Suicide methods

A suicide method is any means by which one or more persons purposely kill themselves. Suicide methods can be classified according to two modes of interrupting life processes: physical or chemical. Physical modes of interruption typically act by incapacitating the respiratory system or the central nervous system, usually by destruction of one or more key components. Chemical modes focus on interrupting biologically significant processes such as cellular respiration or diffusion capacity. Chemical methods of suicide produce latent evidence of action, whereas physical methods provide direct evidence.

Bleeding

Suicide by exsanguination involves reducing the volume and pressure of the blood to below critical levels by inducing massive blood loss. It is usually the result of damage inflicted on arteries. The carotid, radial, ulnar or femoral arteries may be targeted. Death may occur directly as a result of the desanguination of the body or via hypovolemia, wherein the blood volume in the circulatory system becomes too low and results in the body shutting down.

Wrist cutting

Wrist cutting is sometimes practiced with the goal of self-mutilation and not suicide; however, if the bleeding is copious and/or allowed to continue unchecked, cardiac arrhythmia, followed by severe hypovolemia, shock, circulatory collapse and/or cardiac arrest, and death may ensue, in that order.

In the case of a failed suicide attempt, the person may experience injury of the tendons of the extrinsic flexor muscles, or the ulnar and median nerves which control the muscles of the hand, both of which can result in temporary or permanent reduction in the victim's sensory and/or motor ability and/or also cause chronic somatic or autonomic pain.^[1] As in any class IV hemorrhage, aggressive resuscitation is required to prevent death of the patient; standard emergency bleeding control applies for pre-hospital treatment.

Arterial bleeding is identified by the rhythmic gush of blood (in unison with the heartbeat) that is bright red in color. Venous bleeding, on the other hand, produces a continuous stream of blood of a darker red color. Arterial bleeding is more difficult to control and usually more life-threatening. The bleeding may be further controlled by indirect arterial pressure—for example, pressure on the brachial artery can reduce bleeding from the arm; however, pressure points should be used with caution, as inadequate blood flow may cause severe damage to a limb. ^{[citation needed]}

Drowning

Suicide by drowning is the act of deliberately submerging oneself in water or other liquid to prevent breathing and deprive the brain of oxygen. Due to the body's natural tendency to come up for air, drowning attempts often involve the use of a heavy object to overcome this reflex

Drowning is among the least common methods of suicide, typically accounting for less than 2% of all reported suicides in the United States.^[2]

Suffocation

Suicide by suffocation is the act of inhibiting one's ability to breathe or limiting oxygen uptake while breathing, causing hypoxia and eventually asphyxia. This may involve an exit bag (a plastic bag fixed over the head) or confinement in an enclosed space without oxygen. These attempts involve using depressants to make the user pass out due to the oxygen deprivation before the instinctive panic and the urge to escape due to the hypercapnic alarm response.

Helium, argon and nitrogen are commonly used in suicides by suffocation. Breathing inert gas quickly and painlessly renders a person unconscious, and may cause death within minutes.^[3]

Hypothermia

Suicide by hypothermia or by cold, is a slow death that goes through several stages. Hypothermia begins with mild symptoms, gradually leading to moderate and severe penalties. This may involve shivering, delirium, hallucinations, lack of coordination, sensations of warmth, then finally death. One's organs cease to function, though clinical brain death can be prolonged.

Electrocution

Suicide by electrocution involves using a lethal electric shock to kill oneself. This would cause arrhythmias of the heart, meaning that the heart would not contract in synchrony between the different chambers, essentially causing elimination of blood flow. Furthermore, depending on the amount of electrical current, burns may also occur.

“The evidence here shows that electrocution inflicts intense pain and agonizing suffering,” (Justice William M. Connolly, Nebraska Supreme Court) ^[4]

Jumping from height

Jumping from height is the act of jumping from high altitudes, for example, from a window (self-defenestration or auto-defenestration), balcony or roof of a high rise building, cliff, dam or bridge.

