SHORT EXCERPT FROM "The Peaceful Pill Handbook" Dr Philip Nitschke & Dr Fiona Stewart From chapter HYPOXIC DEATH AND THE EXIT BAG This is why it is important not to confuse the peaceful hypoxic deat h that is possible when an Exit bag is used properly, and the grim deat h that results from an obstruction to the airways. And this is why the media are so remiss when they reinforce this confusion. For example, when referring in 2001 to the importat ion of Canadian Exit bags The Australian newspaper reported these bag s as 'reminiscent of the Khmer Rouge's shopping bag executions in Cambodia's killing fields.' Su ch misinformation shows a significant lack of understanding of the process, and such reports have damaged th e image of the Exit Bag. Hypoxia is the term meaning 'low oxygen', and a death that results from inhaling insufficient oxygen is a hypoxic death.. While there are several ways this might occur, the common method used by those seeking a peacef ul death is to place a plastic bag over one's head. To understand why a plastic bag, low oxygen death is an easy and reliable way to die, a basic understanding of human physiology is helpful. In normal everyday life, we live in an atmosphere that is 21% oxygen. Interestingly, when there is a decline in the level of oxygen in the air we are br eathing, we do not experience any particular alarm or concern. As long as one can breathe easily, the sensation one experiences as the oxygen le vel drops is one of disorientation, confusion, lack of coordination and eventual lo ss of consciousness. This experience is sometimes likened to being drunk (alcohol intoxication). If the oxygen level falls too far death will result. Accidental hypoxic deaths are not uncommon and th ere are a number of scenarios that can bring them about. One example is the su dden drop in oxygen level that occurs when an aeroplane de pressurises at high altitude. This can lead to a rapid loss of consciousness and the death of all those in the plane. When the plane de pressurizes, one can still breath easily but ther e will be little oxygen in the inhaled air. This will cause a sudden drop in the oxygen level in the blood reaching the brain, leading to loss of consciousness and death. It is not unc ommon for planes t hat have suddenly de pressurized to travel on autopilot until they run out of fuel while everyone aboard has died. Witnesses (from planes sent to investigate) say that it often appears as though everyone on board has just gone to sleep. Pneumonia is a more co mmon cause of a hypoxi c death. Its peaceful reputation led to its common description as the 'old person's friend'. While the air inhaled may co ntain the full 21% of oxygen, the inflammation of the lungs (c aused by the pneumonic infection) makes it impossible for the necessary oxygen to be extracted. The blood reaching the brain will have less oxygen than that required for life, and a peaceful death often results. The Role of Carbon Dioxide (CO2) In normal respiration, the body makes use of oxygen and produces as waste the gas, carbon dioxide. Carbon dioxide is removed from the body as we breath out. While the human body is relatively insensitive to falling levels of oxygen, it is very sensitive to any rise in the level of carbon dioxide in inhaled air. When the body detects a slight increase of carbon di oxide in the air that we breathe, a warning message from the brain alerts the person. They will be roused and may react by gasping.. If a person is using a plastic Exit bag, the rise in the level of carbon dioxide within the bag may result in the person strugglin g to pull the bag from their head. This reaction is known as a Hypercapnic (h igh carbon dioxide) Alarm Response. Sleep Apnoea provides an example of hypercapnic alarm. He re the person with sleep apnea snores so heavily that th ey deny themselves the oxygen they nee d. However, it is not the lowering of the o xygen level that alarms and wakes the person, but the accompanying rise in the level of carbon dioxide. If t he fall in oxygen were not accompanied by this rise in carbon dioxide, the Sleep Apnoeic would be far more likely to die. In the depressurized airc raft, the oxygen level drops but there is no accompanying rise in carbon dioxide, hence a peaceful death is the common outcome. Aesthetic and Other Concerns The image of a bag tied tightly around one's neck causing a grim death by obstructing the airway has turned many away from the plastic Exit Bag. Even at Exit International workshops, it is common for participants to voice their di sgust at the Exit Bag, saying 'I don't like the though t of being found like that.' Lisette Nigot (of the documentary Mademoiselle and the Doctor) rejected this method. Lisette likened the plastic Exit Bag to being 'wrapped like a piece of ham.' For Lisette and others, the main concern was one of aesthetics. Despite such concerns, if used correctly, the Exit Bag provides a simple, reliable and peaceful wa y of ending one's life. A Peaceful Death There are two common me