9
HELIUM: NEWLY USED METHOD TO END SUFFERING
Patient autonomy at the end of life has been advanced by a new method of hastening death, the use of helium. In 2000 and the years preceding, barbiturates were the most commonly used means for a planned death, but, as we have seen in the last several years, obtaining barbiturates has become so difficult that the use of helium in this country has arisen as an alternative to be considered.
In this chapter, I report how some persons have used helium to relieve intolerable suffering when all else has failed (as similarly in the preceding chapter I have discussed the use of barbiturates for the same purpose). I stress that this is reporting about how these options have been used in such circumstances, and it is not advice. My reporting of what some patients do when facing a bad death simply indicates that ending their life is an option they have felt compelled to consider when making their decisions as to how to cope.
When helium—an odorless, nonflammable and nonexplosive gas—is used, a prompt, easy, and almost certain death has been obtained by terminal patients who have been suffering intolerably and have wished to hasten their deaths. In my discussions with end-of-life rights advocates who have been aware of the details of the use of helium for this purpose, I have learned of extremely few failures, unpleasant symptoms, or unexpected outcomes (one exception I shall discuss later in this chapter). Unconsciousness occurs within forty-five to sixty seconds, and all patients’ hearts stop within fifteen minutes, usually sooner.1
At the time this chapter was written, the medical literature had few reports on the use of helium for planned death, but Rus-sel Ogden in the Department of Criminology, Kwantlen University College, New Westminster, British Columbia, Canada, published a single case report of a death associated with breathing helium. He felt this was the first published report of this sort of death.2 There are a handful of other case reports since his article, but I have been unable to find an article in a major medical journal that reviews the topic and all known deaths from this cause. However, Derek Humphry has described the use of helium in detail in the third edition of his well-known book Final Exit and in a 2006 video of the same name.3 An Internet search of the Web produces quite a few sites that discuss the topic, but most of these are anecdotal and not of the quality a peer-reviewed medical journal would have, although Faye Girsh did produce a very good discussion on the Internet, “The Many Ways to Hasten Death,” which included helium.4
PHYSIOLOGY OF THE USE OF HELIUM AT END OF LIFE
A word about the physiology involved will help in understanding how the helium method works. The use of 100 percent helium brings about death by depriving the brain of oxygen. Normally, when one breathes air into the lungs, 20.9 percent of the room air breathed in is oxygen, which is essential to most basic functions of the body. (In addition to oxygen, ordinary air consists of 78.1 percent nitrogen, 0.036 percent carbon dioxide and a few other gases in trace amounts.) If one is deprived of all oxygen, consciousness is lost in less than one minute. This oxygen lack is not associated with any unpleasant sensation.
If one were to be smothered or otherwise suffocated, air hunger and frightening distress would develop. However, this distress is due not to oxygen deprivation, but to the buildup of carbon dioxide in the body, since the carbon dioxide is not exhaled. (Carbon dioxide is a normal waste product that is disposed of through the lungs with each breath.) Excess carbon dioxide causes one to feel the need to breathe more rapidly and deeply (air hunger). With the acute onset of a severe lack of oxygen alone—in the absence of carbon dioxide buildup—one simply drifts off into unconsciousness due to the reduced oxygen levels in the blood, and there is no sensation of air hunger since there is no time for carbon dioxide to build up in the body.
I have personally experienced oxygen lack and can attest to the absence of any distress. When I was in the Air Force as a flight surgeon in the 1950s, I went through physiology training in a high-altitude chamber at Randolph Air Force Base in Texas. A group of us were in the chamber at a simulated altitude of 43,000 feet, at which altitude the atmospheric pressure is extremely reduced and the concentration of oxygen extremely low. One can maintain consciousness only by breathing oxygen from a pressurized mask. (In an airplane at that high altitude, the cabin is pressurized with air that allows sufficient oxygen to be inhaled without the special pressurized masks we were wearing.) The instructor said that taking off the mask at that simulated altitude would result in passing out in a matter of seconds, due to a lack of oxygen. He asked that one of us demonstrate the effects of insufficient oxygen by taking off his mask and at the same moment begin writing his name on a pad. He promised he would be by the side of the volunteer to reapply the mask immediately when needed. For some reason that now escapes me, I volunteered. I wrote my name normally once, but before I could write it a second time my handwriting degenerated into a scrawl due to a lack of oxygen, at which point the mask was put back on me. There had been absolutely no unpleasant sensation because I had been able to continue to breathe off carbon dioxide with each exhalation—I just was not getting sufficient oxygen from my inhalations of the thin air in the low pressure chamber. There was certainly no air hunger or feeling of suffocation.