In the United States, jumping is among the least common methods of committing suicide (less than 2% of all reported suicides in the United States for 2005).^[2]

In Hong Kong, jumping is the most common method of committing suicide, accounting for 52.1% of all reported suicide cases in 2006 and similar rates for the years prior to that.^[5] The Centre for Suicide Research and Prevention of the University of Hong Kong believes that it may be due to the abundance of easily accessible high rise buildings in Hong Kong.^[6]

Firearms

A common suicide method is to use a firearm. Generally, the bullet will be aimed at point-blank range, often at the head or, less commonly, into the mouth, under the chin, or pointed at the chest. In the United States, firearms remain the most common method of suicide, accounting for 53.7% of all suicides committed during 2003.^[7]

What happens when a human gets shot will be a function of at least the missile velocity, the available energy in the projectile, and the tissue interaction. A high energy firearm and proper barrel orientation to the head is likely to create devastating damage: high class hemorrhage, severe physical brain damage with permanent partial or complete tissue destruction of multiple lobes, nerve destruction, and obvious skull fracture with potential bone fragments embedded in the brain. Structures likely to be affected are intracranial, vascular, middle or inner ear, cranial nerve and external canal structures. With low caliber and low powered weapons, despite optimal orientation of the barrel, the firearm may not be effective in killing the victim.^{[citation needed]}

A failed suicide attempt by firearm may result in severe chronic pain for the patient as well as reduced cognitive abilities and motor function, subdural hematoma, foreign bodies in the head, pneumocephalus and cerebrospinal fluid leaks. For temporal bone directed bullets, temporal lobe abscess, meningitis, aphasia, hemianopsia, and hemiplegia are common late intracranial complications. As many as 50% of people who survive gunshots wounds directed at the temporal bone suffer facial nerve damage, usually due to a severed nerve.^[8]^[9]

Research published in the New England Journal of Medicine and the National Academy of Science found an association between household firearm ownership and gun suicide rates,^[10]^[11] though a study by one researcher did not find a statistically significant association between household firearms and gun suicide rates,^[12] except in the suicides of children aged 5–14.^[12] During the 1980s and early 1990s, there was a strong upward trend in adolescent suicides with a gun,^[13] as well as a sharp overall increase in suicides among those age 75 and over.^[14]

Two separate studies, in Canada and Australia, conducted in conjunction with more restrictive firearms legislation, demonstrated that while said legislation showed a decrease in firearms suicide, other methods such as hanging increased. In Australia, the overall rate of suicide actually increased (following a trend that had been moving upwards for some time), and did not decrease until measures specifically aimed at providing support to would-be suicide victims was enacted.^[15]^[16]^[17]

Research also indicates no association vis-à-vis safe-storage laws of guns that are owned, and gun suicide rates; and studies that attempt to link gun ownership to likely victimology often fail to account for the presence of guns owned by other people.^[18]^[19] Researchers have shown that safe-storage laws do not appear to affect gun suicide rates or juvenile accidental gun death.^[18]^[19]

Shotgun suicides tend to be extremely messy, and can even cause body matter to go under closed doors. Suicides committed with some hollow point bullets can essentially cause the head to explode.^[20]

Hanging

With this technique, the subject attempts to use some form of device around the throat to strangle and/or break the neck. In the event of death, the actual cause of death depends upon the type of hanging used, where type usually refers to the length of the drop.

In a short drop, the victim may die from strangulation, in which the death may result from a lack of air asphyxiating the brain. If the former is true, the patient is likely to experience hypoxia, skin tingling, dizziness, vision narrowing, convulsions, shock and acute respiratory acidosis; if the latter is true, one or both carotid arteries and/or the jugular vein may be compressed sufficiently to cause cerebral ischemia and a hypoxic condition in the brain which will eventually result in or contribute to the death. In the case of a sufficiently long drop, the patient is likely to suffer a fractured 2nd and 3rd and/or 4th and 5th cervical vertebrae, which may cause paralysis or death.

