December 3, 2021
Eyewitnesses on self-inflicted death with Middel X
Doctors doubt whether the suicide powder Middel X leads to a humane death.
De Volkskrant spoke to eyewitnesses of the final hours of six people who wanted to end their lives with it. They recount in detail what they saw happen’ by Maud Effting and Haro Kraak, 3 December 2021, 17:37
PETER – pacer does not want to go on living
On a deserted country road, Maarten drives to his brother Peter’s farm in the autumn of 2020. It is a little past three-thirty. He is a few minutes late.
His brother has asked him to pick up a friend at his house. It is not the only reason Peter has invited him here this afternoon, but he does not know that right now.
In his grey Saab, Maarten turns into the yard. As he gets out, he thinks of his brother. Peter is a 64-year-old physiotherapist who can solve the most complicated physical problems with his hands.
But for the past year he has been increasingly unable to muster the energy to do so. He suffers from depression. Several times already, he has told his family that he would prefer to be dead.
When Maarten walks into the kitchen, he sees that his brother and his wife are not there. Only the boyfriend is sitting at the kitchen table.
‘Where are they?’, Maarten asks.
‘They have gone to the bedroom,’ says the friend. ‘It’s that time again. I don’t know what’s happening there.’
Then they hear a loud scream.
Maarten storms upstairs to the bedroom. There he sees his brother, half lying beside his bed. His wife is sitting with him. ‘Did you take that mess anyway?’, Maarten shouts.
*
It is now more than a year later, and Maarten and his other brother Gijs are sitting opposite two journalists from the Volkskrant to talk about what happened that day.
They want to talk about Middel X, the suicide powder their brother Peter took.
On that autumn day in 2020, they were caught off guard – after all – by his death. Peter was the pacesetter of the family. Funny and sensitive.
You could laugh terribly with him, they say. Never was it quiet around him.
Maarten and Gijs are not their real names: for privacy reasons, they wish to remain anonymous.
The men, both retired, had good jobs in business: they worked in communications and in occupational and organisational psychology. They want to warn.
They say the stories about a humane death that Medium X would cause are untrue.
Middel X is a white powder, a preservative, on sale at chemical wholesalers. It was ‘discovered’ in 2017 as a suicide powder by Coöperatie Laatste Wil (CLW), the organisation fighting for a way to end life humanely without the intervention of a doctor.
That fight provoked fierce reactions: the judiciary is now investigating several CLW members, including its president.
Initially, the drug seemed ‘ideal’: cheap, lethal, easy to store, little of it was needed and no antidote existed. But doctors and scientists were highly sceptical from the start about whether the drug was so humane.
Nursing home physician Bert Keizer warned in the professional journal Medisch Contact. ‘There is,’ he wrote, ‘a significant risk of dying floundering.’
But is this true? The media has so far hardly published detailed eyewitness accounts of the dying process with the suicide powder.
For the Volkskrant, the brothers’ story was therefore the start of an investigation into the experiences with Middel X.
We spoke to four eyewitnesses of a total of six deaths and a police officer who responded three times to a report of suicide.
What does this powder do? What do people go through who take the recommended 2 or 3 grams? Does it lead to a humane death?
The suicides are described by eyewitnesses. It is their perception of the events: only they were there. That makes it difficult to verify. But all the witnesses were questioned in detail and tried to check the stories for inconsistencies. Peter’s wife read the piece and checked it.
In one case, there were two witnesses to a death. The policeman’s story was partly confirmed by another source. Just after Peter’s death, a report was also made by psychiatrist Boudewijn Chabot, who collects cases because he is concerned about Middel X.
*
PETER – brother can’t stop him
Before Peter turns to Middel X, he has been severely depressed for years. He does everything he can, but the mental health service proves unable to help him, his brothers argue.
‘His psychiatrist prescribed him medication,’ says Gijs. ‘But he didn’t look for the causes of his depression.’