thods employed to deal with th e problem of the rising level of carbon dioxide inside the plastic Exit bag. In the following section, we will describe the experiences of two different people, based on eye witness acco unts. These accounts illustrate the different strategies. The first case involved a 75 year old man called Br ian. Brian was diagnosed with bladder cancer in 1999. In 2001, he used a plastic Exit Bag and an overdose of common, non lethal sleeping pills to die peacefully. The second case involved a 69 year old woman called Jo anna. In 2003, Joanna had a heart attack. She survived, but her heart was irreparably damaged and she found herself suffering from congestive cardiac failure. Joanna chose to die peacefully and unassisted, while she still had th e means to do so, and used a plastic Exit Bag together with a canister of helium gas. Here ar e their stories as told by their neighbour and husband respectively. Brian's Story Brian Appleyard (not his real name) made contact with Exit shortly after being diagnosed with bladder cancer. He lived in a retirement village on the Gold Coast and was a well educated man who had served in the airforce during WWII. When Brian made contact with us, he had already done much reading about the use of Exit Bags to achieve a peaceful death. Brian's wife had died some years before and his adult children had long since left home. He was relieved about this because he said he would never want anyone he cared for finding him with a plas tic bag on his head. Several weeks before he died Brian talked to his clos e fiend and neighbo ur Kevin. The plan was that Kevin would not sit with Brian when he used the bag, bu t would visit later and remove and dispose of the bag after 'the event'. Kevin writes: Following information he had learned at an Exit wo rkshop, Brian began his preparation by crushing up a fu ll prescription of temazepam. Authors' note while Brian used Temaze temazepam, he could successfully have used many others, such as oxaz epam Serapax or nitrazepam Mogadon. These common sleeping pills from the benzodiaz epine class of drug are not considered to be lethal even in overdose and are easily obtained. Brian told me that he had learned that while the sleeping tabl ets were not in themselves lethal, they were necessary to keep hi m asleep and to suppress his body's inevitable reaction to the risi ng level of carbon dioxide inside the bag. He prepared the drugs by crushing the full packet of 25 tablets and stirring the powder into a small glass of water. He then prepared a second small glass of a strong alcohol. Brian chose whiskey and said the alcohol would remove the bitter after taste of the mixture. The alcohol wa s also supposed to increase the potency of the sleeping pills, making them act faster and the whole process more efficient. Once these two drinks were prepared, Brian sat in his favourite recliner chair, the drinks on a table by his side. He was well aware that with the Exit Bag, technique was important. He also knew that he did not want to involve me actively in his plan and so would need to carry out his actions without my assistance. Th e idea was that Brian would take the pills, place the bag on his head and fall sleep. While as leep his body would use up the oxygen in the bag. Sleep would give way to unconsciousness and death would follow. The process was expected to take some ti me (up to 1 or 2 hours). Brian adopted the following technique. 1. Prior to placing the Exit bag on his head, Br ian prepared, but did not take, the sleeping pill mixture. He adjusted the elastic at the neck of the Exit bag he had made so that it was a comfortable fit around the neck (not too tight or loose). 2. Brian then tested the bag by placing it over his head and observed it in a mirror. Breathing in and out, he could see the bag expand and collaps e with each breath. 3. When the time was right, Bria n seated himself comfortably, reclining slightly with shoulders supported. He positioned the bag over his head and stretched the elastic neck band horizontally away from his face using the thumbs of both hands. 4. He placed his thumbs inside the neck open ing of the bag, pulling the bag away from his face. By doing this Brian allowed a large opening for fresh air. 5. While keeping the elastic st retched with one hand, with the other hand he drank his prepared drink of str ong sedative mixed with water. He washed the bitter tasting substance down with his whisky. Brian remained seated with the elastic stretched by both hi s thumbs until sleep came, approximately 15 minutes later. At this point his arms relaxe d and lowered and the elastic neck band slipped from his thumbs. The bag posi tioned itself snugly but not tightly around his neck. As Brian fell into a deeper and deeper sleep the bag expanded and contracted in time with his breathing. Each breath lowered the oxygen conc entration inside the bag from the original 21% , each breath raised the level of carbon dioxide. Brian experienced a p eaceful death