HOW LETHAL INJECTION
WORKS

The science, the ethics,
the politics and the history
of how Georgia executes
its condemned prisoners.

By Rosalind Bentley
The Atlanta Journal-Constitution

A humane end, or cruel and unusual?

The narrative around lethal injection drugs in the United States has been complicated since 1977. That’s when Dr. Jay Chapman, an Oklahoma medical examiner, developed a three-drug combination that could be used in place of electrocution to execute prisoners.

Lethal injection was considered by some officials to be “less barbarous” and was first used to kill a prisoner in Texas in 1982. The method was soon adopted by other states, including Georgia, which switched from electrocution to lethal injection in 2001.

Over the past 35 years, the specific drugs have changed, and, in some states, the number of drugs used has been modified from three to two or even one drug.

Yet, how the drugs work is an enduring point of contention. The intent of lethal injection is to end a prisoner’s life without pain. In the video below, we show you how the drugs are supposed to work in both three-drug and one-drug protocols. Later, we’ll show:

· What can go wrong during the process of lethal injection.

· The last AJC interview with Kelly Gissendaner, who is to be the first woman executed in Georgia in 70 years.

· Video of the actual drug that was rejected – hours before Gissendaner’s scheduled execution – because it was “cloudy.”

· Video of AJC staff writer Rhonda Cook, who has witnessed more than a dozen executions, including one of the last electrocutions performed in Georgia.

· Excerpts from the AJC’s groundbreaking 2007 examination of how the death penalty is applied in Georgia.

Meant to heal, used to kill

By Rosalind Bentley
rbentley@ajc.com

A person commits a heinous crime, is tried, found guilty and sentenced to death by lethal injection.

Whether you agree or disagree with the death penalty, the question of how those drugs induce death is as much a consideration of science as politics.

It's a safe bet that if people think about lethal injection drugs at all, they assume they are special drugs designed strictly for executions.

That's partially right.

Historically, the drugs used for executions were the same drugs that for decades were used by doctors in hospital operating rooms. If you've ever had surgery, it's possible you were given one of those drugs to make you unconscious or to keep your muscles still.

For executions, the dosages of those drugs were increased to toxic levels.

But in the last six years, as drug companies came under immense pressure to stop selling the drugs for executions, states began coming up with their own drug combinations and formulations for lethal injections. To make them, states turned to special apothecaries, known as compounding pharmacies.

Although compounding pharmacies are licensed by states, compounded drugs are not approved by the U.S. Food and Drug Administration.

Because of this, several states, including Georgia, enacted shield laws over the last few years to shroud the entire execution process in secrecy. In Georgia and other states, death row inmates, their defense teams and even the general public are now barred from knowing the most basic information about executions, from the names of compounding pharmacies and their inspection records to the identities and qualifications of the execution team. So it's difficult to know how compounded drugs are made, or how they work in the human body when used for lethal purposes.

But we do know how FDA-regulated drugs work in the human body when used therapeutically.

To get a sense of how they work, we talked with anesthesiologists who've either given expert testimony about these drugs on behalf of inmates facing lethal injection, or who've witnessed an execution in a nonprofessional role at the invitation of an inmate's defense team.

None of the doctors we spoke with has ever participated in an execution. Dr. Mark Dershwitz, perhaps the most prominent doctor who for years testified on behalf of states performing lethal injections and advised on drug combinations and dosages, declined comment for this story.

"It's like going to a hardware store and buying a nail gun, which is for construction, but then you turn around and use it to kill someone. This is an impersonation of the practice of medicine."

Dr. Joel Zivot, an intensive care unit doctor at Emory University Hospital

The major boards and associations representing medical professionals have warned doctors, nurses, paramedics and even pharmacies against participating in executions. The American Board of Anesthesiology even went so far as to threaten to pull the certification of any member who helps in an execution.

The rationale, they say, is simple: these drugs and the medical professionals who administer them are meant to save life, not end it.

"It's like going to a hardware store and buying a nail gun, which is for construction, but then you turn around and use it to kill someone," said Dr. Joel Zivot, an intensive care unit doctor at Emory University Hospital and a professor of anesthesiology at Emory. "This is an impersonation of the practice of medicine."

The barbiturates

When the lethal injection procedure was created almost 40 years ago by an Oklahoma medical examiner as an alternative to electrocution, it had three components: a fast-acting anesthetic to render the person unconscious, a paralytic to keep the person immobile, and a third drug to cause cardiac arrest.

The first drug in the process was a barbiturate, sodium thiopental. It's meant to induce short-term anesthesia, making a person unconscious in seconds.

