Good Life, Good Death
A Report by Professor Meinrad Schaer, MD, President of "EXIT', Society for Human Dying, Switzerland
In my lecture given at the 11th World Conference of Right to Die Societies in Melbourne (1996), I reported on the legality and practice of assisted suicide in Switzerland. Today, I would like to present some practical case reports illustrating the procedure.
While the USA struggles with controversy regarding the legality of assisted suicide, the Swiss legal system has condoned the practice for sixty years. In contrast to practices in Holland, Australia and the various US proposals where assisted suicide is limited to physician-assisted suicide, Swiss law permits and EXIT practices aid to the dying by lay persons.
Although Swiss law permits physicians and non-medical persons to assist suicides, the Swiss Academy of Medical Sciences, like many medical organisations, including the American Medical Association, opposes doctors helping patients to die. Swiss laws stipulate that persons who assist a suicide do so for humane reasons with no chance of personal gain. EXIT requires that the applicant be at least eighteen years old, a Swiss resident, mentally competent and suffering from intolerable health problems. He, or she, must personally apply for the service and convince EXIT that there is no coercion or third party influence involved in the decision.
An EXIT physician considers the application and decides whether or not assistance can be offered. In doubtful cases, a team composed of a lawyer, psychiatrist and a physician will jointly make the decision.
The procedure of assisted suicide is as follows:
Assistance offered by EXIT to its members in 1996Table 1. Application of EXIT members for assisted suicide
Table 2. Performed suicides according to gender and diagnosis
Table 3. Time interval between intake of barbiturate and death in 119 cases of assisted suicide
Table 4. Deaths caused by suicide in Switzerland: 1990 and 1995 (Swiss Federal Office of Statistics)
Some case reports from 1997Patient Place of residence: A village near Lucerne.
Rubin T. (1921) Diagnosis: Amyotroph/c Lateral Sclerosis (ALS)
Apart from a 'sciatic hernia'-operation, Rubin T. had never been ill before. About five years ago, however, he began to suffer paralysis in his feet. Slowly the paralysis spread through the lower extremities and after two years Rubin was entirely dependent on a wheel-chair. Later he became partially paralysed in the chest area and in his arms and finally he had great difficulties breathing and swallowing. The patient knew his condition was irreversible and would culminate in a respiratory paralysis. He was also aware that he would be totally dependent on other people's care for the rest of his life. Therefore, he decided to contact EXIT.
When the suicide assistant first visited Rubin's family, the family members were unsure how they should react. Rubin T. was complaining about increasing pain and his wife was afraid she soon wouldn't be able to look after him anymore as she, herself, was suffering from cancer metastases and was expected to undergo operation. The patient, on the other hand, refused to go to a nursing home. Accepting this wish was one of the major aspects in the family s decision making and finally they acceded to Rubin's decision to commit suicide.
On the day of his death we were warmly received by the united family. Everybody, wife, son, daughter and son-in-law, agreed that assisted suicide was the best solution in this hopeless situation. Their family doctor, who had witnessed Rubin's decline over the years also felt that this was the best decision in the circumstances.
After a heartbreaking farewell to his family Rubin T. drank the barbiturate, which had been dissolved in a deciliter of water. During the ensuing few minutes they wished each other well and soon thereafter, Mr. T. Iost consiousness, breathing deeply and with a contented smile on this face. Ten minutes later he stopped breathing and shortly afterwards, no pulse could be discerned. The family stayed with Rubin for a short while praying and expressing hope of a reunion in heaven.
Because it is classified as an exceptional death, each suicide must be investigated by the police and a coroner. Rubin lived in an isolated, sparsely populated, mountainous area of Switzerland and suicides are comparatively rare in this region. Th police officers notified, were uncertain as to how they should proceed. They recorded our statements, called for re-enforcement and finally for the examining magistrate. The widow was spared long questioning and others present were questioned in a friendly manner. Then peace returned to the deathbed and we left. Everyone present thanked us for our assistance. Father McDonald still keeps in contact with the bereaved family.
Patient Wily B. (1926)
Place of residence: An industrial town near Zurich
Diagnosis: Cancer of the pancreas with multiple metastases.