once the oxygen leve l within the bag dropped to <5%. The large dose of slee ping tablets kept him asleep t ill that point was reached, and prevented him from being woken by the rising level of carbon dioxide in the bag. The bag was not dislodged. A graph showing the decrease of oxygen and associated increase in carbon dioxide inside a plastic bag during the first 4 minutes is shown below (Fig 5.1) Fig 5.1: Exit bag O2 and CO2 levels for first 4 minutes Point to Note While death from an Exit bag combined wit h sleeping tablets is peaceful and reliable, technique remains very importa nt. A person needs a high degree of co ntrol and the ability to coordinate arm movements. For this reason, the method may not be suitable for people with specific medical conditions. Neurological conditions such as multiple sclerosis or Parkinsons disease are exampl es. If the technique is not followed closely there is the chance that the Exit bag will not be correctly positioned around the neck when sleep ensues. Clearly a witnes s can ensure that this doesn't hap pen but that woul d be assisting a suicide, and the law would be broken. Remember that the process that leads to t he hypoxic death does not commence until the person's arms relax and the bag takes up its position around the neck. While the person is awake their fingers keep the neck elastic stretched allowing plenty of air to circulate. If one doesn't sleep, one will not die.. Joanna's Story (as told by her husband Stephen) Joanna Cataldi (not her real nam e) joined Exit in 2003 after the development of cardiac failure following a heart attack the previous year. Joanna's prognosis was not immediately apparent. The initial heart attack had left her with significant ca rdiac damage but her doctors were unsure of just how much this would effect her life. While pleased to have survived the initial attack, Joanna soon found that her cond ition was deteriorating. She said it was this uncertainty that led her to make contact, firs t with her local VE Society and then with Exit. At the time of joining, Joanna and Stephen were living in their own home in outer Sydney. Stephen writes: Joanna had heard about the possible use of a plastic Exit Bag with helium gas as a quick and reliable way of obtaining a peaceful death. Back then, disposable helium canisters were not available in Australia, although she had read about their availability in the US. In early 2005, these helium canister s started to be marketed in Australia and Joanna set about obtaining the equipment sh e would need. Joanna knew that the presence of helium in an Exit Bag would dramatically speed the process. When the bag is pulled down over one's head and a deep breath taken, she knew that there would be almost no oxygen in that breath. This lack of oxygen in the inhaled gas would ca use her blood oxygen levels to plummet, and she would lose consciousness almost immediately. Joanna knew her death would be very similar to that which occurs when an aircraft rapidly depressurizes. The helium that fills the bag displaces any oxygen and flushes away the exhaled carbon dioxide. One does not need to wait for the oxygen level inside the bag to fall, and there is no associated build up of carbon dioxide. Authors Note With helium in the bag instead of air, one doesn't have to 'breath down' the oxygen in the bag from an initial 21% to < 5%. Helium in the Exit Bag displaces the air (and oxygen). It is important to note that the helium, itself, does not interact with the body. Helium has no taste or smell and quickly dissipates after death. There is no test that can reveal its use. Helium is not the only gas that could be used .. There is nothing particularly special about helium, i ndeed any gas that does not react with the body, is odourless and available in a compressed form would do. Other inert gases that could be used include: argon, neon, even nitr ogen the gas which makes up 80 % of the air we breath. The important thing is the intr oduction into the bag of a flow of an odourless gas that will displace the oxygen and flush away exhaled carbon dioxide. Many compressed gases are only available in high pressure cylinders which are rented from gas supply companies (like BOC Gases). For many years, helium has only been available in this form. These cylinders are available for lease, either short term or for an annual fee. The drawback with accessing helium this way is the paper trail that is generated. There is no anonymity. A second issue of concern is the size of these commercia l cylinders. Commercial helium cylinders are large, heavy and difficult to transport. High pre ssure gas also needs to be controlled with a regulat or in order for a usable stream of gas to be produced. Suspicion might arise if an elderly or very sick person is seen leas ing a cylinder from their local BOC gas outlet. If someone else were to collect the cylinder for them , this other person may well become legally implicated in assisting in a suicide. These concerns turned many people away