Download Medical Assistance in Dying British Columbia

Medical Assistance in Dying
British Columbia Pharmacy Protocols
Guidance on the Standardized Pharmacy Protocols and
Completion of the Pre-printed Prescription Order Form
For Physicians and Nurse Practitioners administering Medical Assistance in Dying,
and for Pharmacists dispensing medications for Medical Assistance in Dying
Not For General Distribution
December 5, 2016
Developed by the Provincial Medical Assistance in Dying Working Group:
Sub-Committee on Pharmacy
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Health Authorities of BC
College of Pharmacists of BC
College of Physicians and Surgeons of BC
College of Registered Nurses of BC
BC Pharmacy Association
Canadian Society of Hospital Pharmacists (BC Branch)
BC Ministry of Health
Table of Contents
Page
PURPOSE……………………………………………………………………………………………………………. 3
IMPORTANT DEFINITIONS………………………………………………………………………………………….. 3
BC’S STANDARDIZED PHARMACY PROTOCOLS FOR MEDICAL ASSISTANCE IN DYING............................. 5
GUIDANCE ON COMPLETING SECTIONS OF THE PRE-PRINTED PRESCRIPTION ORDER FORM………….... 5
Prescription Submission and Retention…………………………………………………………………. 5
Identification and Declaration…………………………………………………………………………….. 5
Intravenous Drug Protocol – Administered by Medical / Nurse Practitioner………………………… 6
Oral Drug Protocol – Self-Administered (Supervised by Medical / Nurse Practitioner)……………. 6
Prescription Planning……………………………………………………………………………………… 7
Planned Date and Time of Prescription Release……………………………………………… 7
Plan for Concluding Medical Assistance in Dying Process.................................................. 7
Prescription Accountability……………………..………………………………………………………....
Medication Administration Record (MAR)………………………………………………………
Dispensing Sign-Off……………………………………………………………………………….
Return of All Unused and Partially Used Medications to Pharmacist for Disposal…………
7
7
7
7
Medication Administration Record……………………………………………………………………….. 8
Acknowledgements………………………………………………………………………………………... 8
BRITISH COLUMBIA MEDICAL ASSISTANCE IN DYING PRESCRIPTION AND MAR (SAMPLE)……………… 9
MEDICAL ASSISTANCE IN DYING DRUG PROTOCOL MONOGRAPHS…………………………………………. 15
Intravenous Drug Protocol Monographs………………………………………………………………… 16
Oral Self-Administered Drug Protocol Monographs…………………………………………………… 24
SUGGESTED COMPOUNDING PROCEDURE (ORAL COMA-INDUCING SUSPENSION)…………………...…… 30
SUGGESTED INVENTORY LISTS…………………………………………………………………………………… 31
Suggested Pharmacy Inventory Lists (Per Kit) for IV and Oral Regimens…………………………. 31
Suggested Inventory List for IV Insertion Equipment and Additional Supplies Required by
Practitioner for Medication Administration…................................................................................... 33
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Purpose / Important Definitions
PURPOSE
This guidance document has been developed by the provincial Medical Assistance in Dying Working
Group: Sub-Committee on Pharmacy, to assist the providing physician or nurse practitioner and the
pharmacist in their understanding of British Columbia’s standardized pharmacy protocols, and to provide
support for the completion of the pre-printed prescription order form for medical assistance in dying. The
document includes the following information:

Important definitions pertaining to medical assistance in dying, including information on the roles
and responsibilities of practitioners and pharmacists in British Columbia.

British Columbia’s standardized pharmacy protocols for medical assistance in dying.

Guidance for completing the “British Columbia Medical Assistance in Dying Prescription” form.

Sample “British Columbia Medical Assistance in Dying Prescription” form (including Prescription
Planning and Accountability sections, and Medication Administration Record).

Drug information monographs for the intravenous and oral drug protocols.

Suggested compounding procedure for the oral coma-inducing compounded suspension.

Suggested inventory lists for intravenous and oral drug regimens.

Suggested inventory list for intravenous insertion equipment and supplies.
The membership of the Medical Assistance in Dying Committee on Pharmacy included pharmacists and
physicians from the BC Health Authorities, representatives from the regulatory colleges for pharmacists,
physicians and registered nurses, and representatives from the BC Pharmacy Association, the Canadian
Society of Hospital Pharmacists (BC Branch) and the BC Ministry of Health. Protocols from Alberta, Nova
Scotia, Quebec, Oregon and the Netherlands were reviewed and used to inform the development of the
British Columbia Standardized Pharmacy Protocols for Medical Assistance in Dying.
IMPORTANT DEFINITIONS
CANADA
The following definitions pertaining to medical assistance in dying are defined in Section 241.1 of
the Criminal Code of Canada (amended 2016-06-17):
“medical assistance in dying” means
(a) the administering by a medical practitioner or nurse practitioner of a substance to a person,
at their request, that causes their death; or
(b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to
a person, at their request, so that they may self-administer the substance and in doing so
cause their own death.
medical practitioner means a person who is entitled to practice medicine under the laws of a
province
nurse practitioner means a registered nurse who, under the laws of a province, is entitled to
practice as a nurse practitioner – or under an equivalent designation – and to autonomously make
diagnoses, order and interpret diagnostic tests, prescribe substances and treat patients.
pharmacist means a person who is entitled to practise pharmacy under the laws of a province.”
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Important Definitions
BRITISH COLUMBIA
The following further defines the roles and responsibilities of the prescribing medical or nurse
practitioner and pharmacist with regard to medical assistance in dying in British Columbia:
Prescribing Medical / Nurse Practitioner (Prescriber): The prescribing medical or nurse
practitioner (prescriber) who administers the lethal dose of medications intended to cause the
patient’s death, or provides the lethal dose of medications to the patient for self-administration. The
prescriber is responsible for confirming that all of the mandatory eligibility criteria have been met
before the medications that intentionally cause the patient’s death can be administered or provided
to the patient for self-administration. There can only be one prescriber for each patient; however, a
second medical / nurse practitioner or nurse may be present to assist. In British Columbia, the
prescriber must personally attend the patient during the administration or self-administration of
medical assistance in dying and must remain in attendance until death is confirmed.
For additional information on the role and responsibilities of the prescriber, please see the
Professional Standards and Guidelines for Medical Assistance in Dying posted by the College
of Physicians and Surgeons of British Columbia (CPSBC), and the Scope of Practice for Nurse
Practitioners posted by the College of Registered Nurses of British Columbia (CRNBC), which are
available at the following links:
https://www.cpsbc.ca/files/pdf/PSG-Medical-Assistance-in-Dying.pdf
https://crnbc.ca/Standards/Lists/StandardResources/688ScopeforNPs.pdf
Pharmacist: Only a full pharmacist can dispense drugs for the purpose of medical assistance in
dying, and the full pharmacist must dispense directly to the prescribing medical or nurse practitioner
(prescriber), as per the following:

Dispensed drugs for the purpose of medical assistance in dying must be transported
between the pharmacist and the prescriber only. In exceptional circumstances, this
transport can be completed by a safe and secured courier (with terms and conditions
that align with federal legislation, particularly the Controlled Drugs and Substances Act
[CDSA] and the Narcotic Control Regulation).

Telepharmacy remote sites are not eligible to dispense drugs for the purpose of medical
assistance in dying, since there is no full pharmacist on-site.