Hanging is the prevalent means of suicide in pre-industrial societies, and is more common in rural areas than in urban areas.^[21] It is also a common means of suicide in situations where materials are not readily at hand (such as in prisons).

Vehicular impact

Committing suicide by deliberately placing oneself in the path of a large and fast-moving vehicle, resulting in fatal impact.

Rail

Throwing oneself directly in front of an oncoming train, or driving a car onto the tracks.^[22] Suicide by being hit by a train has a 90% death rate, making it one of the most fatal suicide methods. Failed attempts may result in severe injuries, including massive fractures, amputations, concussion, brain damage and physical disability.^[23]

Place

In some European countries with highly developed rail networks and strict gun control laws, such as Germany and Sweden, railway-related suicide is considered a social problem, and extensive research has been carried out into this type of suicide. According to these studies, most suicides occur in densely populated areas, but away from rail stations and terminal points. Wooded areas, curves and tunnels are especially plagued. Many rail-related suicides occur in proximity to mental health wards. Low land prices close to the railroad lines has led to several mental health wards being located in their proximity, making it easy for suicidal patients to access the tracks.

Method and time

Unlike on underground railways, in suicides involving above-ground railway lines, the victim will often simply stand or lie on the tracks, waiting for the arrival of the train. As the trains usually travel at high speeds (usually between 80 and 200 km/h), the driver is usually unable to bring the train to a halt before the collision. This type of suicide may be traumatizing to the driver of the train and may lead to post-traumatic stress disorder.^[24]

Suicides on tracks may take place through the person either jumping onto, walking, lying or sitting on the tracks. Accidents resulting from people jumping onto the tracks usually occur at daytime. Accidents including people walking, lying or sitting on the tracks usually occur at night when the driver's visibility is reduced, reducing the chance of a failed suicide. People who commit suicide in this manner usually stay at or around the place for the suicide for an extended period of time before the actual suicide. The victim may lie in between or across the tracks, resulting in decapitation.

Europe

In the Netherlands, as many as 10% of all suicides are rail-related. In Germany, 7% of all suicides occur in this manner, making this type account for the largest share of overall suicides in the country.^[25] In Sweden, less densely populated and with a smaller proportion of the population living in proximity of railroad tracks, 5% of all suicides are rail-related.

Japan

Trains on the Japanese railroads, e.g. the high speed Shinkansen (bullet) trains, kill a large number of suicides every year.

North America

According to the Federal Railroad Administration, in the U.S., there are 300 to 500 train suicides a year.^[26]

Reducing the number of rail-related suicides

Methods to reduce the number of rail-related suicides include CCTV surveillance of stretches where suicides frequently occur, often with direct links to the local police or surveillance companies. This enables the police or guards to be on the scene within minutes after the trespassing was noted. Public access to the tracks is also made more difficult by erecting fences. Trees and bushes are cut down around the tracks in order to increase driver visibility.

In southern Sweden, where a suicide hotspot is located south of the university town Lund, CCTV cameras with direct links to the local police have been installed. Similar packages will be installed on other hotspots throughout the nation.

In the Netherlands, where several suicide hotspots are located by rail tracks next to mental wards, loud speakers and strong lights that activate when trespassing is noted, have been installed next to these hotspots.

Metro systems

Jumping in front of an oncoming subway train has a 59% death rate, lower than the 90% death rate for rail-related suicides. This is most likely because trains traveling on open tracks travel relatively quickly, whereas trains arriving at a subway station are decelerating so that they can stop and board passengers.

Different methods have been used in order to decrease the number of suicide attempts in the underground: for instance, deep drainage pits halve the likelihood of fatality. Separation of the passengers from the track by means of a partition with sliding doors is being introduced in some stations, but is expensive.^[27]

Traffic collisions

Some car crashes are in fact suicides. This especially applies to single-occupant, single-vehicle accidents. "The automobile lends itself admirably to attempts at self-destruction because of the frequency of its use, the generally accepted inherent hazards of driving, and the fact that it offers the individual an opportunity to imperil or end his life without consciously confronting himself with his suicidal intent."^[28] There is always the risk that a car accident will affect other road users, for example a car that brakes abruptly or swerves to avoid a suicidal pedestrian may get into a collision with something else on the road.

