Assisted Dying: What might the final moments be like?

BBC Sounds. Music, radio, podcasts. Welcome to the Inside Health podcast with me, James Gallagher. Episodes are released weekly wherever you get your podcasts, but if you live in the UK, you can listen to the latest episodes a whole week earlier than anywhere else. First, on BBC Sounds.

Hello there. Later, we're going to find out whether we're all eating a credit card's worth of microplastic every week, and we're answering your questions on hearing loss. But first, it's part three of our discussion on assisted dying, using drugs... to end a life raises a lot of issues and here on Inside Health we've been looking at it from a medical perspective. So if you go back through BBC Sounds we've looked at ensuring an assisted death is what the patient wants as well as seeing who could

Now that would apply to England and Wales, but there are similar discussions taking place in Scotland, the Isle of Man and Jersey too. So today... we're going to consider the assisted death itself. How would it happen and what might those final moments be like? We have the same panel of experts as last time, so let's meet them. My name's Catherine Sleeman. I'm Professor of Palliative Care at King's College London.

I have no in-principle objection to assisted dying, but I have concerns about the practical implementation, in particular the risks to vulnerable people. My name is David Nicol. I'm a consultant neurologist. I was actually opposed to assisted dying, but it took the death of my friend Fabi through euthanasia to teach me that sometimes modern medicine doesn't have it all. And we should think about assisted dying and respecting the dignity of those who are terminal.

who want to make one final decision on their terms. Hi, I'm Erica Borgstrom. I'm a professor of medical anthropology based at The Open University. When it comes to assisted dying, I don't necessarily have a position that says it's wrong or right in and of itself, but I think we need to have a lot more conversations about what it means to us as a society.

And I'm Mark Taubert. I'm an adult medicine consultant in the NHS in Cardiff. When it comes to assisted dying, I would call myself a skeptic. I'm very interested in the safeguards.

Now, Erica, the way the system works is that you're going to have to take the drugs yourself. So your doctor can't do it for you, your partner can't do it for you, your children can't do it for you. You have to be able to do it yourself. That's a decision that has been made. What are the pros and cons of that? So that does mean people need to physically do certain things with their body still. So again, when we're thinking about who does this potential...

bill applied to and not, that means someone's going to have to have some forms of mobility to do that. They are going to possibly have to either ingest it or inject it and do that. final act themselves for some people that will be very liberating because it fits with a sense of control for others that might be quite tricky in that very last moment and there can be hesitation etc it can also be again very Different and sometimes very ambiguous and ambivalent for those who might want to.

actually be the one to help their family member do it because they know it's actually something very difficult for them to do even if it's something they really really want and it's often one of those things that even in countries where assisted dying exists that we have very little insight about what those final moments are actually like for people and what's that lasting impact for those that live beyond that moment. Is there a moral reason why it has to be?

the person self-administering the drugs. I mean, what is the difference hypothetical scenario? Catherine drawing up the drugs and handing them to me to inject versus Catherine just injecting them. Some of it is around intentionality, autonomousness, and sometimes there is this distinction around sort of actively killing someone versus supporting them to do something they're doing themselves. Also really important to acknowledge how suicide itself is currently conceived of in our legal system.

or that's been decriminalised. So we've already accepted that if someone kills himself, that's not a criminal act. So this is kind of like an extension of that. What's the difference between taking your own life versus having an assisted death after a terminal diagnosis? On one hand, potentially nothing, because the result of that action and actually potentially...

The means of that action could be the same, but you can argue it in very many different ways depending on your worldview and your moral and ethical beliefs. Mark, in countries where assisted dying is already legal, they'll have their own protocols for how it happens there and they'll all be different. But can you give me a basic run through of what would happen in an assisted death?

We've got very little detail on what is proposed, but in other countries what usually happens if it's oral administration is that you start off with an anti-sickness medication, that's the first one you take. And then approximately 20 minutes later, people take a sedative. And then a little bit later, they take the medication mix, which causes cardiorespiratory arrest.

It's a very bitter tasting medication. So often sweeteners are added and you can't just drink half of it. You have to drink the whole amount of it. which can be quite a challenge for people. And then there's the assisted suicide via an intravenous route where a practitioner comes in and inserts an intravenous needle and then... A pump is set up with the anti-sickness medication, a sedative, and then the agent that causes the cardiorespiratory arrest and then leads to the asphyxiation event.