Registrants are encouraged to be mindful of their Code of Ethics and use their
professional judgment in ensuring pharmacy services are completed with public interest
and patient safety in mind.
The pharmacist must review the prescription and discuss and confirm with the prescriber the
patient’s eligibility and consent for medical assistance in dying, the patient’s drug therapy and the
drug protocol selected, as well as other details pertaining to the ordering, preparation, dispensing,
documenting, and return of unused drugs.
A full pharmacist may delegate to a pharmacy technician any aspect of the preparation of drugs for
the purpose of medical assistance in dying that is within a pharmacy technician’s scope of practice.
For additional information on the role and responsibilities of the full pharmacist and pharmacy
technician, please see Dispensing Drugs for the Purposes of Medical Assistance in Dying
posted by the College of Pharmacists of British Columbia, available at the following link:
http://library.bcpharmacists.org/6_Resources/6-1_Provincial_Legislation/5195HPA_Bylaws_MAID.pdf
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BC’s Standardized Pharmacy Protocols / Guidance on Completing Sections of the Prescription
BC’S STANDARDIZED PHARMACY PROTOCOLS FOR MEDICAL ASSISTANCE IN DYING
British Columbia’s standardized pharmacy protocols for medical assistance in dying include the following:
1) Intravenous Drug Protocol – for medical or nurse practitioner-administered medical
assistance in dying; and,
2) Oral Drug Protocol – for self-administered medical assistance in dying.
The Intravenous Drug Protocol is the recommended and most often selected option, due to its more rapid
onset of effect and reduced likelihood of complication. If the Oral Drug Protocol is selected, intravenous
access must also be established in the patient so that the intravenous regimen can be administered in the
event the oral regimen is ineffective.
Specific details on the intravenous and oral drug protocols are provided in the attached sample British
Columbia Medical Assistance in Dying Prescription. Additional information on each medication is provided
in the attached Intravenous Drug Protocol Monographs and Oral Drug Protocol Monographs.
GUIDANCE ON COMPLETING SECTIONS OF THE PRE-PRINTED PRESCRIPTION ORDER FORM
Prescription Submission and Retention
Instructions regarding submission and retention are provided at the top of page one of the prescription.
Upon completion of medical assistance in dying:
1) The prescribing medical or nurse practitioner (prescriber) will provide a copy of the completed
medication administration record (MAR) to the pharmacist for reconciliation of the return of all
unused and partially used medications (which will be documented in the “Prescription
Accountability” section of the prescription).
2) The pharmacist will provide a copy of the completed prescription sections (including the
Prescription, and the “Prescription Planning” and “Prescription Accountability” sections) to the
prescriber, since it is the responsibility of the prescriber to submit all completed forms for
medical assistance in dying to the BC Coroners Service.
3) The prescriber will fax a copy of the completed prescription document (all sections, including the
prescription, prescription planning and accountability sections, and the MAR), along with all
other completed forms for medical assistance in dying, to the BC Coroners Service, Attention
Deputy Chief Coroner, fax 604-660-7766.
4) For cases involving a health authority (HA), the prescriber will fax or mail an additional copy of
the prescription (all sections) to the applicable HA (fax numbers and mailing instructions are
provided at the bottom of page 4 of the prescription).
5) The prescriber will retain a copy of the prescription (all sections) in the patient’s health record.
Identification and Declaration
The patient and prescribing medical or nurse practitioner (prescriber) information is recorded here, as is
required on all other medical records which would appear in the patient’s medical record.
Patient Information – The prescriber will record the following patient information: name, birthdate, address,
personal health number, and medical information pertinent to medical assistance in dying (e.g., allergies).
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Guidance on Completing Sections of the Prescription
Medical / Nurse Practitioner Information (Prescriber) – The prescriber will record their name, college
identification number (CPSID #, or CRNBC Prescriber #), address, telephone number and signature.
Medical / Nurse Practitioner Declaration (Prescriber) – The prescriber will initial each of four statements to
declare them true (e.g., statement on determination that the patient is capable of providing consent, and
statement on determination that the patient has a grievous and irremediable medical condition and meets
the eligibility criteria). The prescriber also records the name of the other medical / nurse practitioner who
completed an assessment and confirmed that the patient meets the eligibility criteria.
The pharmacist will initial only the first statement to acknowledge discussion and confirmation with the
prescriber that the medications prescribed on the form are intended for the purpose of medical assistance
in dying, and that the patient’s drug therapy has been discussed.
The pharmacist is not to perform an assessment of the patient’s eligibility criteria or obtain consent
from the patient (functions performed by the prescriber only).
Intravenous Drug Protocol – Administered by Medical / Nurse Practitioner
The prescribing medical or nurse practitioner (prescriber) must record the patient’s name, birthdate, and
personal health number.
The medications recommended to be prescribed for the medical or nurse practitioner-administered
intravenous drug protocol are listed in a table in the order of their administration. The row for each
medication includes information on the dispensed quantity and dosage regimen, a space for prescriber
notes, and a space that the prescriber must initial to indicate the medication is prescribed for the
intravenous drug protocol.
The prescriber must provide their signature at the bottom of the page and record their college ID number
(CPSID #, or CRNBC Prescriber #).
The pharmacist must dispense two identical kits of all medications in a sealed / tamperproof container,
to ensure that a backup intravenous kit is available if required.
(The Intravenous Drug Protocol Monographs attached to this document provide information on each
medication, including instruction on confirming coma prior to administration of the neuromuscular blocker.)
Oral Drug Protocol – Self-Administered (Supervised by Medical / Nurse Practitioner)
The prescribing medical or nurse practitioner (prescriber) must record the patient’s name, birthdate, and
personal health number.
The medications recommended to be prescribed for the patient self-administered oral drug protocol are
listed in a table in the order of their administration. The row for each medication includes information on
the dispensed quantity and dosage regimen, a space for prescriber notes, and a space that the prescriber
must initial to indicate the medication is prescribed for the oral drug protocol.
The prescriber must provide their signature at the bottom of the page and record their college ID number
(CPSID #, or CRNBC Prescriber #).
Note to Prescribing Medical / Nurse Practitioner: The prescriber must also complete the Intravenous
Drug Regimen section of the Prescription, to prescribe the specific contents of the backup intravenous kit.
Note to Pharmacist: The backup intravenous kit should include two orders of proPOFol or phenobarbital
(i.e., total dispensed quantity of “2” x 1000 mg of proPOFol, or “2” x 3000 mg of phenobarbital).
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Guidance on Completing Sections of the Prescription
(The Oral Self-Administered Drug Protocol Monographs attached to this document provide information on
each medication.)
Prescription Planning
The prescribing medical or nurse practitioner (prescriber) must record the patient’s name, birthdate, and
personal health number.
This section includes information on the planned date and time of prescription release from the pharmacist,
and the plan for concluding the medical assistance in dying process (i.e., return of any unused and partially
used drugs).
Planned Date and Time of Prescription Release - The pharmacist will discuss with the prescriber and
record the planned date and time of release of the prescription(s).
Plan for Concluding Medical Assistance in Dying Process - The pharmacist will indicate by checkmark that
procedures have been established with the prescriber for the return of any unused and partially used
medications within 48 hours to the pharmacy (for secure and timely disposal). Any pharmacist within the
dispensing pharmacy may receive back unused and partially used medications from the prescriber.
Prescription Accountability
This section includes information on the Medication Administration Record, dispensing sign-off, and details
pertaining to the return of any unused and partially used medications after medical assistance in dying.
Medication Administration Record (MAR) – The pharmacist will indicate by checkmark that the prescribing
medical or nurse practitioner (prescriber) has been instructed on how to complete the MAR for medical
assistance in dying medications. (Upon completion of medical assistance in dying, the physician will
provide a copy of the MAR to the pharmacist for reconciliation of the return of all unused and partially used
medications.)
Dispensing Sign-Off – The pharmacist will record their name, signature, CPBC license number, and the
date, to indicate their dispensing of the prescription(s) directly to the prescriber. The prescriber will record
their name, signature, CPSID number or CRNBC Prescriber number, and the date, to indicate their receipt
of the prescription(s) directly from the pharmacist. If the prescriber is unknown to the pharmacist, the
pharmacist will confirm and record the prescriber’s identity by means of photo identification.
Return of All Unused and Partially Used Medications to Pharmacist for Disposal – The full pharmacist
should ensure the appropriate return of any unused and partially used medications to the pharmacy for
disposal. The prescriber will return all unused and partially used medications to the pharmacy within 48
hours of the patient’s death. Any pharmacist within the dispensing pharmacy may receive back unused
and partially used medications from the prescriber.
The prescriber will provide a copy of the medication administration record to the pharmacist for review and
reconciliation of the medications returned. The pharmacist will record the name of each unused or partially
used medication, and will document the form, strength and quantity of medication returned. The prescriber
will record their name, CPSID number, signature and the date, to indicate their return of any unused and
partially used medications. The pharmacist will record their name, CPBC license number, signature and
the date, to indicate their receipt of any unused and partially used medications. The pharmacist will then
provide a copy of the completed prescription sections (including the Prescription, and the “Prescription
Planning” and “Prescription Accountability” sections) to the prescriber, since it is the responsibility of the
prescriber to submit all completed forms for medical assistance in dying to the BC Coroners Service.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Guidance on Completing Sections of the Prescription
Medication Administration Record
There is a separate medication administration record (MAR) for the intravenous drug protocol and for the
oral drug protocol. Both MARs contain an identical first section to be completed by the prescribing medical
or nurse practitioner (prescriber), on information about the patient (name, birthdate, personal health
number) and prescriber (name, CPSID # or CRNBC prescriber #, signature, and initials). The second
section of the MAR lists each drug in the order of administration for medical assistance in dying. The
prescriber will record and initial for each medication the dose administered and the time given.
The prescriber will provide a copy of the completed MAR to the pharmacist for review and reconciliation of
the return of any unused and partially used medications.
Acknowledgements: Thank you to the Nova Scotia College of Pharmacists for sharing their drug protocol
documents and for their permission to adapt them, upon which the British Columbia protocols were based.
This document was developed with the assistance and guidance of many individuals and organizations.
Acknowledgement and thanks to the provincial Medical Assistance in Dying Pharmacy Sub-committee for their
contributions and expertise, as well as to the following organizations:

