No Mystery: Arizona Execution Lengthy Due to Drug Choice

Screen Shot 2014-07-26 at 12.19.57 PMThere’s no mystery about why the July 23 execution of Joseph Wood in Arizona took so long. From the anesthesiologist’s point of view, it doesn’t seem surprising that the combination of drugs used—midazolam and hydromorphone—might take nearly two hours to cause death.

Here’s why.

The convicted murderer didn’t receive one component of the usual mixture of drugs used in lethal injection: a muscle relaxant. The traditional cocktail includes a drug such as pancuronium or vecuronium, which paralyzes muscles and stops breathing. After anyone receives a large dose of one of these powerful muscle relaxants, it’s impossible to breathe at all. Death follows within minutes.

But for whatever reason, the Arizona authorities decided not to use a muscle-relaxant drug in Mr. Wood’s case. They used only drugs that produce sedation and depress breathing. Given enough of these medications, death will come in due time. But in the interim, the urge to breathe is a powerful and primitive reflex.

So-called “agonal” breathing, which precedes death, may go on for minutes to hours. The gasping or snoring that eyewitnesses described would be very typical. People who are unconscious after overdoses of heroin try to breathe in a similarly slow, ineffective way, before they finally stop breathing altogether or are rescued by emergency crews.

More about the drugs

Wood Stay

Midazolam is a member of a class of drugs called benzodiazepines. The common “benzos” that many people take include Valium, Xanax, and Ativan. What these drugs have in common is that they produce relaxation and sleep. You might take a Xanax pill, for instance, to help you nap during a long flight.

In anesthesiology, we use benzodiazepines for another important reason: because they produce amnesia. There are stories of people taking a Valium to relax a little before they give an important talk, and the next day panicking because they can’t remember if they actually showed up and gave the talk.

Amnesia can be very helpful in my business. Many of my patients don’t want to remember coming into the operating room and seeing the bright lights and surgical instruments. After I inject one or two milligrams of midazolam into the IV, they’re often smiling and relaxed, and they have no memory later of coming into the operating room at all.  The next thing they know, surgery is over and they’re waking up.

Hydromorphone is a member of a different class of medications: narcotics. These include powerful pain relievers such as morphine, Demerol, heroin, oxycodone, and hydrocodone. These medications, in large doses, will slow or even stop breathing altogether. That’s why the risk of overdose is emphasized so strongly, and why narcotics cause so many accidental overdose deaths.

When you put benzodiazepines and narcotics together, the risk of death by overdose rises sharply. These drugs in combination were implicated in the deaths of actors Heath Ledger and Phillip Seymour Hoffman. There’s no question that if you take enough of these drugs, your breathing will slow and eventually stop if no one steps in to help you.

Why were other executions faster?

The original cocktail designed for lethal injection consisted of sodium pentothal, potassium chloride, and pancuronium. Sodium pentothal produced sleep, potassium chloride stopped the heartbeat, and pancuronium paralyzed the muscles so that the convict was unable to m

ove or breathe. To all appearances, the convict would go to sleep and within a matter of minutes would be pronounced dead.

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But opponents of capital punishment argued that there was no guarantee with this recipe that the convict was ever truly unconscious. There could be a chance that the dose of sodium pentothal would be insufficient or would wear off before the other drugs had time to take effect. Being awake and paralyzed during the dying process would truly be cruel and inhumane, they claimed. Of course, there is no way of knowing if this ever occurred, but there is equally no way of knowing that it didn’t.

I’ve written before about the clearly botched execution of Clayton Lockett in April, where the lethal injection drugs worked slowly because they were probably not injected into a vein at all. Unfortunately, he seems to have been conscious at least during the early stages.

In Mr. Wood’s case, the combination of midazolam and hydromorphone appears to have produced sleep and depressed breathing, exactly as predicted. As time went on, and his breathing became slower and less effective, the amount of oxygen in his bloodstream inevitably decreased to dangerous levels, and the amount of toxic carbon dioxide increased. When that happens, the heart eventually starts to beat erratically, and cardiac arrest leading to death is the end result.

How long it will take to die from the effects of midazolam and hydromorphone is impossible to predict, because there are so many variables:  the age and size of the person, how sensitive the person may be to the effects of sedatives, and how much medication was given.

The only thing we can be reasonably sure of is this: Mr. Wood was asleep and unaware during the process of dying.

Since midazolam and hydromorphone don’t paralyze muscles, if Mr. Wood had been awake he would have been able to open his eyes and move around. The fact that he didn’t move or writhe, as Mr. Lockett did, makes a strong case that he was asleep. While Mr. Wood’s slow demise may have been excruciating for witnesses to watch, there appears to be no evidence that he was conscious after the injection took effect.

