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American Journal of Forensic Medicine & Pathology:
Case Report

Suicide With Inert Gases: Addendum to Final Exit

Gilson, Thomas MD; Parks, Bruce O. MD; Porterfield, Cynthia M. DO

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From the Office of the Medical Examiner, Tucson, Arizona.

Manuscript received December 12, 2002 accepted April 4, 2003.

Address correspondence and reprint requests to Cynthia M. Porterfield, D.O., Forensic Science Center, 2825 E. District Street, Tucson, AZ 85714 E-mail:

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Suicide by asphyxiation with a plastic bag placed over the head is a method that has been advocated by right-to-die groups. Recently, such groups have proposed the introduction of helium into the plastic bag as a means of hastening death. Helium is readily available at toy stores, where it is sold in tanks for balloon inflation. It produces asphyxiation by the exclusion of oxygen in enclosed spaces. We report 7 fatalities throughout an 18-month period involving plastic bag suffocation in conjunction with helium use. These fatalities coincide with publication of an update to a popular right-to-die text in which this method is described. Although right-to-die literature was absent from all scenes, this method was not previously observed in our jurisdiction, and the deaths likely reflect exposure to this information. Because of analytical difficulties in testing for helium in biologic specimens, death certification rests on scene investigation.

Suicide by asphyxiation with a plastic bag placed over the head is uncommon and represents only a small fraction of suicide deaths in North America. 1–3 This method of suicide received increased attention after the publication of Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying4 in 1991. Final Exit included a detailed description of the process of plastic bag suffocation, and a 4-fold increase in this type of suicide was noted in New York City in the year after publication. In 2000, an update, Supplement to Final Exit: The Latest How-To and Why of Euthanasial Hastened Death, 5 was published and recommended insufflation of an inert gas into the suffocating plastic bag as a means to hasten death. Since the publication of Supplement, we have observed 7 fatalities in which a helium source was present at the death scene in conjunction with a plastic bag or mask. These cases form the basis of this report.

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Cases 1 and 2

A common-law couple, man aged 49 years and woman aged 48 years, were found by law enforcement on the floor of the master bedroom of their residence after their attorney received a letter with a suicide note. The decedents were lying supine in a closet with 3 plastic bags over each of their heads. The bags were secured at the neck with an elastic strap. Within the innermost bag of both decedents was a helium tank with the valve in the off position. Each decedent had a straw hat over the face. No right-to-die literature was noted at the scene. Suicide notes with detailed instructions about disposition of personal effects were recovered near the bodies. The motivation for suicide was unclear. The decedents were reportedly in good health, and autopsies were remarkable only for early decompositional changes. Toxicology was unremarkable.

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Cases 3 and 4

A husband and wife, aged 78 and 76 years, respectively, were found dead in bed by a concerned neighbor. Both were wearing half-face filter cartridge type masks attached to helium tanks by plastic tubing. Pinned to the decedents’ clothing were do-not-resuscitate instructions (Fig. 1). Suicide notes with information about mortuary arrangements and disposition of effects were found near the bodies. The husband was reportedly in failing health and described as depressed, although he was not known to be receiving psychiatric treatment. The wife had recently undergone minor elective surgery but was in good health otherwise. Notes referring to the Hemlock Society were found in the apartment. External examination was unremarkable, and toxicology results for alcohol, drugs of abuse, and therapeutic medications were negative for both decedents. In compliance with family wishes, internal examinations were not performed.

Figure 1
Figure 1
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Case 5

An 81-year-old man with squamous cell carcinoma of the throat was found in bed by his daughter, with whom he resided. He was unresponsive and had a plastic bag over his head and plastic tubing running from a helium tank to the space inside the plastic bag. The daughter removed the plastic bag immediately and summoned emergency medical services, who resuscitated the victim and transported him to the hospital. The duration of the suicide attempt before the daughter’s intervention is unknown. He eventually regained consciousness, and 3 days after his suicide attempt he requested that all treatment be withdrawn. He died of respiratory failure shortly thereafter. The decedent was cachectic, with advanced throat cancer. Blood and urine toxicology on admission to the hospital were negative. The family was unable to provide information about a suicide note or the presence of right-to-die literature at the death scene.

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Case 6

A 71-year-old man was found dead in a living room chair by law enforcement officers who had been called to check on his well-being. The decedent had a plastic bag over his head, which was secured at the neck with an elastic band and a Velcro strap. Plastic tubing led from the bag to a helium tank nearby (Fig. 2). The decedent had unspecified health problems, which he cited in a suicide note, as well as the recent death of his wife, as the principal reasons for his suicide. The note included information about mortuary arrangements and attorney as well. No right-to-die literature was noted at the scene. At family request, an external examination was performed and was unremarkable except for suicide paraphernalia and decomposition, which precluded obtaining specimens for toxicology testing.