First, he tries to drown himself in the canal near his house. Soaking wet and crying, he stands in the living room. Then he asks the GP for euthanasia, but he is unwilling to do so.
Then Peter gets in touch with someone from the Last Will Cooperative. The man says he wants to look him in the eye first.
‘My brother went there with his wife,’ Martin says. ‘His wife was desperate. She was incredibly angry that he wanted to die, but she also saw that he was sinking further and further.
She said: if you do it, please don’t do it on a train or in the water.’ The conversation lasted half an hour. ‘The man told how it would go. He said: you sit on a chair, take it and sink down. Then he got a phone number.’
Martin bristles when his brother asks if he wants to be at his death. ‘I said, ’Are you completely besotted? The last thing I want is to participate in your death.’ Peter had been very vocal throughout his life against artificially ending life.
That’s why I was adamantly against it. But he only replied: well, that will be a cosy mess then.’
‘Mán,’ Martin says to his brother. ‘Flick that drug into the bin.’
But his brother perseveres.
Carefully planned
On that Friday in 2020, he takes Middel X as soon as he hears Maarten enter the kitchen. His wife and brothers are almost certain afterwards that he planned it exactly that way, so as not to leave her alone that day.
In the bedroom, Peter lies on the floor in convulsions.
‘Help me,’ he shouts. ‘Help me.’
Martin puts him back on the bed, along with his wife. ‘Puke it,’ he shouts. ‘Vomit it!’
For a moment he considers sticking a finger down his brother’s throat, but he doesn’t. He knows that Peter has made this decision himself. Next to his bed is a letter saying he wants to die.
His brother keeps calling for help. He has cramps. Occasionally he tries to get up, but then he immediately falls back again – convulsing.
‘What can we do then?’ cries Martin. ‘Should we call 112? You said you wanted to die and you didn’t want help. If you don’t say anything, I’ll call. If you don’t want to, you have to say it now.’
His brother looks at him. And remains silent.
And so he calls. When the 112 dispatcher asks if he knows what his brother has swallowed, Peter’s wife arrives with a paper, a kind of manual for Middel X.
To the emergency operator, Peter reads out the name of the drug. The dispatcher says the ambulance is on its way.
On the same sheet, Maarten sees something else. It says that there is no way back after ingestion.
*
MAUD – mother does not want to die like her husband
In its search for witnesses, the Volkskrant also stumbles upon another story surrounding Middel X: the death of Maud, an 81-year-old woman.
Her two sons, educated fifties, talk fondly of their mother. She loves classical concerts, gardening, her friends. But her body is exhausted: every 15 minutes of exertion has to be paid for by two days of rest.
She also feels so distressed at times that she feels like she is drowning.
Yet her request for euthanasia is refused. The GP could not ‘get it into his heart’, her sons tell her. ‘He thought she was still too good.’
Their mother is determined not to die like her husband. He died of lung cancer and his last three weeks were a degrading agony. Yawning with morphine, he lay in bed.
One day she tells her sons and the GP that she has Middel X in the house. She arranged everything herself. For a moment they are startled. ‘I am an advocate of self-determination,’ says her son Rens, ‘but it is different when your own mother suddenly wants to say goodbye for good.’
Still, they accept her decision. ‘We said: we are going to support you, we will go through this together.’
First, they consulted a counsellor from De Einder, a foundation that guides people through a self-determined end of life. ‘He told us what we could possibly expect,’ says Rens.
‘Headaches, convulsions, seizures, foam at the mouth, vomiting. It depended on the body what would happen. My mother was not shocked. She was mostly annoyed that we would have to deal with that.’
‘The good thing about that conversation,’ says her son, ‘was that we got a complete picture.’
Months of goodbyes
In the months that followed, they said goodbye, prepared. ‘My mother included everyone in her decision,’ says Steven. ‘She invited the grandchildren to her place one by one.’ They also hold a meeting with the whole family once a month.
Secretly, they try to make life more and more fun for her. Until she says: ‘Bloody hell, I just have to choose. And I’m going to do it now.’