College of Pharmacists of BC

British Columbia Regional Health Authorities

College of Physicians and Surgeons of BC

British Columbia Pharmacy Association

College of Registered Nurses of BC

Canadian Society of Hospital Pharmacists (BC
Branch)
In addition, we would like to acknowledge the jurisdictions of Alberta, Quebec, Oregon, and the Netherlands for
the publication of their pharmacy protocol guidelines, which have significantly contributed to this work.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Prescription Document
Date:
British Columbia
Medical Assistance in Dying
Prescription – SAMPLE (not for use)
Upon completion of Medical Assistance in Dying (MAiD):
1) Prescriber to provide copy of completed MAR to Pharmacist for reconciling the return of unused and partially used
medications in “Prescription Accountability” section of Prescription;
2) Pharmacist to provide copy of completed Prescription sections (including “Prescription Accountability”) to Prescriber;
3) Prescriber to fax completed Prescription (all sections, including Prescription Planning and Accountability sections and
MAR) with all other MAiD forms to BC Coroners Service, Attention Deputy Chief Coroner, fax 604-660-7766;
4) For cases involving a health authority (HA), Prescriber to fax or mail an additional copy of Prescription (all sections) to
applicable HA (see bottom of page 4 for HA fax numbers and mailing information);
5) Prescriber to retain a copy of Prescription (all sections) in patient’s health record.
Identification and Declaration
Patient Information
Name:
Birthdate (YYYY/MM/DD):
Address:
Personal Health Number:
Medical Information
(pertinent to medical
assistance in dying allergies, etc.):
Medical / Nurse Practitioner Information (Prescriber)
Name:
CPSID #:
Address:
CRNBC Prescriber #:
Telephone Number:
Signature:
Medical / Nurse Practitioner Declaration (Prescriber)
The Prescriber will initial each statement to declare it is true.
The Pharmacist will initial the first statement to acknowledge discussion and confirmation with Prescriber.
The intention is NOT that the Pharmacist performs an assessment of
the patient’s eligibility criteria or obtains consent from the patient –
these functions are to only be performed by the Prescriber.
Prescriber
Initials
Pharmacist
Initials
I confirm the medications prescribed on this form are intended for the purpose
of medical assistance in dying, and patient’s drug therapy has been discussed.
I have determined the patient is capable to consent to medical assistance in
dying.
I have determined the patient is suffering from a grievous and irremediable
medical condition and meets the eligibility criteria.
I have received informed consent from the patient authorizing medical
assistance in dying.
Name of other Medical / Nurse Practitioner who
confirms that the patient meets the eligibility criteria.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Prescription Document
Intravenous Drug Protocol – Administered by Medical / Nurse Practitioner
Patient Name:
Birthdate (YYYY/MM/DD):
Personal Health Number:
The following are the components of the Medical or Nurse Practitioner-Administered medical
assistance in dying intravenous drug protocol.

Initial to confirm the selected drug for each protocol component. Sign the form at the bottom to
prescribe the selected medications.

Indicate by checkmark whether IV Drug Regimen is:
Primary IV Kit x 2
(Pharmacist must dispense 2 identical IV kits of all drugs in a sealed / tamperproof container.)
or
Back-up IV Kit for Oral Regimen
Dispensed Quantity
(Mitte)
Drug
Dosage
Notes
Prescriber
Initials
Anxiolytic (Initial to confirm anxiolytic is being ordered.)
midazolam
(1 mg/mL)
10 mg x 2
2.5 mg to 10 mg IV over 2
minutes.
midazolam 1 mg/mL is
preferred formulation.
May repeat additional dose
x 1 PRN.
Local Anaesthetic
lidocaine
(20 mg/mL)
40 mg
40 mg IV over 30 seconds.
lidocaine 20 mg/mL is
preferred formulation.
COMA Inducing Agent (CHOOSE one of the two alternatives. Initial to indicate selected agent.)
proPOFol
(10 mg/mL)
1gx1
1 g IV over 5 minutes.
May repeat additional dose
x 1 PRN.
1st line agent
3 g (dilute to 50 mL with
sodium chloride 0.9%) IV
over 5 minutes.
May repeat additional dose
x 1 PRN.
2nd line agent
phenobarbital 120
mg/mL is preferred
formulation.
200 mg by rapid IV
injection.
Confirm deep
medically-induced
coma before
administration.
OR
3gx1
phenobarbital
(120 mg/mL)
sodium chloride 0.9%
10 mL x 3 for injection
(for dilution)
Obtain additional PRN
from back-up IV kit, if
required.
Neuromuscular Blocker
rocuronium
(10 mg/mL)
200 mg
IV Line Flush Solution
sodium chloride
0.9% solution
10 mL x 6
Flush IV line after each medication to ensure entire
dose is given AND to avoid incompatibilities.
Medical / Nurse Practitioner Signature (Prescriber)
My signature serves to prescribe the medications initialed above for this patient.
________________________________
Signature
_________________
Date
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
_____________
_______________
CPSID #
or CRNBC Prescriber #
10
Prescription Document
Oral Drug Protocol – Self-Administered
(Supervised by Medical / Nurse Practitioner)
Patient Name:
Birthdate (YYYY/MM/DD):
Personal Health Number:
The following are the components of the Self-Administered medical assistance in dying oral drug protocol.

Initial to confirm the selected drug(s) for each protocol component. Sign the form at the bottom to prescribe
the selected medications.

