Download Prescriber - Northern Health Physicians

Medical Assistance in Dying
Prescribing for
Medical Assistance in
Dying
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
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
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Contact [email protected] or 250-645-6073
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
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
Documentation

Ensure that you have the following
medical assistance in dying documents:
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Record of Patient Request
Record of Assessment (Assessor)
Record of Assessment (Prescriber)
Coroner’s Report of Death
Document Checklist
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
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
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
Planning

Review with the patient the self-administered
(oral) route and the intravenous route
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
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
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
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A shortened wait time for imminent death or loss of
capacity must be agreed upon by both assessor and
prescriber
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
The Oral Route
Three agents:

Gastric motility agent and anti-emetics
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
Anxiolytic
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
metoclopramide, ondansetron, haloperidol
lorazepam
Coma Inducing preparation
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Suspension of phenobarbital, chloral hydrate, and morphine
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
Anxiolytic

The anxiolytic is taken sublingually 5 to 10
minutes prior to the coma inducing
preparation

an additional dose may be given if necessary
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
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
The Oral Route

A oral kit and an IV kit will be dispensed
to the prescriber by the pharmacist in a
sealed tamperproof container
Intravenous Route
Four agents:
 Anxiolytic
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Midazolam
Local anesthetic (to reduce discomfort with propofol
administration)
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Coma inducing agent
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Lidocaine
Propofol or phenobarbital
Neuromuscular blocker
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Rocuronium
Anxiolytic - midazolam

Given over 2 minutes
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May give one additional dose

Flush line with 0.9% NaCl to ensure entire
dose is delivered
Local Anesthetic - lidocaine

Given over 30 seconds

Flush line with 0.9% NaCl to ensure entire dose is
delivered
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
Neuromuscular Blocker rocuronium

Rapid IV injection

Flush line with 0.9% NaCl to ensure entire
dose is delivered
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
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
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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
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
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
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
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
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
Documentation

Record who was present

Record the time of administration and time
of death
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
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
Documentation
Complete the Death Certificate
PART I
a) Immediate cause of death = medical
assistance in dying
b) Antecedent causes = underlying illness,
disease or disability (e.g. multiple
myeloma)
Documentation

Submit all medical assistance in dying forms
to the Care Coordination Centre and to the
Coroner’s Office
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:
 [email protected]
 Phone: 250-645-6417
Fax 250-565-2640