from using high pressure co mpressed inert gas with an Exit bag. The introduction of low pressure disposable cylinders has meant that helium has become a viable gas for use with an Exit Bag and dramatic ally increased the popularity of the method. The compressed helium co mes as part of a Balloon Kit manufactured in the US. These kits are designed to provide an instant system to fill helium party balloons and contain a light weight cylinder of helium, a packet of party balloons (30 or 50 depending upon the size cylinder) and tie ribbon. Joanna purchased the kit outr ight, paid cash and left no paper trail. Stephen continues: Of the two sizes of cylinder available, she purchased the la rger cylinder which contained 420 litres (14.9 cubic feet) of compressed helium at a pressure of ~1500 kPa. (Fig 5.2) She knew this would produce a usable stream of gas which would run for approximately 20 minutes, more than enough time for a peaceful death to occu r. Joanna adopted the following technique: 1. She introduced a controlled stream of helium into the Exit Ba g through a plastic tube. The tube was fed into the Exit Bag through the neck opening and secured to a tie held by adhesive tape inside the bag. 2. She adjusted the neck of the Exit bag to obtain a snug (not tight) fit around her neck. The Bag was positione d on her head like a hair net at her forehead at the front and down towards her lower head, upper neck at the back and above the ears at the side. Joanna' s face was fully exposed (Fig 5.3a). Fig 5.3: Positioning, inflating & Using the Exit Bag with Helium 3. The tap on the cylinder was then turned fully on. With a regul ating jet in place the initial flow of gas at full cylinde r pressure was aroun d 15 liters/min. Th e average Exit bag is around 15 litres in capacity so in about a minute, most of the air (and oxygen) in the bag was displaced. The bag remain ed over the hair and inflated and excess gas leaked from around the elastic (Fig 5.3b). 4. When the bag was fully inflated, Joanna exhaled completely, and pulled the bag down over her face until the neck band was positioned comfortably around the neck. She then took a full, deep breath of helium (Fig 5.3c). 5. The single breath of helium caused a sudden and precipitous fall in the oxygen level of the blood going to her brain. An automatic r eaction was to take a further deep gasp for air, but consciousness was rapidly lost. A peaceful death follow ed a few minutes later. When Joanna had stopped breathing, I removed and disposed of th e Exit Bag and threw away the empty helium cylinder. We had previously discussed in detail how Joanna's death should be dealt with. She did not want to be known as th e grandmother who suicided. To hide the true cause of her death, I removed all of the equipment used and concealed any evidence of her suicide. I hoped that the doctor would assu me it was a consequence of her cardiac disease. I knew though that if t he doctor was uncomfortable and the police became involved, I would have to lie and say that I had no idea how my beloved wife had died. I knew that a hypoxic death is undetectable, but luckily it never got to that point. The Use of Helium In planning the end of her life, Joanna had obtained a number of pieces of equipment. She made an Exit Bag and secured a means to control the gas flow. She also wanted to be sure that the cylinder was full before using it. Joanna made the Exit bag and the control kit herself. While I was willing to remove the equipm ent I did not want to be accused of helping her with her death. Her other equipment included: 1. Plastic tubing (standard 2.1m oxygen tubing with soft connectors). 2. Quick release (Jamec) air line fitting that attaches to helium cylinder. 3. Gas jet regulator this is a small, custom made jet that fits inside the air line fitting. 4. A pressure gauge for testing the cylinder. 5. A plastic Exit bag. Authors Note It is important to check if the cylinder is full as some newly purchased cylinders have been found to be nearly empty presumably be cause the cylinder tap was leaking. Helium Canister Testing At an Exit workshop a year earlier we had learned that occasionally, newly purchased helium cylinders do not co ntain the full 420 litr es of helium. Cylinder s occasionally have a faulty tap and when kept in stor age for a long period there is the possibility that the gas will have leaked from the cylinder. The easiest way to ensure that a cylinder is full is to check the pressure. Joanna had checked her cylinder on purchase and did so again two days before she planned to use it. Her full canister of helium show ed a pressure of 1500kPa (or 220 psi). She used a pressure gauge fitted with a Jamec coupling th at allowed quick testing of pressure, with no gas loss. She borrowed this gauge from our local Exit Chapter (Fig 5.4). Fig 5.4: Cylinder pressure test gauge Helium Gas Flow Control Joanna and I both knew that it would be important when using an Exit Bag with helium to ensure that the stream of helium into the Bag