The same thing that happened to me in the altitude chamber will happen to any person who breathes 100 percent helium or other inert gases (e.g., pure nitrogen) from a small plastic tent over the head.
HELIUM HAS BEEN USED TO END SUFFERING5
Anyone can obtain helium by going to one of the chain discount or toy stores for 100 percent helium that is sold in tanks for the purpose of inflating party balloons. The cost of a small tank is around $30. People who have used helium to end life have bought two tanks to be certain enough is on hand, a point that has been stressed by persons with firsthand knowledge of such patients. Often a plastic T-tube has been used to run helium simultaneously from the two tanks into the plastic tent that is used as a hood, although many persons have used a single tube, with the second tank being held in reserve in case it is needed. The plastic tubing used to convey the helium from the tank to the hood has been obtained in hardware stores, but there are sources from which a manufactured kit can be obtained, helping assure that connections fit properly.
As can be seen in Derek Humphry’s video (and as I learn from colleagues of mine who have observed end-of-life events using helium), when the collapsed small tent has been prepositioned at the forehead level and the helium has been turned on, the tent distends with helium, displacing the air (and oxygen). The tent stands upright, lifted like a balloon by the lighter-than-air helium. If the patient draws it down over the head and secures it loosely around the neck by a soft elastic band or a Velcro fastener, he or she will begin at that point to breathe in the helium contained in the tent. Consciousness is rapidly lost due to a lack of oxygen, as noted previously, and within a very few minutes the heart stops, and breathing ceases. Afterward, an observer/friend has usually disposed of the tubing, tank, and plastic tent, as Derek Humphry has written and portrayed.
Build-up of carbon dioxide (and consequent air hunger) does not occur because there is insufficient time for the carbon dioxide to accumulate significantly, either in the tent or in the blood stream. In the past, plastic bags without helium have been used to end life, and in that instance air hunger can be noted by the patient because the process is not nearly as fast as with 100 percent helium.
Helium has been used to end a suffering patient’s terminal illness probably more than two hundred times in this country with rare difficulty. The only exceptions apparently have been a handful of instances in which there was imprecise matching of tubing at connecting points, such that some room air got into the bag in a quantity that interfered with the action of the helium. This has not happened in situations in which all connections are secure.
The families of patients who have ended their suffering in this manner have usually called hospice or the personal physician to report that the patient has stopped breathing. Many families have delayed the reporting of the death for an hour or two to ensure that, if 911 emergency services become involved, it will be absolutely clear that the patient has died. When the family physician or a hospice worker has pronounced the patient dead, the funeral director has been notified and has come to the scene. The funeral director generally then has the physician or hospice worker sign the death certificate, which indicates the underlying terminal disease as the cause of death. The family that abides by the wishes of the dying patient would not call 911 since the patient would not have wanted to summon resuscitative resources. (The problems of calling 911 when one does not wish for resuscitative efforts are discussed in Chapter 12, on medical planning.)
A PATIENT WITH LOU GEHRIG’S
DISEASE USES HELIUM
Ethel, a patient in her fifties of one of my colleagues, used helium to end her life. She had Lou Gehrig’s disease, a universally fatal condition known as amyotrophic lateral sclerosis (ALS). Ethel and Ron, her ex-husband, had divorced before the end of her life approached, but they were still close friends. Ron and their four children were very supportive of Ethel’s fight against this disease and her ultimate decision to hasten her dying process.