Even though it has been replaced in the United States by other anesthetics, the World Health Organization still lists it among the most essential medicines any rudimentary health care system must have, right up there with ibuprofen, penicillin and morphine.

For decades anesthesiologists used sodium thiopental as one of the first drugs injected at the start of surgery. It was followed up with a more potent anesthetic to keep a person in a deeper state of unconsciousness for the duration of an operation.

Perhaps the drug's first controversial use by law enforcement was in the early 20th century as a so-called "truth serum." If given a small dose, suspects would talk without inhibition, not unlike a person who's drunk.

Yet, in later years, even as it was being replaced in hospitals by other classes of anesthetics such as Propofol, sodium thiopental was sought after by corrections departments across the country. It was cheap. It was quick. And though it wasn't a painkiller, once prisoners were strapped down in a death chamber, the drug was supposed to knock them out so quickly they wouldn't feel the effects of what was coming next.

Anti-death penalty advocates put pressure on drug companies that made sodium thiopental to stop selling it to corrections departments. Since 2011 it hasn't been available in the United States.

The fast-acting barbiturate pentobarbital soon replaced sodium thiopental as the first drug in executions, but it too is no longer available from drug makers, so states such as Georgia must have it made by compounding pharmacies.

Here's one reason why it was chosen as a replacement. In a healthy person there is a balance between neurotransmitters, which help the brain's neurons chemically talk to one another. That cellular conversation enables you to walk, talk and otherwise function normally. In a seizure, the brain's electrical impulses are in chaos. A barbiturate like pentobarbital slows them down, giving the brain time to rest and repair. That's why it was an early drug used to control severe epileptic seizures and treat massive brain trauma.

But pentobarbital isn't a painkiller on its own. That's important to remember when considering the second drug used in executions, pancuronium bromide.

The paralytics

When you're in surgery, even if you're under anesthesia, your muscles will move involuntarily. So, doctors use a paralytic to keep you still. Pancuronium bromide was used for years, though other drugs like it are used more frequently now. They block nerve signals that tell muscles to contract.

"It's like making a muscle wear earplugs," said Dr. Mark Heath, an attending anesthesiologist at New York Presbyterian Hospital/Columbia University Medical Center and an assistant professor of anesthesiology at Columbia University. "You can't generate any movement at all."

In an operating room, a doctor has the equipment and the training to make sure a person is at the right anesthetic depth before giving them a paralytic. If the patient isn't, there's the possibility of "intraoperative awareness." Essentially, you feel what's happening but you can't say a word. All your voluntary muscles from your eyelids to your toes are frozen. But one of the body's smallest glands can signal distress.

"A sign of being awake but paralyzed is tears," said Heath. "It's one of the most dreaded complications an anesthesiologist" can face.

For a person being executed, if a paralytic is injected before the prisoner is unconscious, extreme pain is assured. The high dosage turns off the lungs and diaphragm, though not the heart.

"It would be like being held underwater and you can't breathe but you need to," said Emory's Dr. Zivot. The person "would die from asphyxiation."

For that reason this step in the three drug protocol was always the most controversial. It seemed the most likely to be in violation of the Eighth Amendment prohibition against cruel and unusual punishment. Decades after he created the original three-drug procedure, Dr. Jay Chapman, the former Oklahoma medical examiner and physician, said publicly that the paralytic should probably be eliminated.

The salt

Say you're on a diuretic because you have high blood pressure and you're not supposed to have much salt. With all the urine the pill makes you excrete, you lose potassium, which is vital for good nerve, muscle and heart function. If potassium levels get too low, you can have a heart attack. To bring potassium levels back to normal, potassium chloride is prescribed.

Just as too little potassium can affect the heart, too much can stop it. That's why potassium chloride is often the third compound in a three-drug execution.

"Potassium is a finely regulated compound in the body," said Dr. Zivot. "If potassium is raised to a very high degree it can inhibit the ability of muscles to contract."

As it coursed through a person's body, a lethal dose of potassium chloride would bring on an overwhelming burning sensation. The accompanying chest pain would be excruciating.

Drug or poison?

Fewer and fewer states use a three-drug protocol, though it's still the method in Florida, Alabama and Mississippi, according to the Death Penalty Information Center. The drugs they use have been modified but are meant to achieve the same result: unconsciousness, paralysis, cardiac arrest.

Georgia began lethal injection by three drugs in 2001 and switched to one-drug, pentobarbital, in 2012. As a single compound, a toxic dose turns off all electrical impulses in the brain and causes the entire cardiovascular system to fail. Some death penalty advocates have couched the one-drug method as being more "humane" because it does not involve paralysis. While it is true pentobarbital doesn't paralyze, it is increasingly scarce. And when states do find compounding pharmacies to make it, the quality of the drugs is often challenged by defense teams.