would be adequate and steady. Exit told us that a 420 litre cylinder could provide around 20 minutes of useful gas flow, long in excess of the few minutes that it takes for a peaceful death. We knew that to ensure this steady flow of gas, some met hod of gas regulation would be required. While it is possible to use the tap on th e cylinder to adjust the flow, there is difficulty and risk with this as the tap on the heliu m cylinder is designed to simply switch the gas on and off, not to control the flow. Small tap adjustments can great ly affect the gas flow. If they are opened too wide, the gas will exhaust too quickly. If the tap opening is too small, an insufficient gas stream will result. We knew that control of the gas flow would be particularly important if a small (250 litre) helium cylinde r was to be used. Authors note Exit International has investigated several methods of controlling the gas flow from helium cylinders and developed a gas jet that neatly fits the Jamec cylinder head coupling. Once the jet is clippe d into position and the tap on the cylinder switchedfull on, the gas flows at a rate of 15 l/min at full cylinder pressure. This flow decreases as the pressure falls, which is exactly what is requir ed. At the start of the process, as the bag is filling and prior to the first br eath, the flow rates are highest. The original fitting that comes with the cylinder on purchase, the modified fitting and the control jet to provide the initial 15 l/min flow are s hown in Fig 5.6. Cons truction details are described later in this chapter. Fig 5.6: Modified cyl inder fitting and Jet Large He Cylinder (420 litre) Small He Cylinder(250 litre) Fig 5.7: Flow Rate, Pressure and Volume changes with Time A graph of flow rate, pressure and volume of gas with time is shown for the two available cylinder sizes is shown in Fig 5.7. NOTE: Useful flow rates are obtained from either cylinder (>5 litres/min for 15 minutes with the small cylinde r, and 25 minutes with the larger). Purchasing Helium We purchased our first helium cylinder from a local party shop. We ordered a second cylinder just in case by ma il order. In Australia, dis posable helium canisters can be purchased online or ordered by phone. The telephone number for mail order delivery is: 1300 650 823. Most Spotlight stores also stock the helium canisters. In the US and Canada, major department chains are a good source of supply. In the UK, the larger supermarket chains also stock the cylinders. At our local shop, we t ook the advice of other Exit supporters, telling the sales staff that we wanted the canister on stand by for when the grandchildren visited at weekends and school holidays. Others had told us that it's true, their grandchildren do love filling party balloons with helium. This is why it might be wise to purchase more than one cylinder! Although available in two sizes, we initially purchased the smaller, 250 litre cylinder of compressed helium that is sold in a green bo x. Later we purchas ed by phone the larger 420 litre blue boxed cylinder which cost ~A$70. Disposable he lium cylinders are light and easily moved and stored (preferably in a cool place), an d, as long as ther e is no fault in the cylinder or tap, the gas will keep indefinitely. Authors note While there is enough helium in a smal l cylinder for a peac eful death, close control of the gas flow rate in the small cylinders is essentia l. The larger 420 litre cylinders give greater margin fo r error and are pr eferred for this reason.. Pressure should ALWAYS be checked prior to use to ensure the cylinder is full. Helium Purity In 2006 Exit received th e first reports of failures by people using Exit bags with helium. Although this information has been sketchy, the descriptions sugges t that there has been some unexpected contamination of the helium in the cylinder. The reports have been of people breathing the gas insi de the bag for some minutes but with no loss of consciousness. The only possible contamination that could produce this result would be the addition of a significant quantity of oxygen to the helium. This has long been postulated as a possible means of frustrating the use of disposable helium cylinders by those wanting a peaceful death. The introduction of 10% of oxygen would have no effect on the marketed use of the gas balloons filled with this mixture would float but the gas would be of no use in an Exit bag. In mid 2006, Exit undertook extensive testing. The results of these tests were reassuring. No significant contamination of the cylinders tested was found. The results were: Oxygen 0.4%, Carbon Dioxide <0.01 %, Carbon Monoxide <0.1 ppm, Hydrocarbons ~40ppm. The gas from cylinders used in the failed attempts was not tested. This needs to be carried out. Cylinder gas testing for contam inants is quick but one needs reliable test equipment. Exit offers this service. Comparing Methods There is little doubt that the use of helium has greatly improved the acceptance of the Exit Bag. Looking at the RP