For controlled prescription drugs (e.g. morphine), provide an additional prescription written on a duplicate
prescription form and attach to this form.
Dispensed
Prescriber
Drug
Dosage
Notes
Quantity (Mitte)
Initials
Gastric Motility / Anti-Emetic
metoclopramide 20 mg
(tablets)
ondansetron 8 mg
(tablet)
haloperidol 5mg
(5 mg/mL)
10 mg tablets x 2
20 mg (2 tablets) orally one
hour prior to ingesting comainducing agent.
8 mg tablet x 1
8 mg (1 tablet) orally one
hour prior to ingesting comainducing agent.
5 mg intravenous
vials x 2
5 mg subcutaneous or IV over
1 minute PRN for emesis
during procedure. May repeat
additional dose x 1 PRN.
Use haloperidol 5
mg/mL
intravenous
formulation
Anxiolytic (Initial to confirm anxiolytic is being ordered.)
LORazepam 0.5 mg
(sublingual tablets)
0.5 mg sublingual
tablets x 8
0.5 mg to 2 mg (1 to 4
tablets) sublingually, 5 to 10
minutes prior to ingesting
coma-inducing agent, if
needed for anxiety. May
repeat additional dose x 1
PRN.
COMA Inducing Agent (Initial to confirm each ingredient is being ordered.)
Powder Mixture:
phenobarbital powder*
20 g
chloral hydrate powder*
20 g
morphine sulphate
powder**
3g
*Active ingredients
required for coma
induction.
[Note: Omit morphine if patient
has significant morphine allergy
(i.e. anaphylaxis)]
ORA-Plus® /
®
ORA-Sweet (50/50)
or
Distilled Water for
feeding tube
Shake well. Ingest the
entire prescription in less
than 4 minutes.
**Optional, depending
qs to 120 mL
on patient factors (e.g.,
adverse effects,
tolerance).
Stable for 72 hours.
Patient to follow with a
small amount of nonfat, non-carbonated
drink.
If compound is to be
administered via PEG or
NG tube, replace “ORAPlus®/ORA Sweet®”
with 120 mL of water.
Flush feeding-tube with
60 to 90 mL of water
after medication.
Notes: 1) Prescriber must complete the Intravenous Drug Protocol section of the prescription form to
prescribe the specific contents of the back-up IV kit.
2) Pharmacist must dispense 1 “po” kit plus 1 “IV” kit as backup in sealed / tamperproof
container. The backup IV kit should include a second dispensed quantity of proPOFol or
phenobarbital (i.e., total dispensed quantity of proPOFol 1 g x “2”, or phenobarbital 3g x “2”).
Medical / Nurse Practitioner Signature (Prescriber)
My signature serves to prescribe the medications initialed above for this patient.
________________________________
_________________
_____________
Signature
Date
CPSID #
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
_______________
or CRNBC Prescriber #
11
Prescription Document
Prescription Planning
Patient Name:
Birthdate (YYYY/MM/DD):
Personal Health Number:
Planned Date and Time of Prescription Release and Return of Unused Medications
Planned Release Date (YYYY/MM/DD):
Planned Return Date (YYYY/MM/DD):
Planned Release Time (00:00 am/pm):
Planned Return Time (00:00 am/pm):
Plan for Concluding Medical Assistance in Dying Process
Procedures have been established for the return of any unused and partially used medication(s)
within 48 hours to the Pharmacy for secure and timely disposal. Any Pharmacist within the
dispensing pharmacy can receive back unused and partially used medications from the Prescriber.
 Completed
Prescription Accountability
Medication Administration Record
The Prescriber has been instructed on how to complete the Medication Administration Record for
medical assistance in dying medications.
 Completed
Dispensing Sign-Off
Printed Name
Signature
Dispensed by:
College ID
Date
Time
CPBC License #:
(Pharmacist)
Received by:
CPSID # / CRNBC
(Prescriber)
Prescriber #:
 Completed
Confirmation of photo ID of Prescriber, if applicable:
Return of All Unused and Partially Used Medications to Pharmacist for Disposal
The Prescriber will return all unused and partially used medications to the pharmacy within 48 hours of the patient’s
death. The Pharmacist will reconcile and document the return of unused and partially used medication(s) below.
Medication Name(s)
Printed Name
Form
Strength
Signature
College ID
Returned by:
CPSID # / CRNBC
(Prescriber)
Prescriber #:
Received by:
CPBC License #:
Quantity
Date
Time
(Pharmacist)
Health Authority fax numbers for submission of forms:
FHA: Fax:
604-523-8855
NHA:– 1Fax:
VIHA:
Fax: 250-727-4335
(Please
make
2 photocopies
for 250-565-2640
Prescriber and 1
for Pharmacy
records)
IHA: Fax: 250-469-7066
VCHA: Fax: 1-888-865-2941
PHSA: Fax: 604-829-2631
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
For mailing addresses of Health Authorities,
see Document Submission Checklist, HLTH 1632.
http://www2.gov.bc.ca/assets/gov/health/forms/1632.pdf
12
Prescription Document
Medication Administration Record
(Provide copy of completed MAR to Pharmacist)
Medical Assistance in Dying – Intravenous Drug Protocol (Administered by Medical / Nurse Practitioner)
Date:
Name of Patient:
Birthdate (YYYY/MM/DD):
PHN:
Name of Medical / Nurse Practitioner (Prescriber):
CPSID #:
Signature:
Initials:
Drug
Dose Administered
CRNBC Prescriber #:
Time
Given
Prescriber
Initials
Anxiolytic
midazolam 2.5 to 10 mg IV over 2 minutes
***May repeat additional dose x 1 PRN***
sodium chloride 0.9% solution
Flush line to ensure entire dose is given AND to
avoid incompatibilities
Anesthetic
lidocaine 40 mg IV over 30 seconds
sodium chloride 0.9% solution
Flush line to ensure entire dose is given AND to
avoid incompatibilities
Coma-inducing Agent - Choose proPOFol OR phenobarbital
proPOFol 1 g IV over 5 minutes
***May repeat additional dose x 1 PRN***
phenobarbital 3 g (dilute to 50 mL with sodium
chloride 0.9%) IV over 5 minutes
***May repeat additional dose x 1 PRN***
sodium chloride 0.9% solution
Flush line to ensure entire dose is given AND to
avoid incompatibilities
Neuromuscular Blocker – Confirm patient is in deep medically-induced coma* prior to administration
rocuronium 200 mg by rapid IV injection
sodium chloride 0.9% solution
Flush line to ensure entire dose is given AND to
avoid incompatibilities
* Deep medically-induced coma: No response to verbal stimuli, unable to rouse; serious depression of circulation, evidenced
by weak pulse; serious depression of ventilation, evidenced by slow, shallow breathing; no protective reflexes, such as eyelash
reflex.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Prescription Document
Medication Administration Record
(Provide copy of completed MAR to Pharmacist)
Medical Assistance in Dying – Oral Drug Protocol (Supervised by Medical / Nurse Practitioner)
Date:
Name of Patient:
Birthdate (YYYY/MM/DD):
PHN:
Name of Medical / Nurse Practitioner (Prescriber):
CPSID #:
Signature:
Initials:
Drug
Dose Administered
CRNBC Prescriber #:
Time
Given
Prescriber
Initials
Anti-emetic (prior to procedure)
metoclopramide 20 mg (10 mg tablets x 2)
1 hour prior to the coma-inducing agent
ondansetron 8 mg (1 tablet)
1 hour prior to coma-inducing agent
Anxiolytic
LORazepam 0.5 mg sublingual tablets
0.5 to 2 mg (1 to 4 tablets),
5 to 10 minutes prior to coma-inducing agent,
as needed for anxiety
***May repeat additional dose x 1 PRN***
Coma-inducing Agent
phenobarbital powder 20 g
chloral hydrate powder 20 g
morphine sulphate powder 3 g
(cross-out morphine, if not given)
***Shake well. ***
Ingest entire mixture in less than 4 minutes,
followed by a glass of water or non-carbonated,
non-fat liquid of patient’s choice.
For PEG or NG tube administration,
flush feeding-tube with 60 to 90 mL of
water after medication.
Anti-emetic (during procedure)
haloperidol 5 mg SUBCUT or IV over 1 minute
as needed for emesis
***May repeat additional dose x 1 PRN***
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Drug Protocol Monographs
Medical Assistance in Dying
Drug Protocol Monographs
WARNING: These drug monographs were prepared for use with
the Standardized Pharmacy Protocols for Medical Assistance in
Dying only, and are not intended for other purposes. For
complete drug use and safety warnings please consult other
sources.
Due to the special context of medical assistance in dying and the
intended use of the preparations, shortened beyond use dates
are assigned in these monographs to ensure the medications are
used promptly.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Intravenous Drug Protocol Monographs
Intravenous Drug Protocol Monographs
(drugs are listed in order of administration in the protocol)
Please Note: To prevent IV incompatibilities, stop all other
infusions and flush the IV line with 10 mL Normal Saline (sodium
chloride 0.9%) before proceeding.
Preamble
Vascular access


Vascular access should be established in ALL patients, regardless of whether the
intravenous or the oral regimen is selected. In cases where patients are unable to tolerate
the oral medications or the regimen is ineffective, the provider will have the option of
administering the medications intravenously.
If there are issues with venous access, a central line may be required.
Other medications and treatments



Routine analgesic therapies should be continued right up to the time of the procedure.
Oxygen therapy should be discontinued at the beginning of the procedure to avoid
prolonging apnea and delaying cardiac arrest.
Defibrillator must be deactivated before procedure.
1. Anxiolytic
Drug
midazolam 1 mg/mL