An EXIT suicide assisant told me about a critically ill woman who had asked her for help. The patient Wily B. was suffering from cancer of the pancreas which had led to an obstruction of the bowels. She could take neither liquids nor solids and the only way to administer the barbiturate was via intravenous infusion. Her family doctor agreed with this decision and prepared the saline infusion. Then he said goodbye to the patient and her daughter.
Taking the barbiturate intravenously is not the usual method of assisted suicide. Therefore two EXIT representatives, a physician and a lay person together with the patient's daughter were present when the infusion was administered. Wily B. was instructed how to use the three way switch controlling the infusion. After she had closed it, the barbiturate was injected into the infusion and within two minutes of opening the switch herself she fell into a deep sleep yawning peacefully. Seven minutes later breathing and pulse stopped.
Neither the coroner nor the examining magistrate showed any concem about the uncommon method of assisted suicide used in this special case. The bereaved daughter was relieved that her mother was spared any further suffering and was also glad that Wily B. could depart in dignity.
Patient Linda B. (1913)
Place of residence: At the lake of Zurich.
Diagnosis:Cancer of uterus (1965);Cancer of the small intestine (1986): metastasing cancer of the colon (1995).
Linda B., a widow, had been living alone for many years. She was financially secure and lived in a five bedroom villa at the lake of Zurich. In the course of the past three decades she had undergone several operations, radiotherapies and chemotherapies. Nevertheless she had kept her happy disposition and had always accepted her fate. Only lately, as a result of serious complications with her colon cancer, she began to take stock of her life. An almost complete obstruction of the bowels made it impossible for her to take any solid food. She also had to deal with faecal vomitus.
At first her family doctor disapproved of the idea of assisted suicide. Yet Linda B. came to an agreement with him and contacted EXIT requesting assistance towards a hastened dignified death.
Linda wasn't able to take the barbiturate orally because of her bowel obstruction so EXIT contacted her doctor and asked him to prepare an intravenous saline infusion, to which he agreed. The EXIT suicide assistant instructed the patient how to use the three way switch and then injected a lethal dose of the barbiturate into the infusion. He asked the moribund patient to open the switch when she was ready. Surrounded by mourning family members she quietly fell into her eternal sleep.
Shortly after her death, which occurred within less than fifteen minutes, an uncommonly large police contingent arrived with detectives, examining magistrates, coroners, etc. The district medical officer showed some consternation regarding the administration route of the barbiturate. However, since the patient had switched on the infusion herself and since this had been witnessed by 6 family members as well as two EXIT representatives, the magistrate didn't take any further steps. The mourners were obviously relieved. Together with the EXIT-representatives they left the house of their mother and grandmother leaving a light in the bedroom of their beloved dead.
Patient Martha. H (1932)
Place of residence: a small village in the alps
Diagnosis: Amyolorphic lateralsclerosis (ALS) - late phase
Martha H.'s husband consulted me personally seeking our assistance. His wife's health had worsened in the course of the preceeding weeks. Martha H. had been suffering from the neuromuscular illness ALS for two years and at the time of her husbands call she could utter only unarticulate sounds. Furthermore, she had problems swallowing. After talking to her doctor on the phone I went to see the patient right away. The attending physician had confirmed Martha H.'s desperate state of health and the rapid progression of this genetically caused illness for which there is no cure.
On my visit, Mrs. M.H. was sitting in her wheelchair. Her legs and arms were paralyzed and she could move her right arm only. Nevertheless she seemed pleased to see me and expressed her joy with lively movements of her eyes and by nodding her head. She understood everything but could only answer by scribbling big, shaky letters. To find out if the patient was still able to drink and swallow I handed her a glass of water. Promptly she choked and coughed out most of the liquid. That same day, I contacted her doctor again to discuss further procedures. As the patient was already being fed through a tube, this method was certainly the best. The remnants of strength and agility left in the patient's arm were considered sufficient for her to take the barbiturate herself.
