Death with Dignity: When the Medical Aid in Dying Cocktail Gets into the Wrong Hands

A Denver Health ambulance
Photo/Dustin Keltie

Ambulance 64 is dispatched to a 35-year-old male with possible alcohol overdose. Upon arrival, the crew is directed to a back bedroom where they find two fully clothed males with their legs hanging off a bed. One is elderly, the other is middle aged. Both are unconscious and unresponsive with shallow respirations. A bystander hands a medicine bottle to the attending paramedic frantically saying, “They drank this! They drank this!” The bottle contains digoxin 100 mg, diazepam 1,000 mg, morphine 15,000 mg, amitriptyline 8,000 mg and phenobarbital 5,000 mg. She remarks that the older man “should be dead” and the younger one “should be alive.”

In 2016, Colorado voters approved the “End-of-Life Options Act” permitting terminally ill adults to have access to medical aid in dying (MAID). State residents who have a life expectancy of less than six months and who can make their own medical decisions are eligible to request MAID. Two physicians verify eligibility and assure that the patient has made three (two verbal, one in writing and signed by two witnesses) requests for MAID and counsels them about other treatment options for their condition. Patients are then prescribed a lethal combination of medications that are dispensed as a powder. Patients are instructed to mix with 4-6 ounces of non-carbonated liquid prior to consumption.1

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The bystander states that the older man is a “death with dignity” patient who invited loved ones to be present while he consumed the MAID medication. After his first swallow, he remarked, “Man that burns!” The younger man said, “Let me see,” and then also took a swallow. The attending paramedic directs rescuers to begin ventilating the younger man while requesting evidence of advance directives for the older man. Care was not rendered to the death with dignity patient because he had a valid Medical Orders for Scope of Treatment (MOST) form stating he wanted no lifesaving measures performed on him. The medication bottle was prescribed to the patient. Hospice was contacted to verify he was a terminally ill patient of theirs. Medical control was also contacted for a consult because this was not a typical call.

The younger male patient is found to be atraumatic. His skin signs were significant for cyanosis but otherwise warm and dry. Pupils were constricted, equal and reactive. Without ventilations, his respiratory effort is 6; Sp02 was 72%. The patient is placed on a cardiac monitor and the heart rate is recorded at 144 bpm, blood pressure is auscultated and found to be 134/96 mmHg. Blood glucose is 172 mg/dl. Intravenous access is achieved with a 16-gauge catheter placed in his right external jugular vein. After there is no change in the patient’s presentation following Narcan 2 mg via IV, he is endotracheal intubated. End tidal carbon dioxide is then measured at 56 mmHg. The receiving facility is notified that a patient with a massive polypharmacy ingestion is en route.

Colorado is one of eleven states with MAID, although many countries outside the U.S. also permit it.2 This challenging case is an excellent illustration of the importance of prehospital providers to have an understanding of end-of-life-care as it pertains to advanced directives3 and to be aware they may practice in an area where they encounter patients who may be in a MAID program. In this case, the paramedic had to juggle a complicated scene with two potential patients who both were near death. Education regarding such programs should be a priority to EMS agencies, as is how to handle instances where family members are requesting that no resuscitation be attempted and either advance directives are not in place, or copies of them cannot be located.

The patient is received by the emergency department. As patients who have an ingestion of MAID medication intend to die, resuscitation of such individuals is very rare. A nasogastric tube is placed and he is given 100 grams of activated charcoal. The QRS complex is observed to be prolonged, so 2mmol/kg of Sodium Bicarbonate was given. In consultation with toxicology at the local Poison Control Center, the patient is administered digibind. After discussion between critical care physicians and toxicology, it is determined that the patient will be best served by a facility capable of extracorporeal membrane oxygenation (ECMO). As the receiving hospital’s ECMO program was already at capacity, the patient was transferred to another hospital with ECMO capability. Ultimately, the patient did not require ECMO and he was weaned from the ventilator after a two-day ICU stay. He regained consciousness with full neurologic recovery. He cited no memory of the incident. He was discharged home with a recommendation to seek counseling for alcohol misuse.

Conclusion

Emergency medical services might be initiated by a family member or friend to evaluate a patient after ingestion of this medication cocktail. EMS providers should be thoughtful about attempting resuscitation in such patients. Accidental ingestion should be rare and to our knowledge has never been reported. As was the case in this call, the individual drug components that comprise the MAID medication are intentionally at high doses to ensure death. While the exact preparation varies by program and drug availability, it tends to include medications that offer anxiolysis, induce coma, and provoke arrhythmia.4

In this case, both the benzodiazepine (diazepam) and the barbiturate (phenobarbital) are GABA agonists and are prescribed to reduce anxiety and help the patient lose consciousness. The morphine, an opiate, assures analgesia. Mixing the two GABA agonists and the opiate causes profound respiratory depression and in these doses are often fatal. As there have been cases of individuals surviving MAID, 3 two additional medications are in the Colorado cocktail that are designed to lead to a lethal heart arrhythmia. Amitriptyline is a tricyclic antidepressant and in high doses disrupts cardiac function through sodium and potassium channel blockade in myocardial cells. Digoxin increases intracellular calcium and in high doses can lead to ventricular tachycardia. In some cases, an antiemetic is also recommended so the patient does not vomit after ingestion.

Should accidental ingestion occur, care is mainly supportive. The patient should be placed on a cardiac monitor and have a 12-lead rhythm strip to evaluate for QRS prolongation and consideration of sodium bicarbonate administration. Continuous pulse oximetry monitoring and assisting ventilation as necessary is indicated. If necessary, placement of advanced airway with assisted ventilations with BVM and confirmation by end-tidal CO2 is appropriate. Intravenous or intraosseous access should be obtained and intravenous fluids can be administered if the patient is hypotensive. Naloxone can be trialed, although may not have much effect given the high dose of opiates in the compound. Consideration may be made for transport to an ECMO capable facility.

References

  1.  Bol. K. Colorado End-of-life Options Act. Retrieved August 21, 2022. https://cdphe.colorado.gov/center-for-health-and-environmental-data/registries-and-vital-statistics/medical-aid-in-dying. 2022
  2. Pope TM. Medical aid in dying: Key variations among US State laws. J Health & Life Sci Law. 2020 Oct;14(1):25-59.
  3. Carter AJ, Earle R, Grégoire MC, MacConnell G, MacDonald T, Frager G. Breaking down silos: consensus-based recommendations for improved content, structure, and accessibility of advance directives in emergency and out-of-hospital settings. J Pall Med. 2020 Mar 1;23(3):379-88.
  4. Zworth M, Saleh C, Ball I, Kalles G, Chkaroubo A, Kekewich M, Miller PQ, Dees M, Frolic A, Oczkowski S. Provision of medical assistance in dying: a scoping review. BMJ open. 2020 Jul 1;10(7):e036054.

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