But whether one drug or two drugs or three, as long as lethal injection is practiced, particularly with federally unregulated drugs, the debate will remain over whether drugs intended for treatment should be used as poison.

"No drug company makes any drug with a packet insert that says, 'The purpose of this drug is for execution,'" said Zivot.

Witnessing an execution

AJC reporter Rhonda Cook has witnessed more than a dozen executions. In these videos, she describes how the methods have changed and what it's like to be in attendance.

Should doctors participate in executions?

The role of medical professionals in executions has always been a minefield. Whether they observe on behalf of the state, insert the IVs for lethal injection drugs, or make the pronouncement of death, the role of doctors, nurses, emergency medical technicians and paramedics has been viewed by many as ethically problematic: How can someone who is supposed to preserve life actively work to end it?

Medical boards and associations have condemned the practice, with one threatening to revoke the certification of any doctor who assists in an execution. Though Georgia's execution procedures and identities of assisting personnel are now shielded by law, years before the statute was enacted a handful of doctors in the state assisted with lethal injections. Some helped to insert intravenous catheters that delivered the drugs. Some verified that the inmate was dead after receiving a toxic dose. They were typically paid between $850 to a few thousand dollars per execution.

Physicians who assisted in executions became the targets of lawsuits brought by other doctors who were death penalty opponents. The opponents wanted to see their colleagues medical licenses revoke. Ten years ago one such lawsuit against a Georgia doctor failed, but it highlighted the questionable role of health care practitioners in ending the lives of prisoners.

Here are statements from some of the professional organizations that have either prohibited or warned their members against involvement in executions.

"Anesthesiologists, like all physicians and all citizens, have different personal opinions about capital punishment. … Physicians should not be expected to act in ways that violate the ethics of medical practice, even if these acts are legal. Anesthesiologists are healers, not executioners."

American Board of Anesthesiology issued a statement in 2010 and updated it in 2014 that threatens to terminate the certification of any me

"A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution." The statement goes on to list all the ways a person could be considered a participant.

American Medical Association medical ethics code adopted in 1980

"The act of participating in capital punishment clearly inflicts harm; nurses are ethically bound to abstain from any activities in carrying out the death penalty process. Nurses must not participate in capital punishment, whether by chemical, electrical, or mechanical means."

American Nurses Association, 1983, 2010

"EMTs and paramedics should refrain from participation in capital punishment and not take part in assessment, supervision or monitoring of the procedure or the prisoner; procuring, prescribing or preparing medications or solutions; inserting the intravenous catheter; injecting the lethal solution; and/or attending or witnessing the execution as an EMT or paramedic. The fact that capital punishment is currently supported in many segments of society does not override the obligation of EMTs and paramedics to uphold the ethical mandates of the profession."

National Association of Emergency Medical Technicians, 2010 position statement

"While the pharmacy profession recognizes an individual practitioner's right to determine whether to dispense a medication based upon his or her personal, ethical and religious beliefs, IACP discourages its members from participating in the preparation, dispensing, or distribution of compounded medications for use in legally authorized executions."

International Academy of Compounding Pharmacists, 2015 position statement

Kelly
Gissendaner's
last interview

Kelly Gissendaner, center, walks in handcuffs and with an escort of three Correctional Emergency Response Team officers on her way to an activity therapy session at Metro State Prison in Atlanta in 2004. (BITA HONARVAR / AJC staff)

This article originally ran in the AJC on July 18, 2004. It is the most recent interview that Gissendaner has given publicly.

A lonely wait for her final walk: The only woman on Georgia's death row leads a solitary life

By Carlos Campos

Kelly Gissendaner still has the Christmas card she received in 2000 from some of Georgia's most notorious murderers and rapists.

"Merry X-Mas. Wishing you the best in life," wrote Carl Isaacs, who was executed last year for the 1973 murders of six members of the Alday family in South Georgia.

Signed by a dozen or so men on Georgia's death row in Jackson, the card is a cherished possession for Gissendaner, the only woman awaiting execution in Georgia.

"That's something I'll never part with, " she said of the card. " 'Cause those guys are going through the same thing I'm going through. We may not be blood-related, but those are family."

Gissendaner, 36, a mother of three condemned for her husband's 1997 murder, is held in Metro State Prison in southeast Atlanta, about 45 miles from the 113 men on death row at the Georgia Diagnostic and Classification Prison in Jackson. When her yet-to-be-scheduled sentence is carried out, she will be driven to the men's prison to be put to death by lethal injection.

