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 Contact NHappointment@northernhealth.ca 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: 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 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 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 metoclopramide, ondansetron, haloperidol Anxiolytic lorazepam Coma Inducing preparation 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 Delete bullet one

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 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

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

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

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 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 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 Immediate cause of death = medical assistance in dying 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: kirsten.thomson@northernhealth.ca Phone: 250-645-6417 Fax 250-565-2640 update