The cases of Mr. Wood and Mr. Lockett underscore the fact that even with lethal injection, execution may not be fast or painless for observers to watch. As pharmaceutical companies become even more reluctant to provide medications for the purpose of execution, we can expect to see more experiments with different combinations of drugs.

No one should be surprised if these experiments don’t go smoothly.

 Karen Sibert is an anesthesiologist.

11 replies »

  1. platon20, why don’t you discuss the length and thickness of hanging rope to get a “better” outcome?

  2. It doesnt make any sense to administer lethal injection by IV. Getting and keeping an IV in a decades long prison convict who most likely uses IV drugs is difficult.

    Meds should be given IM instead of IV. That way you dont have to worry about the needle slipping.

    Futhermore, the doses for these meds need to be much higher. A dose of 1000mg of morphine would kill any man, even if he’s a morbidly obese 500lb fatty.

    I never understood why these lethal injection protocols use doses that are just 50% or so over hte max “lethal” dose. Dont take any chances. Dont give 50% above the max dose, give the inmate a 1000% dose instead. It doesnt make any sense at all to use lower doses of these meds.

  3. Dr. Kevorkian seemed to get it right, my vet seems to get it right?? My local Red Cross always finds the vein.

    The only right choice is prison, not death, but I have no doubts that if we made capital punishment a reality show it would be very popular with the gawker masses. I bet “Duck Dynasty” would love the segment on their show, with a touch of God’s approval.

  4. Dr. Sibert makes an important point regarding the dubious choice of agents used in this execution. Why these drugs were chosen is indeed puzzling.

    But putting “life and death power into the hands of the clearly incompetent government and legal system”? We (Americans) are obviously already willing to turn over our healthcare system to the government (the VA, the PPACA, Medicare, Medicaid, etc.), so why not executions? I’m sure the IRS can do an excellent job of overseeing these processes.

  5. My intent with this article was to explain the science, not get into the politics. However, what gives me the most pause about capital punishment in general is putting life-or-death power in the hands of our clearly incompetent government and legal system. Trust the government to get it right all the time? And never convict or execute an innocent person? Seems unlikely.

  6. Executions have come a long way since the old English method of drawing and quartering. Most societies prior to the 18th century (and still some) have horrific modes of punishment for many crimes in addition to capital ones.
    It makes sense that if you’re going to put someone to death, putting them “to sleep” seems very humane, after all that’s what we do to our pets, and I assume what they do in countries with euthanasia. By the same token, someone who is undergoing euthanasia is choosing to die rather than suffer in life.
    The difference is, the prisoner does not usually want to die, and most certainly not to suffer in the process. Secondly, part of the despair in capital punishment is actually knowing the day and time you are going to die. While I consider myself a humanitarian, I must admit capital crimes that involve particularly heinous acts such as rape and murder of children do not engender much sympathy with me for the perpetrator.
    However, by putting the prisoner to death in a similarly heinous manner, while vengeful, does not fit with our idea of civilized society.
    Ironically, the push against capital punishment has made it more difficult to obtain the previous drugs that were used as “cocktails” for the death penalty. I have a feeling this is going to continue until no drugs are available and states will have to seriously reconsider the options.

  7. The outpouring of vengeful rhetorical spittle across the internet in the wake of this execution seems to be running 99-to-1 morbid glee that the inmate would and should suffer. The “medicalization” of execution you detail, once thought to be a “humane” policy solution, continues to prove problematic.

    As far as “constitutionality,” these executions may or may not be “cruel,” but they are certainly “unusual” in the sense of the minute proportion and random selection of death sentences in which the executions actually occur (a complaint at the heart of the recent California strikedown ruling). But, given that such fails the conjunctive “and” judicial construction test in general, we will likely continue to tilt Quixotically at the “cruelness” windmill. Pubic sentiment, by a wide margin, clearly doesn’t care that ANY method of execution rises to the level of “torture.”

    On a sub-capital crime level, you’re supposed to get sent to prison AS punishment, not FOR punishment, but, we chortle at prison rape jokes nonetheless and want inmates to suffer. We take an offender, and to “teach” him a lesson about what society ostensibly values cardinally, we place him in an environment where the Law of The Jungle/Might Makes Right is SOP. Then we wonder why they usually come out worse.

    I don’t wonder in the slightest.

    At the capital crime level, you’re supposed to simply pay for your crime with your life, but we want a topping a vengeful suffering. That it poisons us as well escapes us.

    Difficult issue. I would just do away with the death penalty, on balance.