Test scores for each approach shows why (see below). The helium method used by Joanna was quick. According to her husband, Stephen, Joanna lost consciousness almost immediately. Nevertheless with this method, the person does not die in their sleep and there is some (short lived) al arm and anxiety with the first breath. On the other hand, the use of an Ex it bag with sleeping tablets by Brian meant that there was a period of more than 15 minutes when he sat anxiously with the bag half on his head and with his arms outstretched, waiting for the tablets to take effect. His anxiety almost certainly prolonged this period. More import antly, the whole process Brian used is much slower than with helium and the risk of discovery with possible intervention and resuscitation is much gr eater. For some people, though, the increase d need for associated equipment when helium is used gas cylinder, tubing, regulating jet etc is a significant disincentive.. Note: The helium method produces no changes in the body that can be seen or found on inspection, or discovered at autopsy. If there is no evidence of an Exit bag or cylinder being used, the doctor will likely certify the death as natural, assuming that the person died from their underlying illness. The Exit Bag is the only method that allows this possibility. If sleeping ta blets are used these will be detected at autopsy, although they wo uld probably be at levels unlikely to explain the death. All other approaches described in this book are detectable upon examination or autopsy. Exit Bags While different people make slightly different bags, Brian and Joanna both followed a standard Exit Bag manu facturing outline. Both of their bags were: • a reasonable size • a suitable soft plastic • a neck band of elasti c that allows the bag to make a snug fit around a person's neck In the past, Exit Bags have been able to be purchased from organiza tions such as Right to Die Canada. As the original inventors of the Bag, Right to Die Canada were active for many years in their manufacture and sale and for a while provided a mail order service for their members. For a short period in 2001, Exit International also made bags av ailable to supporters of the organization. However, with the experience of Canadian VE activist, Evelyn Martyns, fresh in our minds, (see Killing Me Softly: VE and the Road to the Peaceful Pill), the organization was forced to revise its position. Recent changes to t he Australian Customs Act have increased the risks associated with distri bution and Exit has now abandoned the manufacture of bags. Exit now concentrates on developing strategies that enable people to construct their own bags and associated equipment. Exit bags vary in size, depending upon whether sleeping tablets or he lium is to be used. Because he was intending to use sleeping pills Brian's bag was quite large. He knew he would need to spend some time with the bag half over hi s head and with his arms holding open the bag's neck before he fell asleep. A smaller bag would have been less comfortable and more likely to bring on a feeling of claustrophobia. For Joanna who used helium, the bag was smaller a nd made of lighter weight plastic. Stephen said that Joanna used a commercial polyester oven bag. Experience has shown that this smaller type of bag can be easily and quickly filled with the helium gas. With helium, the time before loss of consciousness is short, so claustrophobia is less of an issue. In both methods though, the plastic of the bag was thick enough to ens ure that there would be no chance of the plastic obstructing the mouth and nose during deep inspiration (breathing in). Exit Bag Manufacture The following items are needed (see Fig 5.9): • Plastic bag polyester' oven bag' available in superma rkets is a good size (Large 35cm x 48cm) 'A & B' • 1 metre of 10 mm wide elastic, 'D' • 1 toggle to adjust elastic length • 1 roll of 20mm transp arent sticky tape 'C • 1 small roll of ~3 5 mm plastic duct tape • Pair of sharp scissors Fig 5.9: Items used to construct an Exit Bag Construction (See Fig 5.10) Stephen describes how Joanna made her bag (Fig 5.10) 1. She lay the bag out on a flat surface and folded bac k ~25mm (1") around the open end (A B) 2. She made a 25mm cut in the folded polyester 3. She lay the elastic (C) inside the fold a nd had the two ends exit through this cut 4. She taped completely along the folded edge of the plastic with the sticky tape 5. She placed a cut in a ~60mm piece of duct tape and folded this over the exiting elastic to strengthen this part of the bag 6. She threaded a small wire tie through two cuts in another piece (~50mm) of duct tape and stuck this to the inside of the bag ~15cm up from the elastic (E). This was used to secure the plastic helium hose inside the bag. 7. The toggle was then threaded onto the tw o ends of the elastic to complete the bag (D) Fig 5.10: Exit Bag Manufacture Authors 'note the bag should be tested before use. See Point 2 of Brian's story. Fig 5.11: The completed Exit