Appendix 2 – Procedure on the day – the rules from Dignitas (excerpt from “How Dignitas works”)

1.11   Rules governing the carrying out of an Assisted Suicide

If, after the different preparation phases are completed, an AS is to be effectively carried out, two members of the AS assistance team are always assigned.   They are responsible for overseeing a sequence of rules.

1.11.1 Advance care for members arriving from abroad

If members travelling to Zurich for a doctor’s consultation or an AS are able totravel to Zurich in time to take up accommodation in the city or its surroundings before their first appointment, there is the opportunity for a personal meeting between the member and one or both of the AS assistants.

1.11.2 Reception at the AS location

In every case, special care is taken to ensure that members – as well as the family and friends accompanying them – who arrive at the AS location are met in good time and taken to the designated rooms.

1.11.3 Preliminary information for the DIGNITAS assistants

The DIGNITAS assistants can access the member’s dossier, which is prepared for handover to the authorities, in sufficient time so that they can form a clear picture of the member and the reasons that have led to their choosing an AS.   This ensures that the DIGNITAS assistants possess the necessary information about the matter at hand.   They usually arrive at the AS location at least one hour before the appointment.   After making sure that the rooms are in order, they can once more review the information in the dossier regarding the planned AS.

1.11.4 Meeting with the member

Once the member – with any relatives and/or friends accompanying him or her – has arrived, they are greeted, introduced and served with beverages (tea, coffee, mineral water).   After this, the assistants will conduct another detailed conversation with the member, asking about the reasons underlying their decision to end their suffering and life self-determinedly.

1.11.4.1 No proceed to “B” if “A” has been achieved

During this conversation, it is repeatedly and unmistakably stressed that the fact that the member travelled to Switzerland does not automatically mean that he or she must go through with the AS.   At this point, and indeed right up to the last moment before the medication is taken, the member is completely free to decide against going through with the AS.   The member is also told that DIGNITAS is happy every time a member makes the decision to carry on living and returns home.

Making such a decision, even at this very late stage, does not preclude the possibility of a member returning to Switzerland at a later date to undergo an AS.

1.11.4.2 Explanation of the process of the AS

During the conversation, the member and any accompanying people will have the process of the AS explained to them so that they know beforehand exactly what will happen.   This will include precise information about the manner in which the member will administer the medication to himself or herself, depending on the circumstances.

If the member can swallow unaided, the dissolved medication will be taken as a drink in approximately 50 ml of water.

If a stomach tube is in place through the nose or in the form of a PEG tube (percutaneous endoscopic gastronomy) through the abdomen, or if the member has a pre-existing intravenous drip, and if the member, unaided, is able to press the plunger of a syringe (without a needle) filled with the medication and attached to that tube or drip, then the medication will be administered this way.

If the member has a stomach tube or intravenous drip but is not able, unaided, to use a syringe to administer the medication then DIGNITAS can provide an easy-to-handle remote control which they can activate with a small movement (e.g. a finger, toe or jaw) to start the pump.

If an artificial breathing devise is being used to enforce respiration, the member must also activate the so-called “power terminators” which will independently interrupt the power supply some time after they take the medication and shut down the artificial breathing device.

If the medication is to be taken through the stomach, the member must first take up to 70 drops of Paspertin (active ingredient metoclopramide) as an anti-emetic to prevent (as far as possible) them vomiting the unpleasant-tasting NaP.   (If an intolerance for metoclopramide exists, there are other medications available.)   In this context, it is also necessary to warn the member that the medication has an unpleasant taste but, immediately after they take it, they can have a sweetened drink or chocolate to neutralise the unpleasant taste.

If it is decided that the member will take the medication by activating a piece of auxiliary equipment (such as a remote controlled pump) or if a power terminator is required, this process will also be covered in detail during the conversation.

The interview will end by asking the member (and those who accompanied them) whether they would like to ask any other questions.   If so, then the interview will be continued accordingly.

This interview, as well as the entire AS, is conducted without any time pressure on the part of DIGNITAS.   The organisation follows the principle already stated (see 1.10.1) that it is never DIGNITAS which initiates the next phase and further proceedings but that it is always and only the member’s own prompting which leads the entire process of the AS from one phase to the next, after the member requests the next step themselves.