The real percentage of suicides among car accidents is not reliably known; studies by suicide researchers tell that "vehicular fatalities that are suicides vary from 1.6% to 5%".^[29] Some suicides are misclassified as accidents, because suicide must be proven; "It is noteworthy that even when suicide is strongly suspected but a suicide note is not found, the case will be classified an 'accident.'"^[30]

Some researchers believe that suicides disguised as traffic accidents are far more prevalent than previously thought. One large-scale community survey (in Australia) among suicidal persons provided the following numbers: "Of those who reported planning a suicide, 14.8% (19.1% of male planners and 11.8% of female planners) had conceived to have a motor vehicle “accident”... Of all attempters, 8.3% (13.3% of male attempters) had previously attempted via motor vehicle collision."^[31]

Aircraft

Between 1983 and 2003, 36 pilots committed suicide by aircraft in the United States^[32] There have been instances of suicides involving intentionally crashing aircraft:

Poisoning

Suicide can be committed by using fast-acting poisons, such as hydrogen cyanide, or substances which are known for their high levels of toxicity to humans.^[33] For example, most of the people of Jonestown, in northwestern Guyana, died when Jim Jones, the leader of a religious sect, organized a mass suicide by drinking a cocktail of diazepam and cyanide in 1978.^[34] Sufficient doses of some plants like the belladonna family, castor beans, Jatropha curcas and others, are also toxic. Poisoning through the means of toxic plants, however, is usually less quick and is relatively painful.^[35]

Pesticide poisoning

Worldwide, 30% of suicides are from pesticide poisonings. The use of this method, however, varies markedly in different areas of the world, from 4% in Europe to more than 50% in the Pacific region.^[36] Poisoning by farm chemicals is very common among females in the Chinese countryside, and is regarded as a major social problem in the country.^[37] In Finland, the highly lethal pesticide Parathion was commonly used for suicide in the 1950s. When access to the chemical was restricted, other methods replaced it, leading researchers to conclude that restricting certain suicide methods does little to impact the overall suicide rate.^[38]

Drug overdosing

Overdosing is a method of suicide which involves taking medication in doses greater than the indicated levels, or in a combination that will interact to either cause harmful effects or increase the potency of one or other of the substances.

A peaceful overdose is the preferred method of dignified dying among members of right-to-die societies. A poll among members of right-to-die society Exit International has shown that 89% would prefer to take a pill, rather than use a plastic exit bag, a CO generator, or use 'slow euthanasia'.^[39]

Reliability of this method highly depends on chosen drugs and additional measures like use of antiemetics to prevent vomiting. Average fatality rate for overdoses in the US is estimated to be only 1.8%.^[40] At the same time, assisted suicide group Dignitas reported no single failure among 840 cases (fatality rate 100%), where an overdose of a former sleeping pill active agent Nembutal was used in combination with antiemetic drugs.^[41]

While barbiturates (such as Seconal or Nembutal) have long been considered a safe option for suicide, they are becoming increasingly difficult for potential suicide victims to acquire. Dutch right-to-die society WOZZ proposed several safe alternatives to barbiturates for use in euthanasia.^[42] The Peaceful Pill Handbook mentions the still easy availability of solutions containing pentobarbital in Mexico, where they are available over-the-counter from veterinarians for animal euthanasia.

However, a typical drug overdose uses random prescription and over-the-counter substances. In this case, death is uncertain, and an attempt may leave a person alive but with severe organ damage, although that itself may in turn eventually prove fatal. Drugs taken orally may also be vomited back out before being absorbed. Considering the very high doses needed, vomiting or losing consciousness before taking enough of the active agent is often a major problem for people attempting this.