A few days later, on the date chosen personally by Mrs. M.H., the suicide assistance took place. Her husband, two sons with their wives, and 1, as a suicide assistant of EXIT, were present. Five minutes after taking the barbiturate the patient fell into a deep sleep. Ten minutes later, her breathing, and shortly afterwards, her heart stopped. Mrs. M.H. died peacefully in the arms of her husband. The relatives asked me to remain seated quietly for a futher ten minutes to respect the dead.
Afterwards, as required by law, I called the police. They must be informed of every 'uncommon' death and I was rather surprised when only the district medical officer and a police official arrived. Later I was told that the family doctor had already informed the responsible authorities about the planned suicide. The patient's wish had been fulfilled: She had died in peace and tranquility surrounded by her closest relatives.
Patient Andre C. (1949)
Place of residence: Zurich
Diagnosis: AIDS, advanced stage (Illc)
A leading doctor of an AlDS-hospice drew my attention to a patient who was in a deplorable state of health. On the same day I visited the critically ill man and had a private talk with him.
Mr. C. was hemiplegic and had difficulties speaking. He understood everything and made it absolutely clear he didn't want any specific therapy apart from palliative treatment. Mr. C. had written to his family doctor and his two brothers, who lived in the western part of Switzerland, informing them about his decision to commit suicide with the help of EXIT. Everyone, even the doctor in charge of the AIDS - hospice regarded the suicide as the only option to end his unbearable suffering. (The diagnosis of the AIDS specialist was: AIDS Illc).
A few days after my first visit the patient was brought, in a wheelchair, to his apartment where the euthanasia took place in the presence of his two brothers. (Two minutes after taking the barbiturate Mr. C. fell asleep and after another eight minutes his breathing and heart stopped).
Patient Ulla G. (1947)
Place of residence: Zurich
Diagnosis: Breast cancer (metastasing mammacarcinoma)
At the end of May 1997 Mrs. G. asked EXIT for a meeting with a suicide assistant. She was suffering steadily increasing difficulties in breathing caused by the amputation of both breasts. They had Upunctured her several times", she told the E)CIT representative ~and each time had sucked out between half and one litre of a bloody liquid. Lately she had suffered unbearable pains which had only been brought under control with high doses of MST (a morphine derived drug which can be taken orally). Such a high dosage of MST can lead to interrupted breathing especially if the patient already suffers from pleural effusions, which also cause breathing difficulties.
The patient looked happy and regarded her approaching death with composure. She was, she maintained, a 'converted Buddhist'. Her 80 year old mother was looking after her.
To avoid vomiting Mrs. G. was given two tablets of Dramamine. After half an hour she took 1Og of a strong barbiturate, which was dissolved in a deciliter of water. The solution is bitter but no one, to date, has refused the solution on grounds of the bitter taste. Five minutes after taking the barbiturate the patient fell asleep peacefully. Ten minutes later her breathing stopped and soon thereafter her heart stopped. The elderly mother was grateful, because her daughter had been spared a horrible death by suffocation.
Patients: Anonymous -- A (1911) and B (1913)
Place of residence: Lago Maggiore, Ticino
Her husband, B, was suffering from a painful circulatory disturbance in his legs caused by excessive smoking. Their family doctor confirmed the diagnoses and the hopeless prognoses. He refused, however, to prescribe two fatal doses of a potent barbiturate.
Two suicide assistants of EXIT travelled to the Ticino after the manager had ensured that all requirements for assisted suicide had been satisfied. There they were to assist the couple in their joint suicide. At first, Giula and B lay in separate rooms as they wished to speak privately to their respective suicide assistants. Thereafter they lay down together to pass away hand in hand. Both were full of praise for the way EXIT had assisted them during the last hours prior to death. Their only daughter said goodbye to her parents and they died peacefully, after taking the barbiturate, within 10 and 20 minutes respectively.
As suicide is relatively rare in Ticino and because the police were unsure how to proceed, the examining magistrate requested a coroners report which proved satisfactory.
Patient Samuel B. (1923)
Place of residence: Zurich.