Benzodiazepine used for reducing anxiety around the procedure.
1 mg/mL strength is recommended for ease of administration and delivery of accurate
dose.
Dose
Administer 2.5 to 10 mg (2.5 to 10 mL) IV over 2 minutes;
May repeat additional dose of 2.5 to 10mg IV (2.5 to 10 mL), if required.
 Onset of effect: 1 to 5 minutes.1
 Peak effect: 5 to 7 minutes1 (reassess need for additional dose 10 minutes after
delivery of initial dose).
 Adjust dose according to patient-specific factors.
 Patients exposed to prior benzodiazepines may require a higher dose.
 Frail, elderly, and/or benzodiazepine-naïve patients may require lower doses.
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Intravenous Drug Protocol Monographs
Preparation
Draw up 2 syringes of 10 mg (10 mL), each into a 20 mL syringe.
 Protect prepared syringes from light2 – store in amber bag.
 Beyond Use Date3/Stable in a polypropylene syringe at room temperature (RT) for 48
hours when prepared in a laminar flow hood; or 24 hours when prepared on a
countertop.4,5
Administration
Give IV direct over 2 minutes.
 Compatible5 with fentanyl, HYDROmorphone, LORazepam, morphine. For additional
compatibility information, consult pharmacy.
 Flush with normal saline to ensure all the dose is delivered.
Monitoring
Monitor for anxiety, level of consciousness, and need for repeat dose.
 Patient may remain awake or may lose consciousness, depending on their sensitivity
to benzodiazepines.
 Paradoxical agitation may occur in some patients; coma should then be induced
without delay and no further midazolam given.
Counseling for Patient and Family


This medication reduces anxiety and helps the patient relax.
Advise that the patient may or may not lose consciousness.
2. Anesthetic
Drug
lidocaine 20 mg/mL



Lidocaine is a local anesthetic used to decrease the pain on administration of
subsequent medications.
Do NOT administer lidocaine WITH epinephrine IV.
Do NOT use if history of true allergy to lidocaine or other amide-type local
anaesthetics (e.g. bupivacaine, prilocaine, mepivacaine).
Dose
Administer 40 mg (2 mL) IV over 30 seconds.
 Onset of effect: 45 to 90 seconds.1
 Peak effect: unknown, but duration of action is 10-20 minutes.1
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Intravenous Drug Protocol Monographs
Preparation
Draw up 40 mg (2 mL) into a 3 mL syringe.
 Beyond Use Date/Stable in a polypropylene syringe at RT for 48 hours or 14 days
refrigerated when prepared in a laminar flow hood; or 24 hours at RT or 72 hours
refrigerated, when prepared on a countertop.3-5
Administration
Give IV direct over 30 seconds.
 Compatible with fentanyl, HYDROmorphone, LORazepam, morphine.3 For additional
compatibility information, consult pharmacy.
 Flush with normal saline to ensure all the dose is delivered.
Monitoring


High levels of lidocaine can cause ringing in the ears, numbness of the lips, metallic
taste, nausea, and dizziness; adverse effects should subside rapidly once drug levels
fall
Check for level of comfort at IV site.
Counseling for Patient and Family


This medication helps numb the veins and the area around the IV site, so
administration of the next medication is more comfortable.
Advise the patient that they may experience ringing in the ears, numbness around the
lips, metallic taste, nausea or dizziness, but these effects (if any) would pass quickly.
3. Coma-inducing Agent
Drug
proPOFol 10 mg/Ml




proPOFol is used to induce a coma state that is deep enough to prevent the patient
from feeling the effects of the neuromuscular blocker.
proPOFol is the preferred coma-inducing agent due to ease of preparation.
proPOFol may contain egg and soy proteins, and may be contraindicated in patients
with severe allergies to those components (various brands of the product may contain
different components).6
If proPOFol is contraindicated, phenobarbital is the alternative.
Dose
Administer 1g (100 mL) IV over 5 minutes;
May repeat additional 1g (100 mL) IV over 5 minutes x 1, if required.
 Onset of effect: 30 seconds.1
 Peak effect: duration of action is 3 to 5 minutes at usual doses; duration of effect at
this higher dose is unknown.1
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Intravenous Drug Protocol Monographs
Preparation
Draw up & prepare four syringes: 250 mg (25 mL) into each 30 mL syringe.
 Use a vented dispensing pin (if available) to puncture the vial and draw up the
proPOFol into each syringe; this will reduce the pressure in the vial, allowing for easier
withdrawal of the medication.
 Beyond Use Date/Stable in a polypropylene syringe at RT for 48 hours or 14 days
refrigerated, when prepared in a laminar flow hood; or 24 hours at RT or 72 hours
refrigerated, when prepared on a countertop.3-5
Administration
Give IV direct over 5 minutes (each 50 mL syringe given over 2.5 minutes).
 Compatible with fentanyl, SUFentanyl, HYDROmorphone; variable compatibility with
morphine (high concentrations may affect emulsion stability).5 For additional
compatibility information, consult pharmacy.
 Rapid bolus administration may result in loss of venous access; while injecting too
slowly may reduce the effectiveness of the medication and compromise development
of coma.
 Observe for pain during injection.
 Ensure neuromuscular blocker is available and ready to be immediately administered
after proPOFol administration.
 Flush with normal saline to ensure all the dose is delivered.
Monitoring
Monitor for level of consciousness and onset of medically-induced deep coma.
- A patient is in a medically-induced deep coma if the following signs are present7:
o No response to verbal stimuli; unable to rouse
o Severe circulation depression, evidenced by weak pulse
o Severe respiratory depression, evidenced by slow, shallow breathing
o No protective reflexes, such as the eyelash reflex
- The Richmond Agitation and Sedation (RASS) Scale is a reliable and validated tool
developed to titrate sedative medications in critical care settings that can be used
as a monitoring tool.8 The target for medically-induced deep coma is “-5” on the
scale, which corresponds to lack of response to voice or physical stimulation. (The
RASS Scale is provided as an addendum at the end of this drug monograph.)
- Consider an additional proPOFol dose only if medically-induced deep coma is not
achieved with one dose, although the likelihood of inadequate loss of consciousness
is low with the recommended doses.9
- Neuromuscular blocker should only be administered once patient is in a medicallyinduced deep coma.9
- Cardiopulmonary arrest may occur rapidly during administration of the comainducing agent. Those present at the procedure should be advised of this. Even
when cardiopulmonary arrest does occur during coma induction, the neuromuscular
blocker must ALWAYS be administered to prevent any doubt as to the patient’s
death.9
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Intravenous Drug Protocol Monographs
Counseling for Patient and Family



This medication will place the patient in a deep coma-like state.
Advise the patient that they will lose consciousness, and breathing may slow
significantly or stop altogether.
The physician will ensure that the patient is in a medically-induced deep coma before
administering the next medication.
Drug
phenobarbital 120 mg/mL


phenobaribital is a barbiturate used to induce coma state that is deep enough to
prevent the patient from feeling the effects of the neuromuscular blocker.
proPOFol is the preferred coma-inducing agent; phenobarbital is an alternate agent
only if proPOFol is contraindicated.
Dose
Administer 3g IV over 5 minutes;
May repeat additional 3g IV over 5 minutes x 1, if required.
 Onset of effect: 5 minutes.1
 Peak effect: >15 minutes for CNS depression.1
Preparation
Withdraw 3000 mg (25 mL) into a 60 mL syringe and further dilute with normal saline to
total volume of 50 mL.
 Preparation of phenobarbital syringe requires 25 x 1 mL ampoules.
 Use an ampoule breaker device to open each ampoule.
 Use a filter needle when withdrawing medication from the glass ampoule (only when a
filter disc is not available).
 Prior to administration, attach a filter disc (if available) to the syringe and administer
the phenobarbital; the filter disc will prevent any potential glass particles from being
injected.
 Beyond Use Date/Stable in a polypropylene syringe at RT for 48 hours when prepared
in a laminar flow hood, or 24 hours when prepared on a countertop. Store at
controlled room temperature and protect from light in an amber bag. Limit exposure
of solution to air.3-5
Administration
Give IV direct over 5 minutes.
 Compatible with fentaNYL, variable compatibility (concentration-dependent)with
HYDROmorphone, methadone, morphine, proPOFol, SUFentanil.5 For additional
compatibility information, consult pharmacy.
 Rapid bolus administration may result in loss of venous access; while injecting too
slowly may reduce the effectiveness of the medication and compromise development
of coma.
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Intravenous Drug Protocol Monographs



