Ethics Consultation Request Form – American Clinicians Academy on Medical Aid in Dying

Consultations will be considered from clinicians licensed in states/jurisdictions which have legalized medical aid in dying, or from clinicians in other states considering referring a patient to an aid-in-dying state.

Date(Required)

State where Clinician and Patient Reside(Required)

Name of Requester(Required)

First Last

Does the requester wish to remain anonymous in our recommendation document?

Urgency of consultation(Required)

Your role with the patient and/or situation(Required)

Email(Required)

Phone

Does this request for consultation concern?

Patient Care Concerns

Institutional Concerns

Risk Management Concerns

Med-Legal Concerns

Technical or Biomedical Concerns

Prognosis Questions

Patient Eligibility Questions

Self-Administration Questions

Please Summarize the Ethical Questions and Issues (and/or upload a file below). Please do not include information that might identify the patient. When relevant, please include: Age; gender; diagnosis; prognosis; location (home? hospital? SNF? other?); hospice involved? caregivers? estimated illness trajectory; psychosocial and family elements; decisional capacity; active treatments of terminal disease?

Upload Files if Needed (NOTE: Only PDFs accepted. If you have a Word file, or JPG or other photo, please save these in PDF format. Thank you.)

Accepted file types: pdf, Max. file size: 50 MB.

Upload a Second File if Needed (PDF only)

Accepted file types: pdf, Max. file size: 50 MB.

Once this form is submitted, an Ethics Team Leader will contact you within 24 to 48 hours to confirm receipt and see if further information is needed. Thank you!