It is March 2021 when both her sons come to her house. Their mother is uncharacteristically cheerful that day. Everything seems to have fallen away from her. They no longer say an extended goodbye: everything has been said. In the hours before, she has taken the recommended anti-convulsants and painkillers.
‘How nice that nothing more is needed,’ she says.
It is two o’clock in the afternoon when she looks at them and says: ‘Well it just has to happen.’
Without hesitation, she swallows the two capsules. ‘Gee,’ Rens says to her, ‘how long would it take before you feel anything?’
*
The self-chosen end of life largely takes place in darkness in the Netherlands. Those who choose to commit suicide are not always supported in this by those around them.
In October 1991, Huib Drion, a former member of the Supreme Court, wrote a taboo-breaking piece in NRC: he advocated suicide aids for elderly people who considered their lives ‘completed’.
‘Many people would find great peace in it,’ he wrote, ‘if they could have a means to step out of life in an acceptable way at the moment it (…) seems appropriate to them.’
His plea led to fierce debates that still continue, including in politics. Last year, for instance, D66 tabled a bill to make the ‘last-will pill’ possible for over-75s under strict conditions.
At the same time, there are fears that unstable, young people will step over the threshold and commit suicide too easily due to the availability of such drugs.
The argument also unleashed a search for Drion’s ‘pill’. For years, there has been a lively trade in last-ditch drugs. People get them – illegally – from Mexico, China or India. And since the rise of Middel X, also from the Netherlands.
But this is not without risk: assisted suicide has been punishable in the Netherlands since 1886. Anyone who actively participates in a suicide risks a three-year prison sentence.
Handing out a drink, handing out drugs – it is considered assistance. Several over-70s have since been arrested for dispensing Middel X. Only bystanders sitting on their hands have nothing to fear.
It is one of the reasons why there is little reliable information on Medium X: few dare to be open.
Documentation
Nevertheless, attempts are being made to gather information. In The Peaceful Pill Handbook, in which Australian doctor Philip Nitschke documents all methods of suicide, Middel X is called ‘(almost) as lethal as cyanide’.
According to Nitschke, the drug possesses a number of properties that make it a ‘useful suicide agent’, including the fact that it is legally available.
The doctor has included in his book two lists of deaths caused by Middel X.
One list comes from Last Will and involves 29 cases, ranging in age from 31 to 92.
On average, it takes half an hour until someone loses consciousness, according to the figures, and an hour and three-quarters until death.
Side note is that the information was recorded by relatives, so may not be accurate. The other list covers 19 cases recorded by poisoning centre NVIC. The information in this is even less complete.
‘It is extremely difficult to collect data on this,’ Nitschke says by phone. ‘The information I have now is not good enough. It is too fragmentary. We still don’t have film footage of a death caused by Middel X.’
The reported side effects of Middel X in the two lists vary: they range from ‘none’ to severe headache, foam at the mouth, panic, dizziness, tightness in the chest, vomiting, cramps, seizures and cardiac arrhythmias.
It follows from the scientific literature that Middel X causes a sharp drop in blood pressure in all cases. The immediate consequence is often that people faint or collapse.
The mechanism of action of Middel X has not yet been fully unravelled, but it is clear that the drug blocks cellular respiration, says toxicologist Antoinette van Riel of poison centre NVIC.
Cells need oxygen for energy, but the drug blocks this process, she argues. Cells suffocate, as it were. Some tissues can go without oxygen for a while, but vital organs, such as the heart or brain, cannot.
‘The brain is very sensitive to oxygen deprivation,’ she says. ‘The feeling of tightness may explain why some people panic.’
*
PETER – ambulance brings sedative
In his bedroom, Peter feels stuffy after a while. And hot. ‘I’m on fire,’ he shouts. He starts pulling at his shirt. With furious, uncontrolled movements, he tries to rip it off his body.
