of agitation of the water
Body heat production produced by shivering and exercise
Ratio of body mass to surface area
Subcutaneous fat thickness
State of physical fitness
Diet prior to immersion
Physical behavior and body posture in the water
As the deep body temperature falls, humans lapse into unconsciousness. Death
may
occur in two ways drowning through incapacitation, and cardiac arrest.
Death from drowning will occur in a lightly dressed individual even wearing a
lifejacket, approximately one hour after immersion in water at 5 C, or two
hours
in water at 10 C, or in six hours or less at 15 C (Reference 19).
If the deep body temperature continues to fall, death occurs on average from
cardiac arrest somewhere below a body core temperature of 24 C. The lowest
recorded survival temperature in an accidental victim is 13.7 C (Reference 13).
However, after surgical induction of hypothermia, there has been one reported
incident of resuscitation from a body core temperature of 9 C (Reference 48).
Survival predictions were made from experimental data and case histories from
shipwrecks.
[But the heart stops at 20C or above.]
It appears that in 40-50 F water, survival time is around 40 minutes to an
hour for a healthy person without a survival suit, but this is not perfectly
clear. More research is needed.
I am reliably informed that heart fibrillation could occur at a higher
temperature -- " But you really should do more research about this. Sometimes
it
might only get to 28 degC. See
http://perso.wanadoo.fr/dmtmcham/hypothermia.htm "
And heart monitoring by ECG won't work -- "ECGs are a bad idea because
a) They are not a standard cryonics field item
b) They are not a standard field item because of the risk of EMD
(electro-mechanical dissociation), which a heart physically stops beating, but
the ECG
merrily bleeps along for a long time showing a normal *electrical* rhythm, but
without any pumping blood.
c) They won't work well under water.
What you really want is probably a remote-video-monitored finger-tip
pulse oximeter, like the one in the photo at
http://www.alcor.org/AtWork/p1field.html
Here is the central part of the long law: (URL to the whole thing is above)
127.805 2.01. Who may initiate a written request for medication. (1) An
adult who is capable, is a resident of Oregon, and has been determined by the
attending physician and consulting physician to be suffering from a terminal
disease, and who has voluntarily expressed his or her wish to die, may make a
written request for medication for the purpose of ending his or her life in a
humane and dignified manner in accordance with ORS 127.800 to 127.897.
(2) No person shall qualify under the provisions of ORS 127.800 to
127.897 solely because of age or disability. [1995 c.3 2.01; 1999 c.423 2]
127.810 2.02. Form of the written request. (1) A valid request for
medication under ORS 127.800 to 127.897 shall be in substantially the form
described in ORS 127.897, signed and dated by the patient and witnessed by at
least
two individuals who, in the presence of the patient, attest that to the best
of their knowledge and belief the patient is capable, acting voluntarily, and
is not being coerced to sign the request.
(2) One of the witnesses shall be a person who is not:
(a) A relative of the patient by blood, marriage or adoption;
(b) A person who at the time the request is signed would be entitled to
any portion of the estate of the qualified patient upon death under any will
or by operation of law; or
(c) An owner, operator or employee of a health care facility where the
qualified patient is receiving medical treatment or is a resident.
(3) The patient s attending physician at the time the request is signed
shall not be a witness.
(4) If the patient is a patient in a long term care facility at the
time the written request is made, one of the witnesses shall be an individual
designated by the facility and having the qualifications specified by the
Department of Human Services by rule. [1995 c.3 2.02]
(Safeguards)
(Section 3)
127.815 3.01. Attending physician responsibilities. (1) The attending
physician shall:
(a) Make the initial determination of whether a patient has a terminal
disease, is capable, and has made the request voluntarily;
(b) Request that the patient demonstrate Oregon residency pursuant to
ORS 127.860;
(c) To ensure that the patient is making an informed decision, inform
the patient of:
(A) His or her medical diagnosis;
(B) His or her prognosis;
(C) The potential risks associated with taking the medication to be
prescribed;
(D) The probable result of taking the medication to be prescribed; and
(E) The feasible alternatives, including, but not limited to, comfort
care, hospice care and pain control;
(d) Refer the patient to a consulting physician for medical
confirmation of the diagnosis, and for a determination that the patient is
capable and
acting voluntarily;
(e) Refer the patient for counseling if appropriate pursuant to ORS
127.825;
(f) Recommend that the patient notify next of kin;
(g) Counsel the patient about the importance of having another person
present when the patient takes the medication prescribed pursuant to ORS
127.800 to 127.897 and of not taking the medication in a public place;
(h) Inform the patient that he or she has an opportunity to rescind the
request at any time and in any manner, and offer the patient an opportunity
to rescind at the end of the 15 day waiting period pursuant to ORS 127.840;
(i) Verify, immediately prior to writing the prescription for
medication under ORS 127.800 to 127.897, that the patient is making an informed
decision;
(j) Fulfill the medical record documentation requirements of ORS
127.855;
(k) Ensure that all appropriate steps are carried out in accordance
with ORS 127.800 to 127.897 prior to writing a prescription for medication to
enable a qualified patient to end his or her life in a humane and dignified
manner; and
(L)(A) Dispense medications directly, including ancillary medications
intended to facilitate the desired effect to minimize the patient s
discomfort,
provided the attending physician is registered as a dispensing physician with
the Board of Medical Examiners, has a current Drug Enforcement Administration
certificate and complies with any applicable administrative rule; or
(B) With the patient s written consent:
(i) Contact a pharmacist and inform the pharmacist of the prescription;
and
(ii) Deliver the written prescription personally or by mail to the
pharmacist, who will dispense the medications to either the patient, the
attending
physician or an expressly identified agent of the patient.
