Aid-in-Dying Case Data Filing

Date (of filing this form)*

Clinician's Practice Zip Code*

Clinician's state for this death report (select from dropdown menu)*

Only if you are in Washington State (others skip the question): Are you affiliated with End of Life Washington?

Yes
No

Name of Practitioner Filing Report (confidential, and will be anonymized; not required, but helpful)

First Last

Email (for confirmation/clarification of data, if needed)*

Role of reporting clinician*

Date of patient death*

Patient Zip Code*

Patient age*

Gender*

Terminal Diagnosis*

Medications Taken (select one)*

Aid-in-Dying medication combination or dosage not listed above

Please check all prolonged-death risk factors for this patient (even if the patientdid not have a prolonged death). You can use the Academy's Red Flag Checklist tosee the full list of risk factors (https://www.acamaid.org/redfl agchecklist/) . Thisfi eld will be very helpful for us to know the eff ects of individual risk factors.Thank you!*

Risk factors for a prolonged death not in the checklist above

If you used high-dose DDMAPh, were the risk factors above the reason for that decision? (Please do not answer this question if you did not use high-dose DDMAPh.)

Yes, I used high-dose DDMAPh because of the risk factors.
No, I use high-dose DDMAPh in general now.
I used high-dose DDMAPh for another reason (please let us know in "Additionalrelevant information" at the end of this form).

Route of medication self-administration (select one)*

Volume of the medication mixture/suspension?*

If "other" mixture and/or volume, please describe below

Were the medications mixed with simple syrup?*

Sorbet and/or Popsicles Pre and/or Post Med Ingestion*

Medication Taste (when possible, please ask your patients about this immediately after medication ingestion).

Medication burning

Prior opiate exposure (no specific dosage, use judgment)*

Prior benzodiazepine exposure? (lorazepam, clonazepam, diazepam, etc.)*

Time to Sleep (in minutes)*

Time to Death (in minutes)*

Any untoward or unexpected complications?

Present for the aid-in-dying day: (Select one or more)*

Additional relevant information, if any.

Consent*

I agree to the privacy policy.

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.

Death Data Report

The Academy gathers specifics about different aid-in-dying medication regimens and their results, to analyze data, improve our knowledge base, and recommend specific protocols. Clinicians are encouraged to participate and anonymously file their results below (about 3 minutes to complete).

This patient data is solely for the American Clinicians Academy on Medical Aid in Dying. It will be anonymized and no practitioner or patient information will be available to the public, press, or health institutions — other than as anonymous aggregated data.