As her disease progressed, Ethel lost use of her legs and was confined to a wheelchair. Her arms became steadily weaker, and it was only a short time before she would become completely helpless. Her death would probably be caused by respiratory failure due to her increasingly weakening muscles, which no longer would be able to support her breathing. Such a death was a bad prospect that Ethel decided she would meet on her own terms by planning her dying.
Ethel had heard that breathing 100 percent helium could bring about an extremely prompt, easy, and certain death, and she wanted this. She learned more about the method— filling a large plastic bag with helium and then pulling it down like a tent over the head. She learned that by breathing the helium from the bag, unconsciousness would ensue in less than a minute due to a lack of oxygen and that her heart would stop within a few minutes. With her decision made, Ethel bought a small tank of helium from a nearby store that sold the gas for use in party balloons. She also obtained a kit containing the proper tubing, plastic tent, and Velcro fasteners that would allow her easily to implement the procedure. She practiced the method except for turning on the helium valve and felt confident that breathing the helium would spare her the large amount of distress that loomed ahead for her.
Ethel lived at home in a big house. Two of her children lived nearby and were devotedly and frequently at hand to help her through her illness. On the day before she planned to end her life, all her children and her former husband were present. Then, and in the preceding week, there had been favorite stories and reminiscences of good times in the past. A volunteer had seen her again that day, and in the evening a physician also met with her and talked about how death would occur and what would happen, were she to elect to go ahead with her plan. The physician’s presence was psychologically helpful to both Ethel and her family, and they were relatively at ease.
On the next day, which she had selected as the day of her death, Ethel was in her bedroom, propped up in bed, surrounded by her family. Two of the children sat on the bed on either side of her. Although very weak, she was able by herself to turn the valve that filled the tent with helium and then to draw it down over her head. Ethel died very quickly—and her death was remarkably peaceful.
The family, wishing for some private time, waited two hours, and then notified the local hospice that Ethel had died (she had been in hospice care for several months). A “declarer” with legal authority to pronounce death in hospice patients came to the home to do so. The use of helium was not discussed with the hospice personnel, and it was presumed that the patient had simply died of her disease. (The family had taken away all equipment related to the helium so there was no physical evidence of its use). The hospice worker signed the official death certificate, and the undertaker was notified. Ethel’s death was entirely what she and the family had wanted—fast, certain, and free of distress— and she had remained in control.
ADVANTAGES OF HELIUM
Many doctors have found that the use of helium is now the speediest and most available method (outside Oregon) for a patient in this country to end life when faced with intolerable suffering. Helium has had some definite advantages over the use of barbiturates because it is far faster, it is easy to use, and the helium— at least presently—is easily available. Like a lethal dose of barbiturates, it also has been certain.
With regard to legal liability, as far as I have learned, there has so far been no legal action taken anywhere in this country against a bystander or family member when the patient has used this method to end life. The patient without any physical help from those in attendance has carried out the administration of the helium by turning on the helium that fills the bag-like tent and then pulling the tent down over the head, unassisted.
The use of helium can be carried out without the assistance or even the knowledge of the physician. It does not require any prescription writing on the part of the physician, this being a plus, since many physicians outside Oregon, fearing liability, do not wish to write prescriptions for barbiturates in this situation. (On the other hand, nonparticipation by the personal physician deprives the patient and family of the important emotional and psychological support that derives from the moral assistance of the doctor.) It is also a method that can be accomplished by patients themselves. The tubing has been relatively easy to purchase by mail, something the patient could do. Presumably, some of the patients have had family members or friends who have driven them to the store to get the helium tank, but still it has been regarded as an action of the patient, which has been essential in order for bystanders (family, friends, or members of a right-to- die organization) to stay on the right side of the law. If the patient were in a nursing home or other medical facility, it would be much harder to make this event come about purely by the efforts of the patient—a probably insurmountable drawback.
In localities in which the state law or the stance of law enforcement officials is averse to the use of barbiturates, or in which the necessary amount of barbiturates is very difficult to obtain, helium has been found to be an alternative. There also continues to be active research into other somewhat similar means of oxygen deprivation.