Patient and Family Instructions
for an aid-in-dying death
not attended by a medical professional
Planning: Once you have completed the process and become eligible for medical aid in dying, ask your medical providers for continued guidance, planning, and monitoring about when to take it. Aid in dying can only be taken if the patient has:
- Capacity to make medical decision for oneself:
- Understands other options
- knows that taking aid in dying medications results in death
- can communicate this understanding
- The ability to self-administer (swallow, or use a PEG tube or rectal catheter)
- The ability to physically absorb the medications (patients with bowel obstructions cannot do so).
Your attending doctor or hospice can help guide you.
Prescription: Please do be sure that your doctor has the most current prescribing information, as there are older and less effective versions of prescriptions that sometimes get mistakenly utilized. Please don’t hesitate to contact, or have your doctor contact [email protected] for further information.
Medication delivery: A pharmacist will call and arrange for payment and delivery of medications. We suggest you ask the pharmacy to hold the prescription until the week you plan to use it. This will keep these dangerous medications safely out of reach and prevent the disposal of medications and charges for them if they are not used.
Attendance: Having good support for yourself and your family or loved ones on the day of aid in dying is very important. Many hospices will allow their staff to be present before and after taking the medications. A nurse, social worker or chaplain at the time of aid in dying can be an essential source of comfort and experience.
One week before:
- Notify your care providers – Let hospice and your attending doctor know that you are planning to take aid in dying medications, and when. It is especially important to notify your attending doctor promptly if you are having any difficulty with swallowing, any nausea or vomiting or significant constipation. These issues may need to be managed before you take aid in dying medications.
- Practice swallowing – Daily, practice swallowing 4 ounces (1/2 cup) of slightly thickened liquids (the consistency of “Ensure” or “Mylanta”) in two minutes, from a short glass cup (plastic can bind the medications). This practice can help you feel confident that you can swallow all the aid-in-dying medications within the required two minutes, so that you don’t fall asleep before you finish taking the entire dose.
- Bowel care – make sure your bowels are moving easily and regularly, at least every other day, even if you are eating very little. It is also recommended that you try to continue to eat at least small amounts of food 2-3 times a day. This ensures your digestive tract continues to move and can easily absorb the aid in dying medications.
- Medications – Continue all of your usual medications unless you receive specific other instructions.
- Finalize plans for your remains – let you family, or loved ones, and providers know what you want done with your remains. You should contact a local mortuary and make your arrangements. Your death certificate will cite your underlying disease as the cause of your death and will make no mention of medical aid in dying. The death certificate will be available from the mortuary or institution after being signed by your doctor.
24-hours before taking aid-in-dying medications:
- Continue all of your usual medications unless you received specific other instructions.
- Starting after dinner the night before you take aid-in-dying medications:
- Do not eat any solid foods.
- Water and other clear, non-fatty fluids are fine.
- Continue to not eat any solid foods on the day of aid in dying. No breakfast or lunch on that day, only clear liquids.
On the day of aid in dying: (Please also see the Academy video — Video Enactment of Aid in Dying at the Bedside
Medication Preparations: (Please also see the Academy video — Instructions for Mixing Aid-in-Dying Medications.)
- Choose a secure, well lit, uncluttered surface to mix the medications. Any people present should be encouraged to stay away from the area while preparations are in process. These are dangerous medications. Pets should be secured, and children should be closely supervised.
- Cover the surface with a layer of paper towel. Medical gloves may be helpful but are not required. Have all supplies ready, including a small bottle of filtered apple juice, a short glass cup, and a sealed plastic container or bag for garbage.
- Before opening each bottle, gently tap the bottom on the counter so that the powder settles away from the lid.
- Open bottle, away from your face, and slowly fill roughly halfway with clear apple juice. Put the lid back on the bottle and shake vigorously until all the powder appears dissolved. Finally, fill the bottles up to the neck, being careful not to overfill and spill, and secure the lids. Again, shake the bottle vigorously to suspend all the powder particles.
- Once the medications have been mixed, they can be brought to the patient’s bedside in the glass bottles. Shake capped bottles thoroughly one more time, then carefully pour the liquid suspension into a short glass cup just before self-ingestion.
- After the ingestion: Promptly and thoroughly clean the used short glass cup and the bottles. Dispose of the emptied and cleaned bottles in a sealed plastic bag or container.
Procedure for taking aid-in-dying medications:
PROTOCOL 1, if digoxin is given separately from the other medications (it will be in a separate bottle.)
Step 1. To prevent nausea and vomiting, take anti-nausea medications: (most commonly ondansetron/Zofran and metoclopramide/Reglan), at least 30 minutes before any other medications. These medications do not cause sedation, and their anti-nausea effects last 8-12hrs.
Step 2. Take Digitalis: This medication is taken 30 minutes before the final sedative medications, so it can be absorbed more thoroughly. Digitalis slows and stops the heart, but it does not start to affect the heart for approximately an hour. Digitalis does not cause any sedation and the patient should feel no effect from taking it. This is the first lethal medication (there is no turning back once the digitalis is taken), and this must be followed by the final sedative medications within 30 minutes.
Step 3. Wait 30 minutes after digitalis and take the final sedating aid-in-dying medications: Morphine, diazepam, and amitriptyline. The final sedating medications are mildly bitter and can cause a slight burning sensation. This resolves within a few minutes; a few sips of water or clear juice can help. Rare patients have a severe burning sensation: For this reason, we recommend keeping iced fat-free sorbet or a non-fat ice popsicle at the bedside, to relieve the burning for the few minutes before the patient becomes unconscious.
These medications quickly cause deep sleep, within 3 to 10 minutes, soon followed by coma, and then respiratory suppression and death. While in a coma but still breathing, the patient has no conscious awareness and is not suffering. It is very common for patients to have sudden deep, gasping breaths before dying. These are reflexes and the patient does not feel discomfort from these breaths, but the family should be prepared so as not to be surprised or concerned. If breathing does not stop completely and lead to death in the first hour, then the digitalis and amitriptyline stop the heart, usually within the next 2 to 5 hours.
PROTOCOL 2, if digoxin is mixed in with the other medications (one bottle of powders will be provided).
Follow the steps above, but skip Step 2.
- Families should call hospice and the mortuary to notify them of the death. If the patient is not cared for by hospice, the attending physician who wrote the prescription should be contacted.
- Mortuaries commonly come within 30 to 90 minutes to collect remains, and will need basic information (name, address, birth date, weight, height, stairs into the home, name of hospice).
- Hospices offer a nursing visit for support after a loved one dies, to instruct about disposal of medications. Hospices also offer ongoing bereavement support of many types, free of charge.
~ Please promptly call your hospice or your attending provider with any concerns or questions.