It's a little bit removed from the sort of romantic notion that I read a few years ago when Terry Pratchett wrote about it saying he'd like to be in his garden. have a brandy and take a pill that some kindly doctor has provided him with. This is quite a clinical set of processes and you need to be able to follow these instructions quite carefully. Catherine, one of the...

appeals of an assisted death is that it's less painful, it's a nicer way to go than the alternative of say end-stage cancer. Do we know if the reality of that matches up with the ideal? It's really difficult because actually there hasn't been that much research looking actually at the quality of deaths.

I think it's less about pain, it's less about physical suffering and it's about control. And if the most important thing to you at the end of your life is determining where and when you die, then I can see that for you, this might be the thing that... gives you the best quality of life but this isn't about reducing pain this is about killing the person so that pain is no longer relevant to them which i think is quite a relevant distinction

David, how has this played out in countries around the world? Because this isn't a new thing. No, it's not. Different protocols in different places. So Fabi was a friend of mine who had a rare cancer syndrome. and then chose to die through euthanasia. I spoke to Fabi's partner a couple of days ago and asked him, you know, how long did it take her to die, basically. And obviously Belgium, very different, euthanasia.

doctor injecting and she was dead within a couple of minutes now australia they're 85 self-administered i think 15 percent There is assistance you can apply for that. Now, that is not in the lead bidder bill. So again, that's something to think about. I'm thinking about the MND population. If you've got someone who's quadriparatic, how that would be administered.

There might be technological ways of delivering that that could be looked at. Mark, do the drugs work all the time? It depends. So if we're comparing internationally assisted suicides versus physician-administered euthanasia... We have data that in assisted suicides where patients administer the medications themselves as a considerably higher complication rate in countries that measure this. Oregon, for instance.

look at some of the side effect data, look at what happens during the death. And you get data about prolonged deaths lasting over 100 hours. You get data about deaths that have involved seizures, breathing difficulties, sickness. choking events, those countries, it would be useful, as Catherine mentioned earlier, to have some more research in this area in terms of which regimens work best. So at the moment... No drugs in the world anywhere are licensed for this indication.

of bringing about death. While no drug is specifically licensed for assisted dying, where assisted dying is legal, there are certain medications that are prescribed for this purpose though. So David, what's your view on this? Well, I know speaking to colleagues in Australia that 95% of patients die within two hours. And when you talk about complications, if it's delayed, it's because the patient is asleep, but they all die.

when we first started this discussion i introduced it all by saying that i thought a sister dying if it went ahead would be one of those huge changes in society erica If this went through, how different would England and Wales be? I think it could be sort of a landmark change.

We also must acknowledge this is happening at a time where we're also investing a lot in terms of medical interventions to try to prolong life. And so there's sort of this dynamic interplay between those things. So it's one to watch in terms of how we think about life and death. Mark? Advanced care planning, which is an area that I'm quite close to, so planning for what you would like your death to look like in the future.

It's already tricky to bring up. And I think an assisted dying law being in place might set that back by quite a considerable margin. Catherine? I think this bill is sometimes presented as a modest change. It's just a modest change. And I disagree. I think that this is a momentous change that will affect all of society.

The most important question for us to be considering now is around safety. It can't be 100% safe, so how safe is safe enough? David? I mean, I disagree, but in a nice way, I think that... This will improve the quality of end-of-life conversations that we have with our patients, and it's about listening to those who are terminally ill.

I welcome this as a change and even just this discussion now discussing about end-of-life care in a way that wasn't the case anywhere near as much even six months ago has been a good thing. Wow. Thank you to our panel for today and for the past couple of episodes. Let us know what you think about what you've just heard. Do email insidehealth at bbc.co.uk

Well, now for something a little bit different, because there have been a lot of claims about the amounts of microplastic, so tiny fragments of plastic, that we're consuming and is then ending up lodged inside our bodies. So, do we really eat and drink? about a credit card's worth of microplastic every week. And if all the microplastics in our brain were melted down, would there be enough there to build a plastic spoon?

I'm joined now by Professor Kit Yates from the Centre for Mathematical Biology at the University of Bath to sense-check those numbers. Kit, welcome to Inside Health. Thanks for having me. So, a credit card's worth of plastic. Let's start with that claim. That seems... A huge amount. I'm just trying to imagine putting it in my mouth in one go. That's just a lot of plastic. Is it true? I don't think it is. I think it's probably way, way too much. It gets quoted a lot now. Where did it come from?