1.11.4.3 Emerging doubts

If any doubts as to the member’s capacity or discernment arise during the conversation, or if there is a feeling that the member is obviously not making his/her decision free from external pressure but rather is being influenced by a third person or even someone who is present, the conversation will be continued by giving both DIGNITAS assistants the chance to speak with the member alone.   If the doubts of both DIGNITAS assistants cannot be completely removed in this way, then the AS will be cancelled and the member and the people accompanying them will be informed.

1.11.4.4 Information about the investigation by the authorities after the AS

The member and those accompanying him or her will also be informed of the administrative procedures that take place after the death to establish that an “extraordinary death case” has taken place.   In particular, it will be mentioned that any number of authorities may arrive.

1.11.5 Drawing up of the final documents

Once these topics have been covered, the member will be informed that DIGNITAS – in the event that their family does not take on this task – must draw up an appropriate agreement which gives DIGNITAS power of attorney to carry out the necessary arrangements so that their death can be certified and the cremation or the transport of their body carried out.

Without this power of attorney, DIGNITAS is unable to represent the member in dealing with the relevant authorities (registry office, burial office).   Since the issue has been discussed and resolved in advance and the corresponding fees for these additional services have already been invoiced, there is no additional cost for awarding power of attorney.   If the member does not want an autopsy to be performed, they can also convey their wishes in this matter.   However it is necessary to inform the member that, due to still undecided legal issues, it is not always possible to honour this wish.

Relatives and/or friends who accompany the member are also given the opportunity to grant this power of attorney to DIGNITAS.   This is particularly relevant later on, after the death, when the interests of the deceased person need to be upheld in the presence of the authorities.   According to Swiss law, no more demands can be made in the name of the deceased person.   Family members may, however, defend the deceased person in their own right.

The last document to be signed by the member is the “declaration of suicide”, which states that the member is voluntarily ending his or her own life, that they want to use the services of DIGNITAS, and that DIGNITAS has clearly outlined to him or her all the risks involved.   This means that DIGNITAS cannot be held responsible for any problems that might arise during the AS despite the most careful preparations.

1.11.6 Saying farewell

Members and those who came with them are then given the opportunity to say farewell if they desired, this can take place at a specific time without the presence of the DIGNITAS AS assistants, who will withdraw themselves for as long as necessary.

1.11.7 Administration of the medication

If all of the criteria are met and all of the questions have been answered, if the member has been repeatedly informed that he or she is free to return home permanently or temporarily and if the member still expresses a wish to end his or her life, and if the lethal medication is to be administered through the stomach, the medication to prevent vomiting can be given.

Thirty minutes later, the member is questioned once again to see whether he or she will want to end life.   If they do, the prescribed dose of NaP is dissolved in normal tap water and presented to the member in whatever form is necessary for the planned method of administration.

When the medication is being administered, assistance is permitted as long as it does not in any way lead to someone else administering the medication.   For instance, holding a glass containing a straw is allowed, but tipping the glass so that the liquid runs into the mouth is not.   Careful attention is paid so that the “power/control over the action” always remains with the member and is in no way transferred to either of the DIGNITAS assistants opr any other person present.   Directly after the medication has been swallowed, the member –  asdescribed previously – is offered either a sweetened beverage or chocolate to remove the unpleasant taste left in the mouth.

1.11.8 Care of family members or friends

During the entire process, and in particular as soon as the member has lost consciousness, the people who accompanied him or her are given special care.

1.11.9 Confirmation of death

The DIGNITAS AS assistants monitor the process of the dying phase.   When they are confident that death has occurred, they confirm by checking the pulse, breathing and pupil reflexes.   If these indicators, also known as “uncertain signs of death”, are present the escorts can wait until they are able to confirm the “certain signs of death”, in particular livor mortis.

Once they are convinced that death has occurred, they offer their condolences to the people who accompanied the deceased person, then use the emergency telephone number to notify the police of the AS that occurred, so that an official investigation can take place.

The rules then go on to outline the role of the official investigation.