Figure 2
Figure 2
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Case 7

A 25-year-old man was found dead in the bathtub by his landlord, who entered the apartment with the manager of a toy store where the decedent had rented a helium tank. The decedent had a plastic bag over his head, with plastic tubing running into the bag from the helium tank. The tubing attached to a rounded plastic soft drink cap over the decedent’s nose and mouth. The tubing extended from the helium source to the plastic bag, passing through a sink where there was warm water running. There was no water in the tub. The motivation for suicide was unclear, and no right-to-die literature was recovered at the scene. Medical history was unknown, and autopsy was unremarkable except for decompositional changes. Toxicology was remarkable only for an ethanol level of 234 mg/dL in decomposition fluid.

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Final Exit and Supplement are publications intended to provide information about peaceful and nonviolent methods of suicide to terminally ill patients. 4,5 When first published in 1991, Final Exit drew attention to suicide via a plastic bag over the head after ingestion of a sedating dose of sleep medication, as well as via other proposed methods. 6Supplement recommended the addition of inert gases (particularly helium because of the ease with which it may be obtained) to the plastic bag, which has now become familiar to many medical examiners. Helium is a nontoxic gas that hastens asphyxiation by displacing the air gases (including oxygen) from the space within the plastic bag. Immediately after publication of Final Exit, a 4-fold increase in plastic bag suffocation was noted in New York City. 1 After the publication of Supplement, 7 suicide deaths from helium and plastic bag or mask asphyxiation were noted, a type of suicide not previously observed in the authors’ jurisdiction. Despite this increase, these deaths only represent 2.5% of all suicides in the area in this period (approximately 18 months) and are still relatively uncommon. Also noted were 2 simple plastic bag suffocations during this period. Although the appearance of helium at these death scenes since the publication of Supplement (and its absence before) strongly suggests a causal relationship, right-to-die literature was not found at any of the scenes, and only 1 pair of victims was clearly aware of the Hemlock Society, whose president is the author of Final Exit and Supplement. Previous reports of simple plastic bag suffocations after publication of Final Exit, however, also failed to demonstrate such literature in any more than 20% of cases, although a higher rate of exposure to this information seemed likely, 1–3 which could conceivably apply to the present cases as well. The absence of end-stage terminal illnesses in all but 1 of the cases also does not seem to preclude exposure to right-to-die information. Since the appearance of Final Exit, the misuse of this “how-to” information by suicidal individuals without terminal illnesses has been a source of concern. 7 In addition to the sudden appearance of helium, factors favoring the influence of right-to-die literature in these deaths include the presence of coverings over the nose and mouth areas, the nature of the securing devices at the neck, and the presence of detailed instructions about disposition of personal effects and mortuary arrangements.

A final note of interest is that, at present, commercial testing for helium in biologic specimens is unavailable. The only previously reported helium asphyxiation suicide relied on scene investigation for certification of cause of death, 8 which has been the authors’ experience as well. The chemically inert nature of helium and its widespread use as a carrier gas in chromatography instruments represent the essential barriers to analysis at present. Although a chromatography carrier gas substitution may possibly circumvent this difficulty, it is reasonable to rely on a good scene investigation for death certification.

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1. Marzuk PM, Tardiff K, Hirsch CS, et al. Increase in suicide by asphyxiation in New York City after publication of Final Exit. N Engl J Med. 1993; 329: 1508–1510.

2. Haddix TL, Harruff RC, Reay DT, et al. Asphyxial suicides using plastic bags. Am J Forensic Med Pathol. 1996; 17: 308–311.

3. Bullock MJ, Diniz D. Suffocation using plastic bags: a retrospective study of suicides in Ontario, Canada. J Forensic Sci. 2000; 45: 608–613.

4. Humphry D. Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. New York: Dell; 1991.

5. Humphry D. Supplement to Final Exit: The Latest How-To and Why of Euthanasial Hastened Death. Junction City, OR: Norris Lane Press; 2000.

6. Cina SJ, Raso DS, Conradi SE. Suicidal cyanide ingestion as detailed in Final Exit. J Forensic Sci. 1994; 39: 1568–1570.

7. Sacks MH, Kemperman I. Final Exit as a manual for suicide in depressed patients. Am J Psychiatry. 1992; 149: 842.

8. Ogden RD, Wooten RH. Asphyxial suicide with helium and a plastic bag. Am J Forensic Med Pathol. 2002; 23: 234–237.

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suicide; asphyxia; helium

© 2003 Lippincott Williams & Wilkins, Inc.


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