Executions of women in the United States are rare. Since the death penalty was reinstated in 1976, only 10 women have been executed, compared with 908 men.

Georgia has not executed a woman in 59 years. Lena Baker, electrocuted in 1945, was the only woman put to death in Georgia in the 20th century.

"I do believe in general people are more reluctant to give women the death penalty than men, and I've had jurors express that to me," said Gwinnett County District Attorney Danny Porter, who sought the death penalty against Gissendaner.

That could be changing, authorities say. Statewide, prosecutors are seeking the death penalty against five women.

In Gissendaner's case, she didn't personally kill her husband. Her boyfriend, Gregory Bruce Owen, did it at Gissendaner's direction, Porter successfully argued. "The argument was made that Gregory Owen was the bullet, but she was really the gun," Porter said.

There is no official death row for women in Georgia. Gissendaner's cell is one of four at Metro State Prison carved from a unit ordinarily used for solitary confinement of inmates who cause trouble. Gissendaner's cell is at the end of a corridor behind a locked metal gate.

She was sentenced to death in 1998 by a Gwinnett County jury after she and her lover were convicted of conspiring to murder Doug Gissendaner, 30.

Owen pleaded guilty to stabbing Doug Gissendaner. He claimed at Kelly Gissendaner's trial that it was her idea to kill her husband to collect on two $10,000 insurance policies and keep possession of the couple's home.

When Doug Gissendaner arrived at his home in Auburn on the night of Feb. 7, 1997, Owen forced him into a car and drove him into some woods. He forced Gissendaner to his knees, clubbed him with a nightstick, then stabbed him four times in the neck and shoulder. Owen said Kelly Gissendaner had given him a bottle filled with kerosene that the couple used to torch Doug Gissendaner's car.

In exchange for testifying against Kelly Gissendaner, Owen got life in prison with the possibility of parole after 25 years.

'I deserve to be here'

In a recent prison interview, Gissendaner would not talk about the specifics of her case. She hopes that an appeal will at least spare her life. She can't understand how the man who stabbed her husband to death could be paroled in 25 years while she is set to be executed.

"I deserve to be here, but I don't deserve to die," she said. "How can you justify me being here and he could be walking the streets one day?"

Gissendaner once walked on the other side of the cell bars, when she worked as a guard at Phillips State Prison for five months in 1994. Her mother has been a prison guard for 21 years at Phillips, near the north Gwinnett County home where Gissendaner grew up.

Now, when Gissendaner walks through a Georgia prison, she wears a tan prison uniform with "Dept. of Corrections" stenciled on the back. She is always handcuffed and accompanied by at least two guards, even when taken to her daily shower. The cuffs are removed once she's in the shower room. The only other time she isn't cuffed is when she's in her Spartan 12-by-9-foot cell, where she spends about 16 hours a day.

The door of her cell is solid steel, with a 6-by-9-inch window. It has a slot used by corrections officers to slide her three meals a day on a plastic tray. Each time she leaves her cell, she must first extend her arms through the slot to be handcuffed.

Gissendaner is accustomed to the stares from other inmates as she is led through the prison in handcuffs, whether it's to the infirmary, a worship service, Bible study, the gymnasium or recreation yard. On a recent weekday, she joked with the guards accompanying her as she walked outside to a creative writing class in the gym. The smell of fresh-cut grass in the hot summer air contrasted with the stale air of D Building, her home.

An orderly existence

Everything she owns is contained in a small metal wall locker with no doors. It holds her shampoo, soap, deodorant and other toiletries. She keeps snacks in the locker: kosher dill pickles, Cheetos and saltine crackers. She is allowed 10 music CDs that she can listen to on a personal player with headphones. Albums by rocker Melissa Etheridge, Atlanta R&B artist Usher and "American Idol" winner Ruben Studdard are in her small collection.

The furniture in her cell is made of welded steel and is bolted to the floor. Her metal bed has a sleeping bag-thin mattress. A stainless steel toilet and sink are attached to the cinder-block walls.

She has a 13-inch Sanyo TV set in her cell. It's unusual for an inmate to have a television in a cell. The men on death row in Jackson share a television that they watch through the bars of their cells. But given Gissendaner's unique status, prison officials allow the television. She likes reality shows. Her favorites include "Fear Factor," "CSI: Crime Scene Investigation" and "Big Brother."

Awakened at 5 a.m. daily, Gissendaner spends an hour every day in the recreation yard, where she usually walks around a track. All other inmates at Metro are removed from the yard before she goes outside.