He also starts screaming. It goes on for minutes. And it goes through the bone. Martin and Peter’s wife look on helplessly.
‘Give me a knife,’ Peter shouts. ‘Then I’ll put an end to it.’
‘We’re not going to do that,’ shouts his brother. ‘Help is coming.’
He runs outside to meet the paramedics. Peter does not resist them.
He no longer screams. The paramedics look at the Middel X box, check his breathing, his blood pressure, his heartbeat. They also give him a sedative.
‘This is all we can do,’ says the paramedic. ‘I think we should take him to the Emergency Department.’
‘Do you want that, Peter?’ his brother asks.
But the latter does not answer. Martin insists a few times. And then his brother finally says something. ‘No one can help me,’ he states. It’s not an answer, and yet again it is.
In fact, everyone in the room knows there is no point anymore.
Martin watches as his brother loses consciousness and his breathing becomes more irregular. He also has an epileptic fit that lasts for about 15 minutes – the foam is on his mouth.
When the GP arrives, it lasts another few minutes. It is 4.53pm when Peter dies, in his own bedroom. Seventy-three minutes after he took Middel X.
*
A few minutes after 81-year-old Maud swallowed Middel X, it begins.
‘Oh, I feel all sorts of things,’ she tells her sons. ‘I’m dizzy.’
Soon after, she says she has to throw up. Her sons look for a pan in the kitchen, but she keeps it down. Their mother gets hot. Her cardigan has to come off. From her hand, they feel she is starting to sweat.
Moments later, she can no longer walk properly. She staggers. Her sons accompany her to bed and sit down next to her. One holds her hands, the other caresses her head.
The brothers feel calm: everything that happens they have talked through beforehand. Every now and then they glance at each other to see if the other is still holding on.
‘We were determined to help her through this,’ says Rens. Steven: ‘The counsellor had told us we could walk away if necessary if things got intense.’ They stay.
Their mother keeps her eyes closed. She doesn’t say much more.
‘We saw all sorts of things happening in the body,’ says Steven. ‘It must have been intense. But she didn’t show much of that.’ Rens: ‘I think she was working very hard to concentrate, to control herself.
She wanted to keep it in, with everything she had in her. So that it affected us as little as possible. That’s how she was in life, too.’
After about 20 minutes, their mother suddenly starts babbling. Her sons hold her. It lasts for a few minutes. And then she’s gone, they say. Out of consciousness.
For more than three quarters of an hour, she keeps breathing. It goes quietly. She has no spasms, no seizures, no foam on her mouth.
Sad and relieved
‘When she stopped breathing, something fell off me,’ says Steven. ‘She was through.’ Then the brothers fall into each other’s arms. They are sad, relieved, content – all at once.
Steven: ‘I thought: this has gone well. Maybe she suffered intensely, but compared to my father, who had been fighting for three weeks, this was really very short.
I think many people forget that even a natural death can be endless. This was many times more beautiful.’
That same evening, they were heard by the police. ‘The officers were very compassionate. The head lady said: ‘I have been working in the police for 15 years, but I have never experienced this.’
Both sons look back on their mother’s death with a good feeling. It was intimate and intense, they feel.
Steven: ‘She prepared this very well, both for herself and for us.
In the months before, we were so engaged with it that we had already had part of the grieving process before her death. Together with her. That was very special.’
*
HANS – requested four times at deathbed
The Volkskrant has also been making contact with Hans – not his real name – in recent months.
Few people will have witnessed a death by Middel X as often as he has.
Hans is retired and, as a living room conversation leader, talks to members of Last Will about their dying wishes. He is an optimistic man, he says: he assumes that things usually work out.
He himself thinks the rise of Middel X is unstoppable. During conversations, he tries not to be judgmental.
He also tries to make people aware of those left behind. And very sometimes people ask him: ‘Do you want to be there when I do it?’
Four times he said yes to that question.
He talks about it at his kitchen table, in the presence of his wife. He says he finds it an honour that people trust him like that.