Bag Concluding Comments For seriously ill people who wish to have the option of accessing a peaceful death at a time of their choosing , Exit bags with sleeping tablets or helium provide some options. The method is reliable, simple and does not involve difficult to obtain drugs or equipment. Nevertheless, for the successful use of either of these method s, substantial preparation is required. If sedation is used, sleeping pills (only available up on prescription) will also be needed.. If helium is to be used, a disposable cylinder ne eds to be purchased, along with the requisite connections and tubing. For both methods, a plastic Exit Bag is needed. For each approach, technique is important and a certain degree of physical dexterity required. The need for so much equipment and the unaesthetic nature of placing a bag over one's head prevents many people from even consi dering these methods. Exit Helium Flow Control kit The flow control is a simple device for regulating the gas flow from the helium cylinder. The Kit used by Joanna consisted of two parts: 1. A nylon/brass fitting made from the nylon balloon valve that comes with the cylinder and a 1 /4" BSP female Ja mec Pem compressed air coupling (Part No: 13.0980) 2. A control jet (Primus PCS 8925 or equivalent) threaded into Jamec Pem 1/4" hose tail (part No: 31 1117) Fig 5.12: Making t he cylinder fitting The Construction of the Cylinder Fitting (Instruc tions courtesy of Joanna and Stephen Cataldi) 1. Remove the black rubber fr om the nylon of the balloon filler valve that came with the helium cylinder (Fig 5.12, A) 2. Remove the central brass pin using a light blow with a hammer. Retain the brass washer and rubber seal (B) 3. Replace the washer and rubber seal into the nylon fitting 4. Using a 1 /4" BSP die (F) cut a thread on to the shoulder of the nylon. As the shoulder is only 8mm in length a lathe is useful for this step or one can make use of the purpose made jig provided for loan at all Exit Chapters (Fig 5.13) 5. Using Teflon tape on the thread, fit the nylon to the 1/4" female Jamec Pem compressed air coupling (E). 5. Test the fitting by screwin g the nylon onto the Balloon time cy linder and opening the valve. There should be no leak of helium. Test this using soapy water . Fig 5.13 Jig for cu tting nylon thread The Construction of the Jet Fitting (Instructions courtesy of John Edge) 1. Using a 4.5mm metric fine taper tap (E) cut an internal thread into the Jamec Pem 1/4" hose tail (A, the non hose tail end). Th read a Primus jet (B ,C) into the threaded end of the hose tail and tighten with a spanner. 2. Test to see that the hose tail clips neatly into the brass cylin der fitting. Now when the cylinder is turned on the hiss of gas leaking through the jet at ~15 l/min will be heard. Testing the Pressure To test the pressure, obtain a pressure gauge with range up to 2500 kPa (350 psi) and fit to this a female 1/4" Jamec Pem couplin g (Part No 31.1111). (Fig 5.4 & 5.14) Remove the jet assembly from the cylinder fitting. The gauge ca n be fitted and will immediately provide the cylinder pressure. A full cylinder should have a pressure of >1700 kPa (250 psi) Fig 5.14 Checking to s ee the cylinder is full THE RP TEST SCORE Exit Bag + Sleeping Pills Reliability (R = 6/10) Much more dependent on technique Peacefulness (P = 5/10) Depends on the efficacy of the sleeping tablets used Availability (A = 4/5) Requires prescription drugs Preparation (Pr = 2/5) Taking of tablets and positioning of bag requires skill Undetectability (U = 4/5) Undetectable if equipment removed. Sleeping drugs will be found at autopsy Speed (Sp = 1/5) Slow, depends on action of drugs and "breathing down" oxygen level Safety (Sa = 5/5) Presents no risk to others Storage (St = 4/5) Sedative expiry dates must be noted Total RP Score 31/50 (62%) THE RP TEST SCORE Exit Bag + Helium Reliability (R = 8/10) The method is reliable but technique is important and a degree of coordination and dexterity is required Peacefulness (P=7/10) Considered "peaceful" partly because the loss of consciousness comes quickly. There is the sensation of "air hunger" and alarm Availability (A = 5/5) All components are readily available Preparation (Pr=l/5) Considerable assembly and "setting up" of equipment Undetectability (U = 5/5) If equipment is removed there is no way of establishing the method used even at autopsy Speed (Sp = 5/5) Loss of consciousness comes quickly Safety (Sa = 5/5) The method presents no danger to others Storage (St = 5/5) Components do not deteriorate with time. Gas pressure test can readily establish helium cylinder is full Total RP Score 41/50 (82%) THE RP TEST SCORE Exit Bag + Sleeping Pills Criteria Score Reliability 6/10 Peacefulness 5/10 Availability 4/5 Preparation 2/5 Undetectability 4/5 Speed 1/5 Safety 5/5 Storage 4/5 Total 31 (62%) THE RP TEST SCORE Exit Bag + Helium Criteria Score Reliability 8/10 Peacefulness 7/10 Availability 5/5 Preparation 1/5 Undetectability 5/5 Speed 5/5 Safety 5/5 Storage 5/5 Total 41 (82%)