The claim originally comes from a literature review in 2021 with authors from the University of Newcastle in Australia. They suggested actually that we could be ingesting anywhere between 0.1 and 5 grams of microplastics per week, which is quite a big... range but this this five grams figure was quoted by researchers at the medical university in Vienna they just quit with this figure as a sort of throwaway at the start of their paper so it didn't get peer-reviewed

But when their paper was published, the press office said, this is a brilliant figure. Let's get this out there. And so they ran with this headline of five grams of microplastic per week. And that's how it got into all these newspapers and into the public consciousness. that 0.1 to 5 grams, how did that number get constructed? So the way that they calculate the total ingestion is to take the total amount of water that...

drink, which they assume 219 litres of bottled water a year, and multiply that by the figure that they've calculated for the mass of microplastics per litre, which seems like a sensible strategy. Well, so far that sounds fairly... OK? Yeah, absolutely. But just maybe to do a quick common sense check. To make that five grams of plastic a week figure work out, this would mean that you'd have to have over a gram of microplastics per litre. And given the figure that they put in the paper...

this would mean there would have to be on average 420 microplastic particles per litre of water with an average diameter of 1.5 millimetres. You would literally see these things floating around in the water. Do we have a better number then, if that one's a bit nonsense? Yeah, so...

The figure that has been calculated by a follow-up paper, also from 2021 by Mohamed Noor, suggests an average of about 4.1 micrograms per week consumed for adults. OK, that's a bit of a difference. So we're not talking... about going from grams.

to milligrams going from grams to milligrams to micrograms exactly a million times smaller than the figure that went viral so if you were to try to wait long enough to eat a credit card's worth of plastic it would take you about 23 and a half thousand is well what are we roughly 40 down another 22 960 to go yeah exactly nearly that

OK, do we have any idea, though, from looking at the other end about how much plastic is accumulating inside the human body? Because there was another one of those slightly confusing headlines that I saw recently that the brain has a spoon's worth of plastic. accumulating inside it not a teaspoon's worth just literally it's the spoon itself like it's so confusing it's very confusing but yeah it's about seven grams of plastic that this study is suggesting is accumulating in the human brain

Does that number pass the sense check? It's a little bit difficult to say, but there are reasons to be dubious about it. So the concentrations of microplastics that they're finding are... Somewhere between 30 and 4,500 times the concentration of those found in studies which look at the lungs or the heart or the tissues. That's not to say that that necessarily makes it incorrect, but it should perhaps set some alarm bells ringing.

But when you drill down into how the figures are calculated, there are potentially some other causes for concern. So when you're doing these studies in human tissues, you have to be really careful about how you separate out the tissue from the plastic. So usually researchers use chemicals to digest them.

biological tissues or they separate them by density and what you're left with you hope is the plastic and you can analyze that using a technique called mass spectrometry which gives you a sort of chemical signature or fingerprint of your sample the problem is that

If your separating procedure isn't perfect, then you can get a lot of false positive stuff whose signature looks like plastic, but isn't. And this is common across all of microplastics work. But in the brain, for example, it contains lots of lipids whose mass spectrometry... its fingerprint looks similar to those of the plastic polyethylene and actually in this study 75% of the plastics that they found in the brain were nominally polyethylene so it suggests that these samples might

not have been cleaned up properly and what might actually be being picked up is this biological material it's just a fatty brain registering as plastic exactly fatty brain equals plastic kit thank you so much for coming on thanks for having me

Now, earlier in the series, one of our listeners, John, asked us to investigate the state of hearing tests in the UK. And we did that. It's on BBC Sounds. But loads of you got in touch afterwards with more questions. So we're going to answer them with audiologist Dr Hannah Cooper. from UCL's Ear Institute, and Kevin Munro, who's a professor of audiology at the University of Manchester. Hannah, Kevin, welcome back to Inside Health. Thank you.

Good to be back. So we've got lots of questions after the last programme. Hannah, can I start with you and one from Susan? Because she's curious about the difference between what she calls the NHS beige hearing aid and the ones that are widely advertised by private companies. and asks, is there any effective difference or is it just that hearing aids cost more to be less visible?

Lots of people call it the beige banana, right? I think we have moved on from the beige banana. Off-white, grey is more the colour choice. I think in terms of the hearing aids that you get from the NHS, my understanding is that they're generally a mid-range private product.