Observe for pain during injection.
Ensure neuromuscular blocker is available and ready to be immediately administered
after phenobarbital administration.
Flush with normal saline to ensure full dose is delivered into vein.
Monitoring
Monitor for level of consciousness and onset of medically-induced deep coma.
 A patient is in a medically-induced deep coma if the following signs are present7:
o No response to verbal stimuli; unable to rouse
o Severe circulation depression, evidenced by weak pulse
o Severe respiratory depression, evidenced by slow, shallow breathing
o No protective reflexes, such as eyelash reflex
 The Richmond Agitation and Sedation (RASS) Scale is a reliable and validated tool
developed to titrate sedative medications in critical care settings that can be used as a
monitoring tool.11 The target for medically-induced deep coma is “-5” on the scale,
which corresponds to lack of response to voice or physical stimulation.
(The RASS Scale is provided as an addendum at the end of this drug monograph.)
 Consider an additional phenobarbital dose only if medical-induced coma is not
achieved with one dose, although the likelihood of inadequate loss of consciousness is
low with the recommended doses.11
 Neuromuscular blocker should only be administered once patient is in a medicallyinduced deep coma.9
 Cardiopulmonary arrest may occur rapidly during administration of the coma-inducing
agent. Those present at the procedure should be advised of this. Even when
cardiopulmonary arrest occurs during coma induction, the neuromuscular blocker must
ALWAYS be injected to prevent any doubt as to the patient’s death.9
Counseling for Patient and Family



This medication will place the patient in a deep coma-like state.
Advise the patient that they will lose consciousness, and breathing may slow
significantly or stop altogether.
The physician will ensure that the patient is in a medically-induced deep coma before
administering the next medication.
4. Neuromuscular Blocker
Drug
rocuronium 10 mg/mL



Rocuronium is a neuromuscular blocker used to cause skeletal muscle relaxation,
resulting in respiratory arrest.
Neuromuscular blockade causes paralysis of skeletal muscles (including the
diaphragm) within minutes.
Resulting respiratory arrest leads to death by anoxia; death may occur quickly after
neuromuscular injection, if not already during coma induction.9
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Intravenous Drug Protocol Monographs
Dose
Administer 200 mg (20 mL) IV by rapid injection
 Onset of action: 1 to 2 minutes; maximum neuromuscular blockade within 4 minutes1
 Peak effect: unknown; duration is 30 minutes (with standard doses, increases with
higher doses).1
Preparation
Withdraw 200 mg (20 mL) into a 30 mL syringe.
 Beyond Use Date/Stable in a polypropylene syringe at RT for 24 hours regardless of
site of preparation.3,5
Administration
Give IV direct by rapid injection.
 Compatible with fentanyl, HYDROmorphone, midazolam, morphine, ondansetron,
phenobarbital, REMifentanil, SUFentanil.10 For additional compatibility information,
consult pharmacy.
 Flush with normal saline to ensure full dose is delivered into vein.
Monitoring



Confirm that the medically-induced deep coma is “-5” on the Richmond Agitation and
Sedation Scale) prior to administration of the neuromuscular blocker.9
Respiratory arrest generally occurs before cardiac arrest; delays of up to 20 minutes
between respiratory arrest and cardiac arrest may occur.11
Assess for signs of death, including cessation of respirations, heart sounds, pulses,
response to tactile stimuli and pupil response.
Counseling for Patients and Family



This medication will slow down and stop the patient’s breathing
Advise those present, before starting the injections, that death may occur relatively
quickly and the heart may continue to beat for a short period after breathing has
stopped.9,11
The physician is required to perform a physical assessment of the patient to confirm
death.
1
Lexicomp Online®, Hudson, Ohio: Lexi-Comp, inc.: August 5, 2015.
th
Bing, CM. Extended Sterility for Parenteral Drugs, 5 ed. 2013:p.248.
3
“Beyond Use Date” or BUD is defined as the maximum time that you can store a syringe before it is used. It takes into account
both chemical stability and sterility concerns. When there is no supporting stability or sterility testing data BUD is based on USP
<797> guidelines which are the standards for sterile and non-sterile compounding.
4
USP 31-NF 26 Revisions Bulletin, <797> Pharmaceutical Compounding-Sterile Preparation: 2012.
5
th
Handbook of Injectable Drugs™, 18 ed. 2015. (Stat!Ref online). American Society of Health-System Pharmacists. Bethesda,
Maryland. Accessed October 7, 2016.
6
Diprivan [Product Monograph], Mississauga, ON: AstraZeneca Canada, Inc.; July 30, 2012.
7
KNMG/KNMP: Guidelines for the Practice of Euthanasia and Physician-Assisted Suicide 2012. Royal Dutch Medical
Association/Royal Dutch Pharmacists Association, The Hague, Netherlands.
8
Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale; Validity and Reliability in Adult Intensive Care
Unit Patients. Am J Resp Crit Care Med 2002;166(10); 1338-1334.
9
Medical Aid in Dying: 11/2015 Practice Guidelines. Collège des mèdecins du Quèbec:; Ordre des pharmaciens du Quèbec;
Ordre des infirmières et infirmiers du Quèbec, November 2015. Bibliothèque et Archives nationales du Quèbec; Library and
Archives Canada.
10
th
Davis’s Drug Guide For Nurses, 15 ed. 2015. F.A. Davis Company, Philadephia, PA.
11
Medical Assistance in Dying (MAID) Pharmacy Protocols, June 22, 2016. Alberta Health Services.
2
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Intravenous Drug Protocol Monographs
Addendum to the Intravenous Drug Protocol Monographs
Richmond Agitation–Sedation Scale (RASS)
Score
Term
Description
+4
Combative
Overtly combative or violent; immediate danger to staff
+3
Very agitated
Pulls on or removes tube(s) or catheter(s) or has aggressive behavior
toward staff
+2
Agitated
Frequent nonpurposeful movement or patient–ventilator dyssynchrony
+1
Restless
Anxious or apprehensive but movements not aggressive or vigorous
0
Alert and calm
Spontaneously pays attention to caregiver
-1
Drowsy
Not fully alert, but has sustained (more than 10 seconds) awakening,
with eye contact, to voice
-2
Light sedation
Briefly (less than 10 seconds) awakens with eye contact to voice
-3
Moderate sedation
Any movement (but no eye contact) to voice
-4
Deep sedation
No response to voice, but any movement to physical stimulation
-5
Unarousable
No response to voice or physical stimulation
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Oral Drug Protocol Monographs
Oral Drug Protocol Monographs
(drugs are listed in order of administration in the protocol)
Preamble
Patients may choose to take oral medications for medical assistance in dying, rather than
receive the intravenous drug protocol. The prescribing physician or nurse practitioner
(prescriber) must personally attend the patient during self-administration of the oral drug
protocol and must remain in attendance until death is confirmed.1
 The intravenous route is the recommended option, due to its more rapid onset of
activity and reduced incidence of complications.
 Intravenous access must also be established when the oral route is utilized, so that the
intravenous regimen can be administered as a standby option in the event the oral
regimen is ineffective.
 The prescriber and patient should agree on a pre-determined maximum period of time
to allow for the oral regimen to take effect, before deeming it unsuccessful and moving
forward with the administration of the back-up intravenous drug protocol. The
prescriber will record whether the back-up intravenous kit was administered, as well as
the number of hours after ineffective self-administration, on the Assessment Record
(Prescriber) form (in the section “Administration of Medical Assistance in Dying”).2
Note: Based on data from Oregon, the median time between ingestion and
unconsciousness is approximately 5 minutes (range 1-38 minutes) and the median
time between ingestion and death is 25 minutes (range 1- 48 minutes).3
 The patient must be capable of swallowing sufficient volumes of liquids (120 mL).
 Relative contraindications to the oral procedure include severe nausea, dehydration,
esophagitis or gastritis, and/or any significant gastrointestinal transit disorders that
would interfere with absorption.
 Where possible, the patient should not eat or drink 4 to 5 hours prior to the procedure
to improve the rate of absorption and decrease the risk of regurgitation or vomiting.
 Administration of anti-emetics beforehand is recommended to minimize the likelihood
of the patient vomiting, as the mixture’s taste is bitter and may be unpleasant.
 Many patients receive opioids at the end of their lives, which can slow gastrointestinal
transit time and result in longer absorption and distribution time that can delay the
effect of the oral regimen.
1a. Anti-emetic / Gastric Motility (Nausea Prevention)
Drug
metoclopramide 10 mg tablet



Blocks dopamine and serotonin receptors to prevent and treat nausea and vomiting,
and enhances gastric emptying and gastrointestinal motility.4
If patients are already on medications to control nausea and/or vomiting, these should
be continued right to the start of the procedure.
Contraindicated in hypersensitivity to metoclopramide, gastrointestinal hemorrhage,
mechanical obstruction, perforation, parkinson’s disease, history of seizures, or
pheochromocytoma (due to potential for precipitating hypertensive crisis).
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Oral Drug Protocol Monographs
Dose/route
Take 20 mg orally 1 hour prior to procedure.
Note: For patients with history of nausea, may consider 10 to 20 mg PO TID starting 24
hours prior to procedure.
 Onset of effect: 30 to 60 minutes5
 Peak effect: 1 to 2 hours5
Preparation
Supplied as metoclopramide tablets 10 mg x 2.
Monitoring


