Please feel free to share this questionnaire with other nurses involved with aid in dying patients. The more information we have, the better.

Please check the yes/no boxes. Feel free to add details in the field below them.
All information is anonymized, no names or organizations will be publicly identified.

When you click the SUBMIT button, if you don’t see an acknowledgment page, it means you haven’t filled in all the required yes/no boxes. Please fill them in and hit SUBMIT again.

Thank you!!

Nursing Questionnaire

What state do you work in? Please include your Zip Code.(Required)
Do you work for a hospice?(Required)
Did you receive education from your employer/organization within the last year, about caring for patients considering aid in dying?(Required)
Are you permitted by your employer/organization to initiate or “bring up the topic” of aid in dying with patients?(Required)
Do you have internal resources from your employer/organization to give to patients to help them find participating aid-in-dying physicians? ?(Required)
Do you have internal sources of information from your employer/organization to give to patients and families to prepare them for the aid-in-dying day?(Required)
Do you communicate pertinent nursing assessments (eg – swallowing, nausea/vomiting, mental capacity) directly to the attending/prescribing MD (the MD who writes the Rx for aid in dying medications)?(Required)
Do you keep patients informed about their "window of opportunity" for taking aid-in-dying medications, eg – if/when they are beginning to actively die, lose mental capacity or ability to swallow?(Required)
Are you permitted by your employer/organization to insert a rectal catheter for patients to use for aid in dying?(Required)
Are you permitted by your employer/organization to attend the aid-in-dying day?(Required)
Are you permitted by your employer/organization to instruct families about how to mix aid-in-dying medications safely?(Required)
Are you required by your employer/organization to leave the room during ingestion?(Required)