1. Medical Assistance in Dying
Prescribing for Medical Assistance in Dying

2. Overview
This presentation will cover the following elements of prescribing for medical assistance in dying:
Role of the prescriber
Required documentation
Planning for the administration
Medication acquisition and administration
Processes for before, during, and after the administration
Support resources for patients, families, staff and physicians

3. The Prescriber
The prescriber can be a medical practitioner or a nurse practitioner
The prescriber must independently complete an assessment of the patient, plan with the patient and other health care professionals the provision of medical assistance in dying, and be present for the provision.
The physician prescriber must obtain Advanced Procedural Privileges for the provision of medical assistance in dying for provision of the service in an NH facility
Contact or

4. Conflict of Interest - Patient
To the best of your knowledge, you are not a beneficiary under the patient’s will
You do not stand to gain financially or materially from patient’s death, other than through standard compensation
You are not connected to the patient requesting medical assistance in dying in a way that would affect your objectivity

5. Conflict of Interest - Assessor with Assessor
You do not act as a mentor or supervisor to the assessor
You are not connected to the assessor in any other way that would affect your objectivity

6. Documentation
Ensure that you have the following medical assistance in dying documents:
Record of Patient Request
Record of Assessment (Assessor)
Record of Assessment (Prescriber)
Coroner’s Report of Death
Document Checklist

7. Additional Documentation
If a referral was initiated:
Consultant Assessment of Patient’s Informed Consent Decision Capability form
To order the medications:
Medical Assistance in Dying Prescription form (pre-printed order/PPO), which can be obtained from your Care Coordination Centre or the College of Physicians and Surgeons of BC, once the decision to proceed is made
Following the administration:
BC Death Certificate

8. Assessment
Review the Record of Patient Request to ensure that it is complete
Confirm the independence of the witnesses with the patient
Complete an assessment to ensure patient meets eligibility criteria

9. Capacity
Confirm that the patient is capable of making a medical decision
Inform the patient that if they become incapable prior to the provision of medical assistance in dying that you cannot proceed
Reiterate that the patient can withdraw consent at any time

10. Planning
Review with the patient the self-administered (oral) route and the intravenous route
The preferred and most commonly used administration route in BC is the intravenous route due to concerns of delay in effectiveness and patient tolerance
Discuss location and timeline for provision of the service

11. Planning
If the date of administration is less than 10 days from time the Record of Patient Request was signed, then document the rationale and agreement of both practitioners on the Record of Assessment (Prescriber) form
A shortened wait time for imminent death or loss of capacity must be agreed upon by both assessor and prescriber

12. Planning Advise the patient to:
seek advice on life insurance and pension plan implications
Confirm with the patient that:
arrangements have been made for a funeral home to receive the body

13. The Oral Route Three agents: Gastric motility agent and anti-emetics
metoclopramide, ondansetron, haloperidol
Anxiolytic
lorazepam
Coma Inducing preparation
Suspension of phenobarbital, chloral hydrate, and morphine

15. Gastric Motility Agent
A gastric motility agent is necessary due to the high rate of nausea and vomiting with the coma inducing preparation
The agent must be taken one hour prior to the coma inducing preparation

16. Anxiolytic
The anxiolytic is taken sublingually 5 to 10 minutes prior to the coma inducing preparation
an additional dose may be given if necessary

17. Coma Inducing Preparation
Stable for 72 hours after preparation by pharmacist
Must be ingested within 4 minutes
Has a volume of approximately 120 ml volume
Should be followed by a small amount of non-fat, non-carbonated drink
May take over 4 hours to be effective

18. The Oral Route
Inform the patient that the intravenous route is the back up in case of failure of the oral route
Advise that an intravenous line will be established prior to the administration of the oral medications
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19. The Oral Route
A oral kit and an IV kit will be dispensed to the prescriber by the pharmacist in a sealed tamperproof container

20. Intravenous Route Four agents: Anxiolytic
Midazolam
Local anesthetic (to reduce discomfort with propofol administration)
Lidocaine
Coma inducing agent
Propofol or phenobarbital
Neuromuscular blocker
Rocuronium
Add drug names
Describe purposes of each from Alberta guidelines

22. Anxiolytic - midazolam
Given over 2 minutes
May give one additional dose
Flush line with 0.9% NaCl to ensure entire dose is delivered
flush

23. Local Anesthetic - lidocaine
Given over 30 seconds
Flush line with 0.9% NaCl to ensure entire dose is delivered
flush

24. Coma Inducing Agent – propofol or phenobarbital
Given over 5 minutes
May give one additional dose
Flush line with 0.9% NaCl to ensure entire dose is delivered

25. Neuromuscular Blocker - rocuronium
Rapid IV injection
Flush line with 0.9% NaCl to ensure entire dose is delivered

26. Intravenous Route
2 identical kits of all drugs in a sealed tamperproof container will be dispensed directly to the provider
This ensures that there is adequate medication if the IV becomes interstitial or other issues are encountered in the administration of medication

27. Acquiring the medication
Obtain the British Columbia Medical Assistance in Dying Prescription from the Care Coordination Centre or the College of Physicians and Surgeons of BC
The Care Coordinator will link you with a health authority pharmacist
Review with the pharmacist the request, assessments, and plan to provide the service
Ensure the pharmacist has several days notice to prepare the medication kits for dispensing
The pharmacist must be made aware of the purpose of the medications

28. Acquiring the medication
The pharmacist will only dispense the kits directly to the provider
Only the provider can sign for the release of the prescription
The provider must provide photo identification, if applicable

29. Acquiring the medication
The pharmacist will review:
the procedure to return unused medication within 48 hours of the patient’s death for secure and timely proposal
how to complete the Medication Administration Record for Medical Assistance in Dying

30. Prior to Administration
The patient must be conscious and competent at the time of the service
Immediately prior to administration of medication, provide the patient with an opportunity to withdraw their consent

31. Following administration
Do allow the family time to grieve
Allow for time for emotional support to family, friends and caregivers who are present for the patient’s death
Allow time for the professional team to share their experience and support each other

32. Following administration
Consider debriefing with a colleague
If you are staff, consider the Employee and Family Assistance Program
If you are a physician, consider the Physician Health Program

33. Documentation Record who was present
Record the time of administration and time of death
All medication administration times are recorded on the Medication Administration Record provided in the kits
Provide any comments or suggestions for improvement to the Care Coordinator

34. Documentation Complete the Death Certificate PART I
Immediate cause of death = medical assistance in dying
Antecedent causes = underlying illness, disease or disability (e.g. multiple myeloma)

35. Documentation
Submit all medical assistance in dying forms to the Care Coordination Centre and to the Coroner’s Office

36. Care Coordination Centre
The role of the Care Coordinator is to:
Connect patients requesting assisted dying with participating physicians
Facilitate the care required for assisted dying in an NH facility
Offer to support assisted dying provided by physicians and nurse practitioners in the community
Contact:
Phone: Fax
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