In all cases, he came to people’s homes. He usually wore gloves; he does not want to leave fingerprints anywhere. Afterwards, he quietly left the house, hid the key somewhere near the door and informed the family doctor through an anonymous letter or mail.
Relatives did not know about his involvement: the people who invited him did not want that. They asked him because they did not want to be alone at their death.
The first time is with Ank, a woman in her 70s. Just before she takes Middel X, she jokes, Hans says. ‘She was relieved. Delighted. Like the party was going to start now.’
After taking it, she starts talking about her life, but a few minutes later she says: ‘I feel something. I feel a struggle inside myself.’ Moments later, she starts talking gibberish.
‘She repeated syllables, words, like she was drunk. I held her hand. Without a glove.’
She falls backwards and starts breathing heavily. For a while she lies still. But then she unexpectedly gets up and looks at him. She calls his name. ‘Thank you,’ she says. She also says something more about her daughters. It moves him.
‘Hold me,’ she says. Then she starts shaking, he says, a phase that lasts about a minute.
‘It looked like an epileptic fit. It startled me. This was what I was afraid of. It was quite violent. Uncontrolled. But she didn’t seem to experience it consciously.
Then her body went limp and she started breathing more and more irregularly. It was a bit like snoring.’ In total, it lasted an hour and a half. ‘It was immediately clear she was dead.’
The second time, Hans comes home to a husband and wife, a duo who are at their wit’s end. ‘They were happy,’ says Hans. ‘Like they were going on a school trip.’
In the kitchen, they each spoon away three capsules of Middel X with a full bowl of custard. Then they lie down in bed upstairs.
And then, says Hans, nothing happens for a very long time. Fifteen minutes pass, half an hour, three quarters of an hour – nothing. ‘They got nervous and asked each other: do you feel anything yet?
They were very much paying attention to each other. That maybe didn’t help. They didn’t surrender.’
The man gets nauseous. Hans tells him to throw up next to the bed. A small amount comes out.
‘It’s not going well,’ says the woman.
‘I can see it too,’ says Hans. ‘But we have to wait. It has to work.’ He tries to reassure them. But deep down he has his doubts. ‘It made me a bit nervous. I thought: what is happening here? Are they going to survive this dose? I started wondering if I should end up calling 112.’
Quietly, the two lay on the bed. They don’t touch each other and barely move. Sometimes Hans thinks for a moment that they are nodding off. But then they start talking again.
‘I feel weird,’ says the man. ‘I do feel like I’m dying.’
‘Oh, how beautiful this is, oh, how peaceful this is,’ says the woman. But not much later her mood turns. ‘How goddamn awful this is,’ she says.
Worried, Hans stares at the two on the bed. ‘I wasn’t really shocked,’ he says. ‘But I wasn’t quite sure what was so awful then. I didn’t want to ask any questions that would keep them awake longer.’
An hour and a half later
It is only after an hour and a half that they lose consciousness. Snoring, they breathe. Finally, the woman dies after two and a half hours. The husband fifteen minutes later. Startled, Hans calls his wife. ‘It didn’t go well,’ he says.
‘At least: they did die, but it shouldn’t have been like that. It took far too long.’ In retrospect, he suspects this is because they took capsules with custard.
On a full stomach, it may enter the bloodstream later. ‘It seems to go fastest if you dissolve it in a glass of water.’
The latest case Hans experiences is a widow in her 70s. Beforehand, she is calm. She has taken a sedative. She drinks a glass of water in which Middel X has been dissolved.
‘Oh, so now I’m going to die,’ she says. ‘How extraordinary.’
This time it goes fast, very fast. ‘Within three minutes she fell away. She was moving and then she slumped backwards. She lifted another arm.’ Then she lay staring with her eyes open for a while.
‘I don’t know if she saw anything. She lifted one leg and straightened it again. A few times her right hand came up slowly – almost a kind of greeting.’ The movements lasted about 20 minutes, Hans says.