So they are digital hearing aids. They will have lots of digital features that will help you hear better in noisy situations, potentially. So digital noise reduction, feedback cancellation, directional microphones, those kinds of things are what you're going to get from.

the NHS. You'll often be able to control them from an app. But yeah, independent providers will provide something maybe potentially more discreet, might have more features on there compared to an NHS hearing aid. But definitely you're getting a good level product. from the NHS I suppose Kevin an NHS hearing aid doesn't really exist does it's not like the NHS is sat there

Mass-producing hearing aids. Absolutely. So basically all the hearing aids available in the NHS have been purchased from hearing aid manufacturers. Mine is a sort of sexy metallic grey colour and I'm a professor of audiology so I know a thing or two about hearing aids. aids and i'm perfectly happy to be using an nhs hearing aid kevin if you find metallic gray sexy i'm going to keep you away from my cutlery drawer

Kevin, while I'm talking to you, Barbara got in touch after hearing you on the last programme and was really curious about your Bluetooth microphone that you're using in that loud and noisy cafe we're in. I should point out at this moment that we have put a full transcript of that programme up on our Inside Health website.

if anybody wants to follow that in more detail. But Kevin, tell us again about the Bluetooth kit that you were using. Yeah, great question, because one of the main difficulties... that an individual with hearing loss has is understanding speech in the presence of background noise. A fantastic way to hear better in background noise is to have a remote microphone that you can place in front of the speaker and then the signal can be sent to you.

hearing aid almost all the big leading hearing aid manufacturers will have remote microphones so I have a small one that's multifunctional I can clip it on my wife's lapel so if we're out having a meal and it's very noisy

I can hear her without having to put in too much effort. If I'm in a meeting, I can sit on the table and it picks up speakers from around about. Or if I'm standing socialising with someone, I might just hold it in my hand and it will just be slightly closer to the mouth and that will help me.

The downside is you can't currently, as an adult, get these via the National Health Service. So unless you have access to work or access to education scheme that will provide it, you have to go out and buy these yourself. But they're fantastic. with your NHS hearing aid.

Yes, that's right. Probably not every model of NHS hearing aid, but the one I have works with my NHS hearing aid. That's right. Got a question now from Elaine, who's seen many older people whose ability to balance declines with age. And she's wondering, what's the link between...

loss of balance and hearing. And we actually got ear, nose and throat surgeon Dr Nish Mehta to answer this one. He was in the previous programme and he's answered Elaine. Hearing and balance are intricately related. In fact, they are... provided for by exactly the same organ, the inner ear. Your overall sense of balance is actually a very interesting special sense that receives information from your eyes.

from your inner ears and from the joints in your spine, shoulders and hips. This information is then computed by your brain to give you an overall sense of where you are in this world and what movement you have in relation to it. When there is a condition that affects the inner ear, it not only affects hearing, but it also affects balance. And that's why people often feel that their sense of balance has got worse as their hearing has got worse. As we get older, not only does

the inner ear degrade, but also so does vision and our joints and our ability to compute this information. Those are the key reasons why balance gets worse as we get older. Hannah, can you tackle this one from Carolyn, who's curious about the loudness of events, so things like sporting events and music concerts and things like that. And she's curious about the impact on children. Are we heading for future generations of people suffering with hearing loss at ever earlier?

ages and to greater extent yeah so i think we've been worried about this for a while particularly with people listening to very high levels of music through headphones And the thing about noise exposure is that it doesn't cause an instant hearing difficulty. It builds up and builds up gradually and gradually over. many years. And so you don't know that you're causing damage to your hearing whilst you're doing it. So I absolutely encourage people to take breaks.

regularly, if they're listening to amplified music over headphones. I think Carolyn's questions about sporting events and things like that as well. If they sort of go over workplace guidance for noise exposure, then there's a possibility of... you having some damage to your hearing. Does it matter when you have those one-off events though? Like if you go to a football match, that might be two hours of loud noise. Is that really going to do the damage in comparison to...

wearing your headphones and playing music every day? I mean, if you go to a lot of loud sporting events and they're at a very loud level, then you might cumulatively get damaged from doing that. But you're right, if you're listening to hours and hours of amplified music a day and then you're going...

to a loud sporting event once a year or something like that, it's unlikely that the sporting event is going to cause as much damage as the amplified headphones. Kevin, keep an ear out for this one because this is from... Carl. And he likes going to concerts and gigs. He has his NHS supplied hearing aids. He says that they work most of the time. But what he struggles with is when he's playing his clarinet or saxophone whilst wearing them because they just give.