May cause drowsiness, confusion, and/or extrapyramidal symptoms such as tremors,
restlessness and dystonia.5
While the risk of adverse effects with a single dose is low, the effects may be additive
if patients are frail, elderly, or on other medications that have similar effects.
Counseling Patient and Family

Inform patient that the medication will assist in preventing symptoms of nausea and
vomiting.
1b. Anti-emetic (Nausea Prevention)
Drug
ondansetron 8 mg tablet




Selective 5-HT3-receptor antagonist that blocks serotonin to prevent and treat severe
nausea and vomiting.5
Ondansetron is used together with metoclopramide to prevent nausea and vomiting,
but it lacks the pro-motility effects of metoclopramide.
Contraindicated in patients with hypersensitivity to ondansetron or in concomitant use
of apomorphine.
Caution when given with other serotonin agents, due to the risk of serotonin
syndrome.
Dose/route
Take 8 mg orally 1 hour prior to procedure.
 Onset of effect: approximately 30 minutes5
 Peak effect: 1 to 2 hours5
Preparation
Supplied as ondansetron tablet 8 mg x 1.
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Oral Drug Protocol Monographs
Monitoring


May cause headache, fatigue, drowsiness; serotonin syndrome (agitation, tachycardia,
flushing, tremor, rigidity).5
While the risk of adverse effects with a single dose is low, the effects may be additive
if patients are frail, elderly, or on other medications that have similar effects.
Counseling Patient and Family

Inform patient that the medication will assist in preventing symptoms of nausea and
vomiting.
2. Anxiolytic
Drug
LORazepam 0.5 mg sublingual tablets


Benzodiazepine that reduces anxiety symptoms.
Contraindicated in hypersensitivity to benzodiazepines or history of paradoxical
reactions to benzodiazepines.
Dose/route
Take 0.5 to 2.0 mg sublingually or orally 5 to 10 minutes prior to procedure, if needed for
anxiety. May give additional dose, if required.
Note: Avoid over-sedating patient, as this can impair their ability to swallow the oral comainducing compound.
For benzodiazepine-naïve or debilitated patients, 0.25 mg is recommended.
 Onset of effect: unknown1
 Peak effect: 1 hour1
Preparation
Supplied as lorazepam sublingual tablets 0.5 mg x 8
Monitoring


May cause drowsiness, dizziness, and/or paradoxical agitation especially in frail and/or
benzodiazepine naïve patients.5
Observe for alleviation of anxiety, comfort and readiness to proceed with the
procedure.
Counseling Patient and Family

Inform patient that this medication will help relieve anxiety around the procedure and
help the patient relax.
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Oral Drug Protocol Monographs
3. Coma-Inducing Agent
The coma-inducing agent is a combination of phenobarbital (a barbiturate) and chloral
hydrate (a sedative), plus or minus morphine (an opioid), in an oral suspension.
 The recommended regimen is to include all three medications (phenobarbital, chloral
hydrate, and morphine).
 The regimen MUST at least contain phenobarbital and chloral hydrate powders, as
ingredients.
 Morphine may be omitted if the patient has a significant morphine allergy
(anaphylaxis), has experienced a severe adverse reaction to morphine (neurotoxicity),
or is already taking significant doses of opioid medications.5
Drugs (Components of the Oral Suspension)

phenobarbital - a barbiturate used to induce a coma-like sedative state.

chloral hydrate - a general CNS depressant that also depresses cardiac
o Onset of effect: 5 minutes5
o Peak effect: 15 minutes or greater for CNS depression5
contractibility, and has sedative and anti-anxiety effects.
o Onset of effect: 10 to 20 minutes5
o Peak effect (time to sedation/loss of consciousness): 30 to 60 minutes5
Note: Chloral hydrate is a gastric irritant, and may cause pain and discomfort for
patients who have mouth ulcers, esophagitis or gastritis.5 This irritant property may
be a relative contraindication to using the oral route. However, if the patient still
prefers using the oral route, pre-treatment with a local anesthetic product such as
lidocaine endotracheal spray, lidocaine viscous or benzocaine spray may be
considered.

morphine - an opioid agonist which is also a generalized CNS depressant and an
analgesic.
o Onset of effect: variable, but generally 30 minutes for oral route5
o Duration of effect: 3 hours at usual doses5
Preparation/Storage/Stability



Please refer to compounding formulation sheet for information on how to prepare the
suspension.
Store at room temperature
Stable for 72 hours at room temperature6
Administration



The patient must be sitting upright and in bed when they take the suspension - this
would prevent the situation in which they are unable to make it back to bed in time.
Alternatively, the oral suspension may be administered via a feeding tube. The tube
must be flushed post-administration with 60 to 90 mL of water.
Shake well prior to administration; mixing of contents may need to be repeated if
patient takes a long period of time to consume the suspension.
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Oral Drug Protocol Monographs



It is ideal to ingest the entire dose within 4 minutes, before the patient becomes
extremely drowsy or unconscious; the risk of a failed procedure or a prolonged dying
period increases if the patient is unable to take the full amount.
Do not allow the patient to consume the drink through a straw, as this will generally
take longer, and may increase the risk of the medications taking effect before the
whole dose is consumed.7
Because this mixture is bitter and can cause a burning sensation, a room temperature
non-fat liquid such as non-carbonated soda, fruit juice, liquor of patient’s preference,
or water should be taken after ingestion.
Monitoring



The period of time between administration and time of death varies from person-toperson, but in a vast majority of cases, unconsciousness occurs within 5 minutes and
death within 30 minutes.
Monitor closely for signs of nausea, reflux, regurgitation, and vomiting.
Assess for signs of death, including cessation of respirations, heart sounds, pulses,
response to tactile stimuli and pupil response.
Counseling Patient and Family





This medication will cause the patient to first lose consciousness and then their
breathing may slow down significantly or stop; it is normal for the heart to continue to
beat for a while after the breathing has stopped.
The effect of the medication may take anywhere from a few minutes to a few hours to
work.
Most people will be unconscious within 5 minutes and pass away in less than 30
minutes.
Since the time of onset of death is unpredictable, the prescriber and patient should
agree on a pre-determined maximum period of time to allow for the oral regimen to
take effect. If the maximum period of time is reached and the oral drug protocol is
deemed unsuccessful, administration of the back-up intravenous drug protocol would
then proceed.
The physician is required to perform a physical assessment of the patient to confirm
death.
4. Anti-emetic (Nausea and Vomiting Treatment)
Drug
haloperidol 5 mg/mL


Butyrophenone used to treat severe nausea and vomiting.
Contraindicated in documented hypersensitivity to haloperidol or at high risk of
extrapyramidal reactions.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Oral Drug Protocol Monographs
Dose/route
Administer 5 mg (1 mL) subcutaneously, or IV over 1 minute, as needed for nausea and
vomiting;
May give additional 5 mg subcutaneously or IV dose x 1, if required.
 Onset of effect: unknown5
 Peak effect: unknown5
Preparation
Withdraw 5 mg (1 mL) into a 3 mL syringe.
 Beyond use date/Stable for48 hours at RT when prepared in a laminar flow hood or 24
hours at RT when prepared on a countertop.8,9 Protect from light and store at
controlled room temperature.10
Administration
Give subcutaneously or IV direct.
 Compatible with fentanyl, HYDROmorphone, lidocaine, methadone, midazolam,
morphine, ondansetron, proPOFol, SUFentanil.5,10 For additional compatibility
information contact pharmacy.
 Flush with normal saline to ensure full dose is delivered into vein.
Monitoring