Analgesic overdose attempts are among the most common, due to easy availability of over-the-counter substances.^[43] Overdosing may also be performed by mixing medications in a cocktail with one another, or with alcohol or illegal drugs. This method may leave confusion over whether the death was a suicide or accidental, especially when alcohol or other judgment-impairing substances are also involved and no suicide note was left behind.

Carbon monoxide poisoning

A particular type of poisoning involves inhalation of high levels of carbon monoxide. Death usually occurs through hypoxia. In most cases carbon monoxide (CO) is used because it is easily available as a product of incomplete combustion; for example, it is released by cars and some types of heaters.

Carbon monoxide is a colorless and odorless gas, so its presence cannot be detected by sight or smell. It acts by binding preferentially to the hemoglobin in the victim's blood, displacing oxygen molecules and progressively deoxygenating the blood, eventually resulting in the failure of cellular respiration, and death.

In the past, before air-quality regulations and catalytic converters, suicide by carbon monoxide poisoning would often be achieved by running a car's engine in a closed space such as a garage, or by redirecting a running car's exhaust back inside the cabin with a hose. Motor car exhaust may have contained up to 25% carbon monoxide. However, catalytic converters found on all modern automobiles eliminate over 99% of carbon monoxide produced.^[44] As a further complication, the amount of unburned gasoline in emissions can make exhaust unbearable to breathe well before losing consciousness.

The incidence of suicide by carbon monoxide poisoning through burning charcoal, such as a barbecue in a sealed room, appears to have risen. This has been referred to by some as "death by hibachi".^[45]

Carbon monoxide is extremely dangerous to bystanders and people who may discover the body, so "Right to Die" advocates like Philip Nitschke recommend the use of safer alternatives like nitrogen, for example in his EXIT euthanasia device.

Other toxins

Detergent-related suicide involves mixing household chemicals to produce hydrogen sulfide or other poisonous gases.^[46]^[47]^[48]^[49] The suicide rates by domestic gas fell from 1960 to 1980.^[50]

Several creatures, such as spiders, snakes, and scorpions, carry venoms that can easily and quickly kill a person. These substances can be used to conduct suicide. For example, Cleopatra supposedly had an asp bite her when she heard of Marc Antony's death.

Immolation

Immolation usually refers to suicide by fire. It has been used as a protest tactic, most famously by Thích Quảng Đức in 1963 to protest the South Vietnamese government; and by Malachi Ritscher in 2006 to protest the United States' involvement in the Iraq War.^{[citation needed]}

Self-immolation was also carried out as a ritual known as sati in certain parts of India, where a Hindu wife "voluntarily" immolated herself in her dead husband's funeral pyre.^{[citation needed]}

The Latin root of "immolate" means "sacrifice", and is not restricted to the use of fire, though in common US media usage the term immolation refers to suicide by fire.

This method of suicide is relatively rare due to the long and painful experience one has to go through before death sets in. This is also contributed to by the ever-present risk that the fire is extinguished before death sets in, and in that way causes one to live with severe burnings, scar tissue, and the emotional impact of such horrific injuries.

Seppuku

Seppuku (colloquially hara-kiri "belly slitting") is a Japanese ritual method of suicide, practiced mostly in the medieval era, though some isolated cases appear in modern times. For example, Yukio Mishima committed seppuku in 1970 after a failed coup d'état intended to restore full power to the Japanese emperor.^{[citation needed]}

Unlike other methods of suicide, this was regarded as a way of preserving one's honor. The ritual is part of bushido, the code of the samurai.

As originally performed solely by an individual, it was an extremely painful method by which to die. Dressed ceremonially, with his sword placed in front of him and sometimes seated on special cloth, the warrior would prepare for death by writing a death poem. The samurai would open his kimono, take up his wakizashi (short sword), fan, or a tantō and plunge it into his abdomen, making first a left-to-right cut and then a second slightly upward stroke. As the custom evolved, a selected attendant (kaishakunin, his second) stood by, and on the second stroke would perform daki-kubi, where the warrior is all but decapitated, leaving a slight band of flesh attaching the head to the body, so as to not let the head fall off the body and roll on the floor/ground, which was considered dishonorable in feudal Japan. The act eventually became so highly ritualistic that the samurai would only have to reach for his sword, and his kaishakunin would execute the killing stroke. Later still, there would be no sword, but something like a fan for which the samurai would reach.

