Assisted Suicide and “Failure of Unconsciousness”

As a nurse, I have seen patients assumed to be unconscious while in a coma or sedated on a ventilator later tell me about some memories and feelings during that time. This is why I always cared for such patients as if they were awake.

Now in a stunning February, 2019 Association of Anaesthetists article titled “Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying”, a group of international doctors explore the difficulty in ensuring unconsciousness to death in lethal injection capital punishment and assisted suicide/euthanasia. (Note: Since the authors are international, some quoted terms here are spelled differently than here in the US)

Believing that “A decision by a society to sanction assisted dying in any form should logically go hand‐in‐hand with defining the acceptable method(s)”, the authors reviewed the methods commonly used and contrast these with an analysis of capital punishment in the US. They “expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used.”

They were wrong.

They found that with self-administered lethal overdoses “with death resulting slowly from asphyxia due to cardiorespiratory (heartbeat and breathing) depression”, helium self-suffocation and the Dutch lethal injection that resembles US capital punishment, “there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re‐awakening from coma (up to 4%), constituting failure of unconsciousness.” (Emphasis added)

The authors take no position on assisted suicide and state their intention to “dispassionately examine whether the methods used to induce unconsciousness at the point of death in assisted dying achieve their objective”. With many of the authors being anesthesiologists themselves, they used the most recent research into “accidental awareness” during anesthesia to try to find an “optimal means” that could better achieve unconsciousness.


It was difficult for the authors to find discussion of actual methods to cause death but the Dutch have published guidelines for both “passive participation” where the doctor prescribes a high-dose barbiturate and “active participation where the doctor administers a high dose of IV anesthetic and a neuromuscular (paralyzing) drug.

Notably, the authors found that a lethal injection is recommended by the Dutch when self-ingestion death fails to occur within 2 hours and that this is “an explicit recognition” that self-ingestion can fail.

The Dutch lethal injection resembles (except for the use of potassium to stop the heart) the US method of capital punishment so the authors looked at the US method of lethal injection capital punishment because it is “designed to be ‘humane’ and bears technical similarities” to lethal injection assisted suicide/euthanasia. The US lethal injection protocols also includes technical aspects such as drugs, dosage and monitoring of the patient.

However, as the authors note, “prisoners have been reported to be clearly awake and in distress during some executions”. Two death row prisoners even petitioned the US Supreme Court to consider a requirement for a physician to confirm unconsciousness before the lethal drugs are given. They argued that they “might be awake but paralysed at the point of death, making the method a ‘cruel or inhumane punishment’ which violated the US constitution’s Eighth Amendment”. (Emphasis added) The authors note that this “situation has clear parallels with the problem of ‘accidental awareness during general anesthesia’, where the patient awakens unnoticed and paralysed during surgery, which is known to be a potent cause of distress.” However, the US Supreme Court rejected this argument in 2008, “concluding that the anaesthetic doses used reliably achieved unconsciousness without any need to check that this was the case.” (All emphasis added)

As the authors state, “We now know that the Court was wrong.” (Emphasis added)


The US assisted suicide laws mandate secrecy in reporting requirements and the little yearly data available about complications is self-reported by the doctors who are not required to be with the person during the process or even afterwards to pronounce death.

However, the authors were able to use data from the Dutch protocols, and other similar methods used elsewhere and state that after taking the lethal overdose:

“patients usually lose consciousness within 5 min. However, death takes considerably longer. Although cardiopulmonary collapse occurs within 90 min in two‐thirds of cases, in a third of cases death can take up to 30 h(ours) 3133. Other complications include difficulty in swallowing the prescribed dose (in up to 9%) and vomiting thereafter (in up to 10%), both of which prevent suitable dosing, and re‐emergence from coma (in up to 2%). Each of these potentially constitutes a failure to achieve unconsciousness, with its own psychological consequences, and it would seem important explicitly to acknowledge this in suitable consent processes.” (Emphasis added

The authors also note:

“that the incidence of ‘failure of unconsciousness’ is approximately 190 times higher when it is intended that the patient is unconscious at the time of death 3133, as when it is intended they later awaken and recover after surgery (when accidental awareness is approximately 1:19,000)21, 22. (Emphasis added)


The authors discuss the limitations of just using EEGs (brain wave tests) and the isolated forearm technique (IFT) where the person can move their single, non-paralysed forearm to signal their awareness.

