The Pharmacology of Aid in Dying: From Database Analyses to Evidence-Based Best Practices.

Background: Medical aid in dying is legal in 10 states plus Washington DC, covering 22% of the U.S. population. Much has been written about the ethics of aid in dying, but little about evidence-based care, especially the medications used. We investigated the efficacy of four commonly used aid-in-dying medication protocols-using the time to sleep and time to death as proxies for efficacy. Methods: We performed an independent, secondary analysis on deidentified data from four organizations, comparing four different medication protocols. Descriptive statistics for time to sleep and time to death for the different medication protocols were calculated. Medication protocols included one sedative and three sedative/cardiotoxin combinations. Results: We analyzed data from 3332 death reports covering 2009 to 2023, comparing a single sedative medication protocol with three different sedative/cardiotoxin combinations. The sedative alone yielded the most rapid median time to death of 0.4 hours, but with days-long outliers. Two of the sedative/cardiotoxin combinations yielded median times to death of 0.8 hours. But from 2018 to 2023, as the medication combinations shifted, the mean time to death declined while the median remained relatively steady-confirming that these combinations reduced the incidence of longer deaths (especially extreme outliers). Conclusion: This first-time analysis of aid-in-dying medication protocols showed that while a sedative alone had the best median time to death, the most recent sedative/cardiotoxin protocol had an acceptable median time to death of 0.8 hours, but with fewer prolonged-death outliers.