Starvation (apocarteresis)

A hunger strike may ultimately lead to death. Starvation has been used by Hindu and Jain monks as a ritual method of penance, and Albigensians or Cathars also fasted after receiving the 'consolamentum' sacrament, in order to die while in a morally perfect state.

This method of death is often associated with political protest, such as the 1981 Irish Hunger Strike during which 7 IRA and 3 INLA POWs died in H-Blocks of Long Kesh prison. The explorer Thor Heyerdahl refused to eat or take medication for the last month of his life, after having been diagnosed with cancer.^[51]

Dehydration

Dehydration can be hard to bear,^[52] and requires patience and determination, since it takes from several days to a few weeks. This means that unlike many other suicide methods, it cannot be accomplished impulsively. Those who die by terminal dehydration typically lapse into unconsciousness before death, and may also experience delirium and deranged serum sodium.^[53] Discontinuation of hydration does not produce true thirst, although a sensation of dryness of the mouth often is reported as "thirst." The evidence this is not true thirst is extensive and shows the ill feeling is not relieved by giving fluids intravenously, but is relieved by wetting the tongue and lips and proper care of the mouth. Patients with edema tend to take longer to die of dehydration because of the excess fluid in their bodies.^[54]

Terminal dehydration has been described as having substantial advantages over physician-assisted suicide with respect to self-determination, access, professional integrity, and social implications. Specifically, a patient has a right to refuse treatment and it would be a personal assault for someone to force water on a patient, but such is not the case if a doctor merely refuses to provide lethal medication.^[55] But it also has distinctive drawbacks as a humane means of voluntary death.^[56] One survey of hospice nurses found that nearly twice as many had cared for patients who chose voluntary refusal of food and fluids to hasten death as had cared for patients who chose physician-assisted suicide.^[57] They also rated fasting and dehydration as causing less suffering and pain and being more peaceful than physician-assisted suicide.^[58] Other sources, however, have noted very painful side effects of dehydration, including seizures, skin cracking and bleeding, blindness, nausea, vomiting, cramping and severe headaches.^[59] There can be a fine line between terminal sedation that results in death by dehydration and euthanasia.^[60]

Explosion

Another method is death by explosion. High-explosives (such as dynamite, TNT, and C4) that are certain to explode and release an extreme amount of energy are often used to avoid unnecessary pain.^[61]

Suicide attack

A suicide attack is an attack in which the attacker (attacker being either an individual or a group) intends to kill others and intends to die in the process of doing so (e.g. Columbine, Virginia Tech and 9/11). In a suicide attack in the strictest sense, the attacker dies by the attack itself, for example in an explosion or crash caused by the attacker. The term is sometimes loosely applied to an incident in which the intention of the attacker is not clear, though he is almost sure to die by the defense or retaliation of the attacked party, e.g., "suicide by cop", that is, menacing or assaulting an armed police officer with a weapon or apparent or proclaimed harmful intent which all but ensures that the cop will use deadly force to terminate the attack. This can also be referred to as murder/suicide.

Such attacks are typically motivated by religious or political ideologies, and have been carried out using numerous methods. For example, attackers might attach explosives directly to their bodies before detonating themselves close to their target, also known as suicide attack. They may use a car bomb or other machinery to cause maximum damage (e.g. Japanese kamikaze pilots during World War II).

Additionally, teenage students (most often in the US, and recently in Finland and Germany) have committed several notable suicide attacks in recent years, in the form of school shooting massacres. Often, these suicide attacks involve guns or homemade bombs brought into high schools or college campuses. After the attack, the perpetrator will commit suicide before being apprehended.