Diagnosis: Amyotrophic Lateralsclerosis (ALS)
In the fall of 1993, Samuel B., an internationally famous concert pianist, first felt his legs become limp. Within a short period of time he was partly paralyzed. He consulted a neurologist who examined him with electromyelography and provided Samuel B. with a diagnosis of amyotrophic lateral sclerosis (ALS). This illness of the nervous system usually follows a chronic progressive course and afler a few years the patient generally dies of respiratory paralysis. Two years later, Samuel B's illness had progressed to the extent that the patient's legs were totally paralyzed, which meant that he required a wheelchair. Increasingly, the muscles of his midriff and back became paralyzed. The patient was suffering unbearable pain. Occasionally, especially at night, he had difficulty breathing. His pain could not be relieved by an opiate as he was already suffering from respiratory depression.
In January 1997 Mr. B. called EXIT and asked for immediate help. His condition had significantly deteriorated. Visiting the patient, it was obvious that he had difficulties not just with breathing but also with swallowing. We made an appointment. Samuel B. had to sort out some family affairs before he was ready to die.
A few days later the 'assistance' (euthanasia) took place with an EXIT doctor, just as the patient had requested. Seven minutes afler taking the barbiturate, Samuel B. died in the arms of his wife. Every one present was relieved that he had been spared weeks of suffering, breathing difficulties and intolerable pain.
Patient Jakob H. (1929)
Place of residence: Zurich
Mr. and Mrs. H. called to my office. Mr. Jakob H. was limping and his wife had to assist him when he was walking. He wanted to die with the help of EXIT as soon as possible because he could hardly bear the pain in his leg. His pain was caused by a circulatory disturbance and Mr. H. refused to have his leg amputated, a step which sooner or later would have been inevitable. At night he slept for one hour at most and then only while sitting on a chair. Some of his toes were already necrotic and on his right ankle he showed me an open, foul-smelling growth.
Patient H. had been a passionate smoker for decades. Even when his family doctor strongly advised him to give up smoking he paid no attention. Nothing could keep him from indulging in this passion.
The diagnosis of endangitis obliterans had been confirmed radiologically and angiologically.
The assisted suicide was arranged for May 22nd. The 'playboy' Mr. H. received a suicide assistant and myself with extreme friendliness, even somewhat euphorically, while his wife appeared rather reserved. Mr. H. entertained everyone present (his wife, son, brother, a couple they were friendly with, the suicide assistant, who was relatively inexperienced at that time and myself) to a goodbye party at his home bar.
After taking an 'antiemetic' the patient's last wish was to smoke a final cigarette. Fifteen minutes after taking the barbiturate, J.H. died peacefully among his friends and family of a respiratory and cardiac arrest.
Patient Anna B. (1910)
Place of residence: a mountain village near Chur
Diagnosis: Metastasing basal cell epithelioma of the vulva
On June 11th the genera! practitioner and former student of mine, Dr. Werner R wrote to me about his cancer patient Anna B. who had no hope of cure or respite and who was suffering from severe and painful complications of her condition.
The patient Anna B. was suffering from metastases of an epithelioma of the vulva (cancer of the greater labia). Three years before the labia had been operatively removed and at the time of his letter, metastases had appeared in the Iymphatic gland and the ribs. There was no hope of cure or recovery for the patient. Mrs. B. declined any form of further therapy such as surgery, radiotherapy, or chemotherapy.
Her family doctor came to meet me personally at the train station of the famous winter health resort and brought me to the restaurant and hotel, that had previously been run by Mrs. Anna B. Both her sons received us warmly. The emaciated patient was sitting crouched down in the background. Her mind was calmly set on her immediate death and she saw this option as the only way to find relief from her infinite suffering.
Mrs. B. fell into a peaceful sleep within a few minutes of taking the barbiturate and fifteen minutes later her breathing and pulse stopped. Everyone present expressed relief especially her two sons who prayed at their mother's deathbed.
The police were called and they themselves mobilised the responsible medical officer, i. e. the coroner. The coroner instructed the GP by phone to release the body for burial without any post mortem examination.
Patient Peter McG (1939)
Place of residence: a small town near Zurich.
Diagnosis: metastasing prostate cancer, pain unrelieved by morphine.
Peter McG.'s family doctor drew my attention to the patient's unbearable suffering. He asked me to get in contact with Peter as soon as possible.
