Aid-in-Dying Case Data Filing – American Clinicians Academy on Medical Aid in Dying

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.

Date (of filing this form)*
MM slash DD slash YYYY
Clinician's Practice Zip Code*
Clinician's state for this death report (select from dropdown menu)*
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*
MM slash DD slash YYYY
Patient Zip Code*
Patient age*
Gender*
Terminal Diagnosis*
Medications Taken (select one)*
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)*
How were the medications mixed and taken?*
If "other" mixture and/or volume, please describe below
Were the medications mixed with simple syrup?*
Other than simple syrup, was a taste or anti-bitterness or anti-burning additive used in the medications?
If additive used, please list Ingredients and dosages (if known). If unknown, please state that.
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)*
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/
Any untoward or unexpected complications?
Present for the aid-in-dying day: (Select one or more--use control or command key if needed)*
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.