Indirect suicide

Indirect suicide is the act of setting out on an obviously fatal course without directly committing the act upon oneself. Indirect suicide is differentiated from legally defined suicide by the fact that the actor does not pull the figurative (or literal) trigger. Examples of indirect suicide include a soldier enlisting in the army with the express intention and expectation of being killed in combat. Another example would be provoking an armed officer into using lethal force against them. This is generally called "suicide by cop". In some instances the subject commits a capital crime in hope of being sentenced to death. This state-assisted suicide was extremely popular in Enlightenment Era Scandinavia, where law and religion forbade suicide.^{[citation needed]} Today, this type of suicide is relatively rare.

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^ Poisoning drugs
^ Ministry of Terror - The Jonestown Cult Massacre, Elissayelle Haney, Infoplease, 2006.
^ Poisoning methods
^ Gunnell D, Eddleston M, Phillips MR, Konradsen F (2007). "The global distribution of fatal pesticide self-poisoning: systematic review". BMC Public Health. 7: 357. doi:10.1186/1471-2458-7-357. PMC 2262093. PMID 18154668.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
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^ Philip Nitschke. The Peaceful Pill Handbook. Exit International US, 2007. ISBN 0-9788-7882-5, p 33
^ Stone, Geo. Suicide and Attempted Suicide: Methods and Consequences. New York: Carroll & Graf, 2001. ISBN 0-7867-0940-5, p. 230
^ Wenn Sie das trinken, gibt es kein Zurück Tagesspiegel.de Retrieved 2008-04-12
^ Guide to a Humane Self-Chosen Death by Dr. Pieter Admiraal et al. WOZZ Foundation www.wozz.nl, Delft, The Netherlands. ISBN 9078581018.
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^ Japanese girl commits suicide with detergent
^ CSCS.txstate.edu
^ Tena911.org
^ DCFA.org
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^ Radford, Tim (2002-04-19). "Thor Heyerdahl dies at 87". London: The Guardian. Retrieved 2009-07-06.
^ Symptomsofdehydration.com
^ Baumrucker, Steven (May/June 1999). "Science, Hospice and Terminal Dehydration" (Document). American Journal of Hospice and Palliative Medicine. {{cite document}}: Check date values in: |date= (help); Unknown parameter |issue= ignored (help); Unknown parameter |volume= ignored (help)
^ Lieberson, Alan D. "Treatment of Pain and Suffering in the Terminally Ill".
^ James L. Bernat, MD; Bernard Gert, PhD; R. Peter Mogielnicki, MD (27 December 1993). "Patient Refusal of Hydration and Nutrition". Archives of internal medicine. 153 (24). Archives of Internal Medicine: 2723–8. doi:10.1001/archinte.1993.00410240021003. PMID 8257247. {{cite journal}}: More than one of |number= and |issue= specified (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)CS1 maint: multiple names: authors list (link)
^ Miller, Franklin G. and Meier, Diane E. (2004). "Voluntary Death: A Comparison of Terminal Dehydration and Physician-Assisted Suicide". Annals of internal medicine. 128 (7). Annals of Internal Medicine: 559–62. doi:10.1059/0003-4819-128-7-199804010-00007. PMID 9518401. {{cite journal}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help); Unknown parameter |unused_data= ignored (help)CS1 maint: multiple names: authors list (link)
^ Jacobs, Sandra (July 24, 2003). "Death by Voluntary Dehydration — What the Caregivers Say". The New England journal of medicine. 349 (4). New England Journal of Medicine: 325–326. doi:10.1056/NEJMp038115. PMID 12878738.
^ Arehart-Treichel, Joan (January 16, 2004). "Terminally Ill Choose Fasting Over M.D.-Assisted Suicide". Psychiatric News. 39 (2). American Psychiatric Association: 15–51.
^ Weeklystandard.com
^ Orentlicher, D (October 23, 1997). "The Supreme Court and Physician-Assisted Suicide — Rejecting Assisted Suicide but Embracing Euthanasia". The New England journal of medicine. 337 (17). New England Journal of Medicine: 1236–9. doi:10.1056/NEJM199710233371713. PMID 9340517.
^ Methods of suicide