In an old wooden house, I found Peter in a small, musty, living room, surrounded by countless books. He was suffering acute pains that radiated from his spine into the back and down the legs. We didn't talk about his illness and his hopeless future. (I knew enough about that from his doctor.) Instead we discussed books, mainly those dating from before World War II. Peter McG. wasn't only an antiquarian but also a successful author. Before I left he told me he was determined to put an end to his unbearable life. If EXIT didn't help him he would know what he had to do.
Two months after this conversation Peter McG. called me up again. His condition had worsened. He wasn't able to sleep even with large dosages of morphine. However, he wanted to finish a final piece of work before putting an end to his Iife. This decision was clearly stated to his family doctor on several occasions. The doctor himself sympathized with him knowing about the patient's intolerable situation and hopeless prognosis.
Surrounded by his family, a son, a daughter and other relatives, Peter McG. took the deadly dosage of the barbiturate. The family doctor and a suicide assistant were also present. Two minutes after taking the drug, Peter fell into a deep sleep. Soon afterwards his heart stopped for an instant and ten minutes later he died. Everyone present heaved a sigh of relief and were glad, that Peter McG. could die in peace and dignity.
Patient Werner B.(1939)
Place of residence: Village at the lake of Lucerne.
Diagnosis: Metastasing cancer of the large intestine (Sigmoid)
Since May 1996 Mr. Werner B. had been suffering undefinable pains in his stomach. On several occasions he visited his doctor and was examined by gastroscopy and ultr~ound but nothing was found and he was regarded a malingerer! In the fall of 1996, Mr. B. collapsed while on holiday in Spain and had to return to Switzerland ahead of schedule. He went to his family doctor suffering unbearable pain, a distended abdomen and continual constipation. Although the patient had lost seven kilos weight, his doctor wasn't at all alarmed.
At the end of 1996 Mr. H. was hospitalized as an emergency. The surgeon, a Dr. W., found an inoperable colon tumour. The patient could only be treated palliatively, via an 'anus praeter' (colostomy).
On my first visit Mr. B. showed great relief about my assistance but was very concerned about the fact that he soon would not be able to swallow anymore.
We arranged for the euthanasia to take place two days later. The patient was still very weak but was able to drink through a straw. Half an hour after taking two tablets of Dramamine he drank a solution of 1Og of barbiturate. Sobbing and crying, his relatives said goodbye to him and soon afterwards he fell into a deep sleep which changed to a coma-like state and then to death.
I was surprised by the fact that only the examining magistrate and a police officer arrived at deceased man's appartment and that they didn't insist on any formalities.
The examining magistrate respected the wishes of the relatives and allowed the body to be returned to the bereaved family after the obligatory coroner's examination.
The examining magistrate gave me lift to the next train station where he thanked me for the exemplary collaboration.
Patient Lilly R. (1930)
Place of residence: Zurich
Diagnosis: metastasing cancer of the skeleton and lungs Primary focus unknown.
Since 1995 Mrs. R. had been treated by physicians and in hospitals. The illness began with a growth on her arm but the primary focus could not be established. In the course of three years multiple metastases appeared on the skeleton, in the lungs and on the skin.
The patient suffered greatly and was nursed in a clinic where she refused to take any further treatment. The senior consultant of the clinic brought her case to our attention. On my first visit I met an emaciated woman who had difficulty breathing despite the provision of an additional oxygen supply. Two days later, accompanied by her lawyer, she was taken to her sister's house by ambulance. She received a constant supply of oxygen from hospital personnel during the journey.
The patient was so weak that she fell asleep while drinking the barbiturate and after 12 minutes she was already dead. Half an hour later the police, the district medical officer and the district attorney arrived. We had phoned them after Mrs. R.'s death. They did not insist on a coroner's report and allowed the body to be buried.
END OF REPORT
Meinrad Schaer -- Bio:
A professor of social and preventive medicine at the University of Zurich for over 20 years, and former Vice-Director of the Swiss Federal Office of Public Health. One of the founders of EXIT - the Swiss Association for Human Dying - and its president for many years. Dr. Schaer died in 2007.
Prof. Schaer's report issued by EXIT, Switzerland, and distributed by the Euthanasia Research & Guidance Organization).