A horrible noise, basically. He's after specialist advice for hearing aids for musicians. Well, modern hearing aids have multiple programmes. So just like you can use your remote control and change the television channel you're listening to, you can do the same with your hearing aid, including NHS.

ones and the audiologist could set up programs that are more suitable for listening to music and currently there's a lot of work being done with artificial intelligence where the incoming speech signal or the music and the background noise are analyzed

broken down. All the things that we don't want to hear are removed. The thing we want to hear is reconstituted and into someone's ear. And I know there are companies and research groups specifically working on AI for listening to music. So watch this space. Hannah, question from Gail. This basically does our ability to adapt to hearing aids decline as we age because her audiologist says it does. What's going on?

Yeah, so I think where we might be coming from with this is that it takes people quite a long time to seek help for their hearing. So maybe 10 years from when they first notice a problem to when they go to the GP or go to the audio.

physiologist and try to get some help for it, which is a long time, especially compared to something like vision, where you might go after a couple of years. So the thing that will happen in that 10 years is potentially that your hearing will gradually decline over the years.

then get a hearing aid at that point it might be quite a big difference between your hearing difficulty that you've been living with but then to have the amplified sound with the hearing aid might be quite a big jump so maybe if you get a hearing earlier, your hearing won't have declined so much and therefore it won't be quite such a big change to go from your hearing with your hearing loss to your hearing with the hearing aid. How long does it take to get used to a hearing aid?

Ah, that's a good question as well. So I think it is a very individualised thing. So getting used to a hearing aid is very individual. It could be that you get used to it within a few hours. It might take you a few weeks or maybe even months. Kevin, I've got a question here from Gail and it really taps into this link between hearing and...

And she asks, as we understand social isolation as a contributing factor to brain degeneration, things like dementia, should we be making more of an effort to encourage and destigmatize the wearing of hearing aids? We used to think hearing loss was an isolated condition, but more and more we realise...

that hearing loss can coexist with a whole range of conditions. Now, that's not to say that hearing loss causes dementia, but there is an association. So the chances as we get older, if you have a hearing loss, it's slightly higher that you're going to get dementia. we don't know there could be some common cause but what it does highlight for us is and it links back to the earlier question about when should someone do something like start to where hearing is if you break a leg you wouldn't say

I'll give it 10 or 15 years before I do something about it. And the same applies to hearing. Hearing better helps you to live better. It might help you to think better because your brain's freer to do other things instead of concentrating in background noise to hear every single word. So if you notice a problem...

problem the sooner you do something about it the better a question now from susan about airpods so they're the bluetooth headphones you can get from apple because they've been in the news a lot recently as some of the models can also function as hearing aids. Hannah, can they do the job of a hearing aid? So, this is a really recent thing.

You can set up your iPhone AirPods Pro 2 to do a hearing test for you and then to act as a hearing aid. So this is very recent, just happened in the last few weeks that the UK got. licensed to do this so I think there's a few things to bear in mind

The first thing is that if you're worried about your hearing, you should definitely speak to an audiologist. However, if you think, oh, I'm not quite sure, I'm having a bit of difficulty hearing, I'm going to give this a go, then I think, great, give it a try. They're not hearing aids.

So you possibly won't get the added features that you might get with a hearing aid. You won't necessarily get the power that you might actually need with a hearing aid. But it might be a good starting point. So if someone is not quite ready to think about hearing aids yet, I think... might be a really good first step.

Difficult balancing that. Do you look rude having your headphones still in? Because they don't look like hearing aids, they just look like headphones, but they might actually be able to make you communicate better. So my colleague did actually look at this quite recently to see what people felt about using that kind of device. their ear while they were with friends out socializing things like that and they said that they always had to explain

what the device was doing in their ear that it was trying to help them to hear rather than that they were being rude and just listening to some music or listening to Inside Health. I love that thought that everyone's out there having a wild night out with their headphones in listening to Inside Health.

health. Just to finish off the AirPod bit, Hannah's right, there could be a bit of a stigma because it looks like you listen to music and not paying attention. Also, the battery won't last all day long like a hearing aid, but it could be a stepping stone. Great questions from our audience, weren't they? Really great questions.

They were on the ball. Yeah. Kevin, Hannah, thank you very much. You're welcome. No problem. And thank you to Dr Nish Mehta as well. And to all of you who emailed in questions, insidehealth at bbc.co.uk. Next week, as we get closer to Easter, we'll be asking, can you be addicted to sugar? And in the meantime, if you want to compare how other countries view different forms of assisted dying after our discussion earlier, well, there's an interactive map.

produced by The Open University, go to bbc.co.uk slash Inside Health and follow the links to The Open University. See you next time. You've been listening to Inside Health with me, James Gallagher. The producers were Hannah Robbins and Tom Bonnet. The show was a BBC Wales and West production for Radio 4.