Physician-assisted Suicide

Drug Information Issues

Currently in Oregon, secobarbital is the medication most commonly prescribed for physician-assisted suicide, followed by pentobarbital.^[3] The lethal dose prescribed is typically 9 g of secobarbital in capsules or 10 g of pentobarbital liquid, to be consumed at one time.^[4–6] The contents of the secobarbital capsules or the pentobarbital liquid should be mixed with a sweet substance such as juice to mask the bitter taste. Until the time of use, the medication must be stored out of reach of children and kept away from others to prevent unintentional overdose or abuse.

The pharmacist or physician should instruct patients to take the lethal dose on an empty stomach to increase the rate of absorption.^[7] The typical dose of pentobarbital as an oral hypnotic for adults is 100–200 mg at bedtime, and that of secobarbital is 100 mg orally at bedtime. Patients receiving the lethal dose of secobarbital or pentobarbital should be instructed to take an antiemetic (e.g., metoclopramide) about one hour before ingesting the barbiturate to prevent nausea and vomiting.^[6] Cases of vomiting after taking an antiemetic have been reported; in the event of vomiting after medication ingestion, patients should be instructed to have a family member contact the attending physician to determine the course of action.^[2] Also, patients should be instructed that if they decide not to end their life after ingesting the medication, they must contact emergency medical services to begin lifesaving measures.^[2]

Patients need to be informed of appropriate disposal methods in case the medication is not taken; the Food and Drug Administration provides guidance on that issue.^[8] Secobarbital and pentobarbital are not among the medications recommended for disposal by flushing, and they should be placed in the household trash after mixing with an unpalatable substance such as coffee grounds. Unused medications also can be brought to a drug "take-back" program involving law enforcement personnel. Patients are not permitted to return controlled-substance medications to a pharmacy.^[9]

Proper reporting by pharmacists to the Oregon Department of Human Services is mandated by the DWDA so the agency can collect information and publish an annual statistical report.^[10] Pharmacists are required to complete and submit, within 10 calendar days of dispensing a lethal medication dose, a pharmacy dispensing record form with the following information: the patient's name and date of birth; the prescribing physician's name and phone number; the pharmacist's name, address, and phone number; the medication and quantity dispensed; and the dates the prescription was written and dispensed.

Since the Oregon DWDA took effect in 1997, 460 patients have died by self-administration of a lethal dose of a prescription medication.^[11] In 2009, 95 prescriptions were written for lethal medications, resulting in 59 deaths (in the remaining cases, the medication was not ingested). About 80% of the patients had malignant cancer, and the most commonly ingested lethal medication was secobarbital (85% of cases). About 78% of the patients were 55–84 years of age. The time from ingestion to death ranged from two minutes to 4.5 days.^[3,11]

The state of Washington passed a DWDA that mirrors Oregon's statute and became effective in March 2009. Participating pharmacists in Washington must submit the pharmacy dispensing record within 30 days of dispensing to the registrar of the state's Center for Health Statistics.^[12] The Washington State Department of Health issued its first report in March 2010. According to the report, a lethal dose of medication, usually secobarbital (89% of cases), was dispensed to 63 patients by 29 different pharmacists.^[13] Of those 63 patients, 36 individuals died as a result of ingesting the medication, 7 died without ingestion, and data are missing for 4 individuals; data collection for the remaining 16 individuals is pending. The most common reported illnesses were cancer (79%), respiratory disease or other illnesses (12%), and amyotrophic lateral sclerosis (9%). The required dispensing record form was submitted to the Department of Health for all 63 patients. The reported times from medication ingestion to death ranged from nine minutes to 28 hours.

Pharmacists and physicians cannot be held liable for participating in physician-assisted suicide in Oregon and Washington if they adhere to the legal requirements.^[1,12] In December 2008, the Montana supreme court ruled that physician-assisted suicide is legal after a patient with terminal cancer sued the state in the case of Baxter v. Montana,^[14,15] but legal requirements such as reporting regulations have not been established. A bill to ban the practice in Montana was introduced in the state legislative session on January 6, 2011, and a hearing scheduled for late January. Montana still has not established rules and regulations.

Am J Health Syst Pharm. 2011;68(9):846-849. © 2011 American Society of Health-System Pharmacists, Inc.

All rights reserved. Posted with permission.

Cite this: Physician-assisted Suicide - Medscape - May 01, 2011.