Instead the authors state:

“Recent lessons from anaesthesia lead us to conclude that, if we wish better to ensure unconsciousness at the point of death… then this can be achieved using: (1) continuous drug infusions at very high concentrations; (2) concomitant EEG‐based brain function monitoring, targeted to the very low, burst suppression or isoelectric values; and (3) clinical confirmation of unconsciousness by lack of response to command or to painful/arousing stimuli (and this last could include an IFT). Alternative methods that do not include these elements entail a higher, possibly unacceptable, risk of remaining conscious and so, by definition, are suboptimal.” (Emphasis added)

However, the authors acknowledge practical problems with this protocol such as the technical requirements requiring the involvement of trained practitioners like anesthetists.

And the “optimum method” for ensuring unconsciousness is so medicalized that:

“Society or individuals might prefer to retain a choice for alternative methods, even if these are suboptimal and carry a greater risk of consciousness at the point of death 54. If so, then legal frameworks and consent processes should explicitly acknowledge this choice. ” (Emphasis added)


The assisted suicide legalization movement led by Compassion and Choices portrays assisted suicide as an easy and dignified death, even one that can be a cause of celebration.

Polls about assisted suicide like the latest Gallup poll find 65% say “yes” when asked “When a person has a disease that cannot be cured and is living is severe pain, do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?” even though assisted suicide laws don’t mention pain and state that the person must be terminally ill and expected to die within 6 months.

But how many people, especially legislators, would still say “yes” to legalizing assisted suicide after learning the truth in this article about the so-called “peaceful” assisted suicide?

And how many people would still pursue assisted suicide if they knew they might be conscious and in more distress during the process?

Unfortunately and right now, no assisted suicide law requires that kind of  explicit “informed consent”.

The obvious solution is to fight all assisted suicide laws and support all suicidal people.


5 thoughts on “Assisted Suicide and “Failure of Unconsciousness”

  1. This was an impressively thoughtful article that definitely possessed an objective vibe while maintaining a sensible opinion on the subject.

    Cheryl, I must respectfully disagree with your opinion. Natural death has the exact qualities inherent in the name: natural. Natural causes of death are enormously extensive, and contain varieties of experiences; it would be an exaggeration to issue a blanket statement that natural death is always horrifying. Death, however fearful and painful, is an essential part of life that everyone must face. It is unatural death, such as war and murder, that is horrifying, because such requires a suspension of nature (though an argument could be made to the contrary).
    I’m not sure how suicide could be considered a universal human right. Your argument holds a certain amount of merit for those who will certainly expire (and I can’t question the pain they would suffer through), but by extension such a right could be given to any individual no longer desirous of living. But this is incredibly selfish and morally reprehensible. A mother or father has a duty to raise and support their children; to decide “No more; I’m done” would be a immoral disregard for personal responsibility. Life should be allowed to play its course; humans aren’t very good at playing God.


  2. It is ridiculous to compare assisted suicide & abortion. Abortion is taking a life without consent, assisted suicide is a CHOICE by a competent adult.

    Natural death is horrifying & those that have ever witnessed it would have to be cruel beyond belief to not anesthetize those suffering to ease the anxiety & PAIN. Also NO ONE has the right to tell a dying person that they must SUFFER to death so that other people can feel morally superior. Sorry, but the one sovereign right every human being should have is to be able to end their lives when they feel like it. It takes an amazing arrogance to tell a suffering person too bad so sad you must suffer because I say so.


    • As a nurse with almost 50 years of experience, I have cared for many people with life-threatening illnesses or disabilities, including family and friends. I made sure that these people were as comfortable and supported as possible. The only deaths I found truly horrifying were those where death, not care, was intended by family or doctors.
      One of my daughters said it best when she was just 14 and challenged a teacher praising the infamous Dr. Jack Kevorkian and his “suicide machine” in class. The teacher asked her where she got her information and she said “From my mom, who’s a cancer nurse”. “So”, the teacher responded, “Your mom LIKES to watch people suffer?” My daughter responded, “No. She just refuses to kill her patients!” The discussion ended.


    • Cheryl I understand your empathy, and that is to be applauded. The article was saying that medically administered suicide is not as easy, peaceful, and pain free as many would like to promote. IMO society either feels life is sacred, or it does not. Once a society crosses that line…there is no natural stopping point. The scientific principle that a body in motion tends to stay in motion applies to thought patterns and societies as well. Study patterns in history and think about the logical conclusion/direction of this pushing of the boundaries and legalities. We are currently headed towards a death culture. It is no wonder that people growing up in our culture that does not respect life, have a significantly higher rate of committing violent crimes/murder. And, of course, those in positions of power always have a tendency to use whatever they can to promote their own self-interests and destroy their enemies. It is only a matter of time before this type of law is clearly abused and the people are (more) afraid of their government.


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