‘Then she lay breathing for another hour. Then it was quiet.’ In total, it takes an hour and a half.
In his experience, all four times were peaceful, despite the long duration with the couple. He was struck by the conviction he found.
‘Everyone was determined, everyone was sure that life had to end.’
*
One evening in November, the Volkskrant gets a call from a police officer. He has now faced suicide by Middel X three times and he is struggling with distress of conscience.
After long hesitation, he decided to make the call. Although as a police officer he is not allowed to talk about these cases in detail, he feels he should.
In the course of his work, he frequently encounters people who take their own lives, he says. He sees everything from hangings to people throwing themselves in front of trains.
‘From experience, I know that some people cannot be helped. So I can well imagine that they then choose this. I am not against that in itself. But it stings me that the whole truth is not put on the table.’
Three times he finds bereaved relatives at home distraught after a report about Middel X. Each time they are women who have seen their husbands die.
‘At first I thought they were upset because their husband had just died. But they weren’t. It had turned out completely different from what they had thought.’
The first report involved a man in his 50s. ‘His wife was hugely emotional. It had taken hours and he had had terrible cramps. She had had to forcefully keep him on the bed. She said: this is the worst thing I have ever experienced.’
On a subsequent report, the husband and wife agreed that he would take Middel X upstairs and she would wait downstairs. ‘She had said: I’ll wait until it’s quiet. About five or six times she ran upstairs, thinking: now it’s done. But each time he was still alive. He was crumpled up on his bed.’
‘A policeman is practical,’ he says. ‘He goes somewhere, does his thing, and leaves again. If I were to raise this with the police, I would be told: this is not up to us, we don’t get involved in this. But I want clarity on this.
‘Look: a hanging is a terrible thing to encounter. People who jump in front of trains are hardly identifiable. As a police officer, you come to the door afterwards and have to tell relatives that they can no longer see their loved one.
These are things you don’t want either. In that sense, this might be a solution. But this is not the right remedy. These women have seen their husbands suffer so much. This may be burned into their retinas forever.’
*
Is Middel X humane or not?
‘In any case, it doesn’t always happen quickly and not always peacefully,’ notes toxicologist Antoinette van Riel of poison control centre NVIC. ‘It is a distorted view that this is an ideal remedy.’
‘We tell our members that in very many cases it goes well and peacefully, similar to a natural death,’ says chairman Jos van Wijk of Coöperatie Laatste Wil. ‘But there are exceptions, due to rolling eyes and draws.’
Philip Nitschke, author of The Peaceful Pill Handbook, predicts that Middel X will become a cocktail of drugs. ‘CLW finds this attractive because it is simple,’ he says. ‘But there are reasons to add drugs.’
Just painkillers and anti-seizure drugs are not enough, he thinks. ‘You can add a sedative. Once asleep, cramps and lowering blood pressure are no longer a problem.’
‘I think,’ says Nitschke, ‘that Middel X could eventually develop into a rather perfect Drion’s Pill.’
Furious
Peter’s brothers look at this completely differently since his death. They are still furious, also because the drug is irreversible and there is no antidote.
‘I am convinced that my brother did not know this could happen,’ says Martin. ‘He must have thought: with this I am just slipping away.’
For a while, they wondered what to do with this. ‘We are not the type to go straight to a lawyer,’ says Gijs. ‘Besides, Peter had very emphatically chosen this himself.
But the fact that Last Will insists that Middel X ensures a humane death – I actually find that criminal. They have become blinded by their idealism.’
The death of 81-year-old Maud proves that death with Middel X can also be gentle.
In retrospect, the sons think that good preparation, acceptance in the family and calmness ensured that everything went so well.
‘The process beforehand was very important,’ says Steven. ‘We had discussed all scenarios with each other. When unexpected things happen, you get panic and things can go wrong. ‘
‘My mother felt secure because we were there,’ says Rens. ‘She didn’t have to do it alone.’