Date (of filing this form) *
MM slash DD slash YYYY
Clinician's Practice Zip Code * Name of Practitioner Filing Report (confidential, and will be anonymized; not required, but helpful)
Email (for confirmation/clarification of data, if needed) *
Role of reporting clinician * Attending/Prescribing Physician Hospice Doctor Physician, other P.A. or N.P. Hospice RN/LVN Hospice SW Hospice Chaplain Hospice Volunteer Non-hospice RN Aid-in-Dying Volunteer End-of-Life Doula Other Date of patient death *
MM slash DD slash YYYY
Patient Zip Code * Patient age * Gender * Female Male Transgender male Transgender female Non-binary (gender neutral) I don't know Terminal Diagnosis * Medications Taken (select one) * DDMAPh DDMA Other (clarify below) I don't know
D: Diazepam 1gm;
D: Digitalis 100mg;
M: Morphine 15gm;
A: Amitriptyline 8gm;
Ph: Phenobarbital 5gm
Aid-in-Dying medication combination or dosage not listed above Route of medication self-administration (select one) * Oral Feeding Tube Ostomy Rectal I don't know How were the medications mixed and taken? Oral: 4-ounce suspension Oral: 2-ounce suspension Oral: 2-ounce suspension, followed by a two-ounce liquid chaser Oral: 2-ounce suspension, unable to complete two ounces of liquid chaser Rectal, Ostomy, or Feeding tube: Any volume I don't know Was a taste or anti-bitterness or anti-burning additive used in the medications? Yes (if known, please list the additive used in the question below). No I don't know Ingredients and dosage of additive used (if known). It not known, please indicate that. Sorbet and/or Popsicles Pre and/or Post Med Ingestion No sorbet/popsicles used Sorbet/Popsicles immediately before med ingestion Sorbet/Popsicles immediately after med ingestion Sorbet/Popsicles immediately before and after med ingestion I don't know Not applicable (PEG or rectal administration) Medication Taste (when possible, please ask your patients about this immediately after medication ingestion). Not applicable (PEG or rectal administration) Taste was ok Mildly bitter Moderately bitter Very bitter Barely tolerable, I nearly had to stop drinking Not tolerable, I couldn't drink it all I don't know Medication burning Not applicable (PEG or rectal administration No burning Mild burning Moderate burning Severe burning Barely tolerable, I nearly had to stop drinking Not tolerable, I couldn't drink it all I don't know Prior opiate exposure (no specific dosage, use judgment) * Opiate naive Mild opiate tolerance Moderate opiate tolerance Major opiate tolerance I don't know Prior benzo exposure? (lorazepam, clonazepam, diazepam, etc.) * Benzo naive Mild benzo tolerance Moderate benzo tolerance Major benzo tolerance I don't know Time to Sleep (in minutes) * Time to Death (in minutes) * Risk factors for a prolonged death?
Examples: Gastroparesis or other GI disorder. For full Red Flag Checklist for Risk of Prolonged Death: https://www.acamaid.org/redflagchecklist/
This patient data is solely for the American Clinicians Academy on Medical Aid in Dying (www.ACAMAID.org). It will be anonymized and no practitioner or patient information will be available to the public, press or health institution other than as anonymous aggregated data.