Observe for alleviation of nausea and vomiting.
Counseling Patient and Family

Inform patient the medication will assist in stopping symptoms of nausea and
vomiting.
1
Professional Standards and Guidelines- Medical Assistance in Dying. June 23, 2016(revised September 9, 2016). College of
Physicians and Surgeons of British Columbia. Accessed Oct 10, 2016 at http:/www.cpsbc.ca/file/pdf/PSG-Medical-Assistance-inDying.pdf.
2
British Columbia Medical Assistance in Dying form: Assessment Record (Prescriber).
3
Dunn P, Reagen B (co-editors). The Oregon Death With Dignity Act: A Guidebook for Health Care Professionals. 2008.
4
Lexicomp Online®, Hudson, Ohio: Lexi-Comp, Inc. August 5, 2015. Accessed October 15, 2016.
5
Swarte NB. Guidelines for an acceptable euthanasia procedure. Best Pract Res Clin Obstet Gynaecol 2001;15(2):313-21.
6
USP –Revision Bulletin, <795> Pharmaceutical Compounding-Non-sterile Preparations. January 1, 2014.
7
KNMG/KNMP Guidelines for the Practice of Euthanasia and Physician-Assisted Suicide. August 2012.
8
“Beyond Use Date” or BUD is defined as maximum time that you can store a syringe before it is used. It takes into account
both chemical stability and sterility concerns. When there is no supporting stability or sterility testing data BUD is based on
USP<797> guidelines which are the standards for sterile and non-sterile compounding.
9
USP 31-NF 26 Revisions Bulletin, <797> Pharmaceutical Compounding-Sterile Preparation: 2012.
10
th
Trissel, LA. Trissel’s stability of compounded formulations, 5 ed. 2012. American Pharmacists Association. Washington, DC.
BC Pharmacy Protocols for Medical Assistance in Dying, 2016 12 05
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Suggested Compounding Procedure
Suggested Compounding Procedure (Oral Coma-Inducing Suspension)
Medical Assistance in Dying
PREPARATION:
Oral Coma-Inducing Compounded Suspension
INDICATIONS: Medical Assistance in Dying - for oral self-administration
INGREDIENTS:
phenobarbital powder USP
chloral hydrate powder USP
morphine sulfate powder USP
Ora-Plus®/ORA-Sweet® 50/50
OR if to be given by enteral tube use:
Distilled water
20 g
20 g
3 g (if required)
qs to 120 mL (suspending agent)
qs to 120 mL
EQUIPMENT:
Enclosed weighing scale - if possible
Mortar and pestle
Conical graduate- 180 mL
Stirring rod
250 mL amber glass bottle
Preparation:
1. Prepare the compound in an area designated for compounding of prescriptions that is clean and uncluttered. 1
2. Assemble ingredients and equipment required for compounding.
3. Personal preparation – Wash hands and don personal protection items including a clean gown, powder-free
gloves, mask, beard guard (if necessary) and eye protection.
Procedure:
1. Weigh the powders within the enclosed scale and transfer into the mortar and pestle.
2. Triturate the powders well. Filter through a sieve into a large conical graduate.
3. Slowly add the suspending liquid to the powders mixing gently to avoid aerosolizing the powders and qs to 120
mL.
4. Transfer suspension to a 250 mL amber GLASS bottle for dispensing.
5. While USP <795> standards would allow a 7 day beyond use date (BUD) at room temperature, it is suggested to
give it a 72 hour expiry date to ensure prompt use of the suspension.
6. Apply patient – specific label.
7. Labels with SHAKE WELL and WARNING: Contains LETHAL DOSE
SHAKE WELL
WARNING: Contains LETHAL
8. Decontaminate the compounding area after the procedure is complete.
DOSE
EXPIRY DATE: 7 day beyond use date at room temperature
Expires: 72 hours from time
of dispensing
REFERENCE:
(Adapted from P-C-M Suspension Formulation, Union Avenue Compounding Pharmacy, Tacoma WA)
1
US Pharmacopeia Convention (USP) General Chapter <795> pharmaceutical compounding - non-sterile preparations. USPO 39.
Rockville, MD: USP; 2016.
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Suggested Pharmacy Inventory Lists
Suggested Pharmacy Inventory Lists (Per Kit) for IV and Oral Regimens
Medical Assistance in Dying
Inventory List (Per Kit)– IV Regimen
Quantity
2
2
2
2
1
Drug/Equipment
midazolam 1 mg/mL (10 mL vial)
20 mL syringe
18G needle
syringe label (for identifying medication and sequence)
5x8 plastic bag
1
1
1
1
1
lidocaine 2% (20 mg/mL) (5 mL polyamp)
3 mL syringe
18G needle
syringe label (for identifying medication and sequence)
5x8 plastic bag
1
4
4
1
4
1
proPOFol 10 mg/mL (100 mL vial)
30 mL syringe
18G needle (if required)
Vented dispensing pin (if available)
syringe label (for identifying medication and sequence)
10x10 plastic bag
25
1
1
1
1
1
1
phenobarbital 120 mg/mL (1 mL glass ampoule)
sodium chloride 0.9%
(10 mL vial x 3)
60 mL syringe
18G needle
Ampoule breaker device
Filter disc (5 microns)
syringe label (for identifying medication and sequence)
6x10 plastic bag
4
1
1
1
1
rocuronium 10 mg/mL (5 mL vial)
30 mL syringe
18G needle
syringe label (for identifying medication and sequence)
5x8 plastic bag
4
1
sodium chloride 0.9% (10 mL pre-filled syringes x 4)
6x10 plastic bag
6
1
alcohol swab
5x8 plastic bag
3
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Suggested Pharmacy Inventory Lists
Medical Assistance in Dying
Inventory List (Per Kit) – Oral Regimen
Quantity
2
1
2
Drug/Equipment
metoclopramide 10 mg tablet
ondansetron 8 mg tablet
4x4 plastic bag
2
2
2
2
2
2
1
haloperidol 5 mg/mL IV (1 mL vial)
3 mL syringe
18G needle
25G needle (for SC administration)
alcohol pad
syringe label (for identifying medication and sequence)
5x8 plastic bag
8
1
LORazepam 0.5 mg SL tablet
4x4 plastic bag
Initials
Compounded Oral Suspension – 120 mL
20 g
20 g
3g
phenobarbital powder
chloral hydrate powder
morphine sulphate powder (if required)
ORA-Plus® / ORA-Sweet (50/50)
qs to 120 mL
Distilled water
1
250 mL glass amber bottle
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Suggested Inventory List for IV Insertion Equipment and Additional Supplies
Suggested Inventory List for IV Insertion Equipment and Additional Supplies
Required by Practitioner for Medication Administration
Medical Assistance in Dying
Inventory List (Per Kit) – IV Regimen
Quantity
2
2
2
2
2
2
Equipment
Blue pad
20 gauge IV cannula
22 gauge IV cannula
24 gauge IV cannula
IV extension set with positive pressure cap
Securement dressing (e.g., IV StatLock®, 3M™ Tegaderm™ I.V.
Advanced)
2 of each
2
6-10
4
1
4
4
1 roll
1
Gloves – large, medium and small
Tourniquet
Alcohol swab
Chlorhexidine with alcohol swabs
Local anesthetic cream (e.g., Emla™)
Transparent film dressing (e.g., Tegaderm™)
2x2 gauze
Tape
Scissors
8
1
5
5
2-10
Sodium chloride 0.9% 10 mL pre-filled syringe
Sodium chloride 0.9% 50 mL minibag*
10 mL syringe (for sodium chloride)*
Blunt fill needle*
Syringe caps
1
1
Initials
Garbage bag
(small paper bedside one, hospital type)
Small sharps container
Additional Supplies required by Practitioner for Medication Administration (Per Kit) – IV Regimen
Quantity
Syringes
1
5
2
1
Needles
9
Accessories
1
1
Equipment
Initials
60 mL syringe
30 mL syringe
20 mL syringe
3 mL syringe
18G needle
Vented dispensing pin (for proPOFol only) – if available
Ampoule breaker (for phenobarbital IV only)
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Suggested Inventory List for IV Insertion Equipment and Additional Supplies
1
9
1
2
4
Filter disc (5 microns) (for phenobarbital IV only) – if available
syringe label (for identifying medication and sequence)
10x10 plastic bag
6x10 plastic bag
5x8 plastic bag
Additional Supplies required by Practitioner for Medication Administration (Per Kit) – Oral Regimen
Quantity
Equipment
Syringes
2
3 mL syringe
Needles
2
18G needle
2
25G needle (for SC administration)
Accessories
2
Alcohol pad
2
syringe label (for identifying medication and sequence)
1
5x8 plastic bag
3
4x4 plastic bag
* If prefilled sodium chloride 0.9% syringes are not provided.
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