(2) Notwithstanding any other provision of law, the attending physician
may sign the patient s death certificate. [1995 c.3 3.01; 1999 c.423 3]
127.820 3.02. Consulting physician confirmation. Before a patient is
qualified under ORS 127.800 to 127.897, a consulting physician shall examine
the patient and his or her relevant medical records and confirm, in writing, the
attending physician s diagnosis that the patient is suffering from a terminal
disease, and verify that the patient is capable, is acting voluntarily and
has made an informed decision. [1995 c.3 3.02]
127.825 3.03. Counseling referral. If in the opinion of the attending
physician or the consulting physician a patient may be suffering from a
psychiatric or psychological disorder or depression causing impaired judgment,
either physician shall refer the patient for counseling. No medication to end a
patient s life in a humane and dignified manner shall be prescribed until the
person performing the counseling determines that the patient is not suffering
from a psychiatric or psychological disorder or depression causing impaired
judgment. [1995 c.3 3.03; 1999 c.423 4]
127.830 3.04. Informed decision. No person shall receive a
prescription for medication to end his or her life in a humane and dignified
manner
unless he or she has made an informed decision as defined in ORS 127.800 (7).
Immediately prior to writing a prescription for medication under ORS 127.800 to
127.897, the attending physician shall verify that the patient is making an
informed decision. [1995 c.3 3.04]
127.835 3.05. Family notification. The attending physician shall
recommend that the patient notify the next of kin of his or her request for
medication pursuant to ORS 127.800 to 127.897. A patient who declines or is
unable to
notify next of kin shall not have his or her request denied for that reason.
[1995 c.3 3.05; 1999 c.423 6]
127.840 3.06. Written and oral requests. In order to receive a
prescription for medication to end his or her life in a humane and dignified
manner,
a qualified patient shall have made an oral request and a written request, and
reiterate the oral request to his or her attending physician no less than
fifteen (15) days after making the initial oral request. At the time the
qualified patient makes his or her second oral request, the attending physician
shall
offer the patient an opportunity to rescind the request. [1995 c.3 3.06]
127.845 3.07. Right to rescind request. A patient may rescind his or
her request at any time and in any manner without regard to his or her mental
state. No prescription for medication under ORS 127.800 to 127.897 may be
written without the attending physician offering the qualified patient an
opportunity to rescind the request. [1995 c.3 3.07]
127.850 3.08. Waiting periods. No less than fifteen (15) days shall
elapse between the patient s initial oral request and the writing of a
prescription under ORS 127.800 to 127.897. No less than 48 hours shall elapse
between
the patient s written request and the writing of a prescription under ORS
127.800 to 127.897. [1995 c.3 3.08]
127.855 3.09. Medical record documentation requirements. The following
shall be documented or filed in the patient s medical record:
(1) All oral requests by a patient for medication to end his or her
life in a humane and dignified manner;
(2) All written requests by a patient for medication to end his or her
life in a humane and dignified manner;
(3) The attending physician s diagnosis and prognosis, determination
that the patient is capable, acting voluntarily and has made an informed
decision;
(4) The consulting physician s diagnosis and prognosis, and
verification that the patient is capable, acting voluntarily and has made an
informed
decision;
(5) A report of the outcome and determinations made during counseling,
if performed;
(6) The attending physician s offer to the patient to rescind his or
her request at the time of the patient s second oral request pursuant to ORS
127.840; and
(7) A note by the attending physician indicating that all requirements
under ORS 127.800 to 127.897 have been met and indicating the steps taken to
carry out the request, including a notation of the medication prescribed. [1995
c.3 3.09]
127.860 3.10. Residency requirement. Only requests made by Oregon
residents under ORS 127.800 to 127.897 shall be granted. Factors demonstrating
Oregon residency include but are not limited to:
(1) Possession of an Oregon driver license;
(2) Registration to vote in Oregon;
(3) Evidence that the person owns or leases property in Oregon; or
(4) Filing of an Oregon tax return for the most recent tax year. [1995
c.3 3.10; 1999 c.423 8]
127.865 3.11. Reporting requirements. (1)(a) The Department of Human
Services shall annually review a sample of records maintained pursuant to ORS
127.800 to 127.897.
(b) The department shall require any health care provider upon
dispensing medication pursuant to ORS 127.800 to 127.897 to file a copy of the
dispensing record with the department.
(2) The department shall make rules to facilitate the collection of
information regarding compliance with ORS 127.800 to 127.897. Except as
otherwise
required by law, the information collected shall not be a public record and
may not be made available for inspection by the public.
(Emphasis mine, Alan)
(3) The department shall generate and make available to the public an annual
statistical report of information collected under subsection (2) of this
section. [1995 c.3 3.11; 1999 c.423 9; 2001 c.104 40]
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