A prison recreation employee spends an hour with her three times a week. Sometimes they play cards or bingo, listen to music or perform calisthenics. Recently, Gissendaner quietly sang along to "The Thunder Rolls, " a song about marital infidelity, by country singer Garth Brooks as she played rummy with Michael Sean Hendrix, whom she calls "Coach."

The activities are designed to keep prisoners busy and sane. They also help prison officials keep inmates out of trouble. "You know what they say: An idle mind is the devil's playground, " Gissendaner said with a laugh.

At 4 p.m., she goes back into her cell for the remainder of the day. Sometimes she reads books by crime writers such as Patricia Cornwell and Stuart Woods. Sometimes she writes poetry or letters to friends, relatives or other inmates she's met in prison. Sometimes she watches TV.

She always thinks of her three children, 18, 14 and 10 years old. The two younger ones live with her mother; the older boy lives with her father.

Gissendaner insists that she is still a mother to her children. By telephone, she praises them for good grades or hitting a home run.

"I really enjoy my time with them, " she said of the kids' twice-monthly visits to the prison. "It's been hard seeing them grow through the years and me not being there. But they still know I'm Mom.

"Once you're on death row, the outside world looks at us as monsters," she said. "And we're not. We're human, just like anybody else. We have feelings. We have families."

Staying upbeat

Gissendaner has grown accustomed to solitude. She's not sure she wants company on death row.

"I'm so used to being by myself, used to my privacy. But at the same time, it'd be nice to have somebody up here that went to rec with me, went to the gym with me."

She believes that being the lone woman on Georgia's death row could work to her advantage, noting the highly publicized, though unsuccessful, efforts to stop Texas' 1998 execution of Karla Faye Tucker, who became a born-again Christian in prison. "If you add another person up here, it's easier to execute one of us, " she said. "You can execute them [men] and execute them and nobody notices. It happens so much with the men that society starts to ignore it."

She is surprisingly upbeat for someone facing lethal injection. She laughs a lot. She kids about her last meal.

"Anything I can possibly eat, I'm going to eat," she laughed, mentioning steak, lobster, hamburgers, french fries and ice cream as possible menu candidates. "If I ever get to that point, I'm going to go out fat and happy."

But she is under no delusions about her future.

"Every day that's there, that's in the back of my mind," she said of her unscheduled execution date. "Every day that's a reality — I'm either one step closer to my case being overturned or one step closer to laying on that gurney."

Excerpt: A matter of life and death

In 2007, the AJC published a four-part series about the arbitrary nature of how death sentences are handed down in Georgia. The following is an excerpt from the first part of that series. For more, you may read Part One and Part Four in their entirety.

By Bill Rankin, Heather Vogell, Sonji Jacobs and Megan Clarke

Two men begged a ride from a Wal-Mart shopper in Milledgeville. Minutes later he was dead, shot once in the head. The killers sit on death row.

Two men begged a ride from a college student at a Tifton nightclub. Minutes later he was dead, shot four times in the stomach and chest. The killers are serving life in prison and will be eligible for parole.

Two exceedingly similar crimes, just a few months and 135 miles apart. Two starkly different outcomes.

The murders illustrate what a two-year investigation by The Atlanta Journal-Constitution has revealed: Getting the death penalty in Georgia is as predictable as a lightning strike. Thirty-five years ago, the U.S. Supreme Court threw out the death penalty nationwide after finding it was arbitrary and capricious in Georgia.

It still is. Reforms that persuaded the high court to reinstate the death penalty have fallen far short of the state's promises, the Journal-Constitution has found.

• Horrible murders are sometimes treated more leniently than lesser crimes. Reginald Acres, for instance, avoided death for viciously stabbing and killing his wife, infant daughter and a pregnant relative. But David Aaron Perkins is on death row for stabbing a drinking buddy and crushing his skull with a whiskey bottle.

• For 25 years, Georgia's Supreme Court has flubbed a critical duty, repeatedly citing cases that had been overturned to justify other death sentences.

• More prosecutors and juries are rejecting lethal injection in favor of life without parole. Since 2000, juries have decided against death in two of every three sentencing trials. The trend makes each remaining death sentence more out of step with punishment for similar crimes.

The newspaper's investigation explored the darkest depths of human behavior. Court records told tales of torture, mutilation, child murder — the kinds of cases that give cops and jurors nightmares. They were also, the newspaper found, the kinds that often didn't get the death penalty.

"It's like a roulette wheel,” said former Georgia Chief Justice Norman Fletcher.” Arbitrariness is a weakness of the death penalty."

The Journal-Constitution found 1,315 murder cases from 1995 through 2004 that could have been prosecuted for death.

But prosecutors pursued a death sentence for only one in four of those killers. Only one in 23 of them landed on death row.