Completing the Path to Aid in Dying

Medical aid in dying is legal in nine states and the District of Columbia, covering about 22% of the U.S. population. In order to legally qualify, a patient must have (or obtain) residency in one of those states, be over 18, have a terminal illness with a prognosis of less than six months to live (confirmed by two physicians), and have the capacity to make their own medical decisions.

• Step one: Finding doctors who provide medical aid in dying
  • Be sure to ask all of your primary and specialty doctors about their willingness to consider your request. Ask specifically if they will act as the attending/prescribing or the consulting/confirming physician for medical aid in dying. (Note: Many doctors do not participate because they are not experienced with this new aspect of end-of-life care. If that’s the case, please let them know that the Academy’s physicians will work with them on the details, from the law to the medications used. There is no charge for this.)
  • Hospices: We strongly encourage patients who are not yet receiving hospice care to contact their local hospice and begin this care. Hospices share the Academy’s goal of comfort at the end of life. Many hospices will provide consulting/confirming doctors for patients who qualify for medical aid in dying, and some will provide attending/prescribing doctors. When contacting a hospice, ask specifically if their doctors participate in either role. As well, in many but not all geographic areas, the Academy can recommend a hospice that provides consulting and/or attending physicians. If you are already in hospice care, please ask if their doctors participate as consulting and/or attending physicians.
  • The Academy’s Patient-to-Doctor Referral System: If you have completed the above and cannot find a participating doctor, please fill in the Academy’s intake form and we will do our best to find a doctor who can work with your request.

• Step two: Become eligible for medical aid in dying (Eligibility does not require you to ever take the medications; it simply gives you this legal option.)
  • Once you have found a participating doctor, the next step is to make a first verbal request and have that documented in your medical record. This begins the legally mandated 15-day waiting period (20 days in Hawaii; can be bypassed in Oregon under certain circumstances). Note: Many patients start this process late and may become too ill to complete the waiting period. Please work with your doctor to take the first request as soon as possible (it can be made by telemedicine).
  • As soon after the waiting period as possible, make a second verbal request to the aid-in-dying attending physician.  
  • During the waiting period:
    • See the consulting (second opinion) doctor. If that doctor agrees that you qualify for aid in dying, encourage her to send the appropriate forms verifying this to the attending physician.  

• Step three: Planning and Preparing
  • Once you have completed the process and become eligible for medical aid in dying, ask your attending doctor and/or hospice providers for continued guidance, planning, and monitoring about when (or if) to take the medications. 
  • Aid in dying medications can only be taken if the patient has: 
    • The capacity to make their own medical decisions. This includes:
      • Knowing the illness they have and that they are dying;
      • Knowing that taking aid-in-dying medications will result in their rapid death 
      • Understanding other options, i.e. continued hospice care with aggressive symptom management while awaiting a “natural” death.
      • Having the ability to communicate their understanding of the above (if speech has been lost, other methods such as head nods, writing, and other clear communication techniques can be used)
      • The ability to “self-administer” the medications (swallow, administer via feeding tube or rectal catheter). (NOTE: Family members, nurses or doctors can mix the medications and bring them to the patient, but the patients must take the medications themselves.)
      • The ability to physically absorb the medications (i.e. have a functioning stomach and upper intestinal tract, and/or a feeding tube into the stomach, and/or an intact rectum to use a rectal catheter).
      • NOTE: Aid-in-Dying medications cannot, by law, be injected by a syringe (into a muscle, an IV, a Port, or other injection).
      • The Academy strongly believes that having solid support for the patient and family or loved ones on the day of aid in dying is essential. Many hospices provide for their staff to be present on that day, and the Academy strongly recommends this. The presence of a doctor, nurse, social worker, chaplain, or trained/experienced aid-in-dying volunteer can be an essential source of comfort. It also provides the family with the freedom to be with their loved one rather than distracted by the technical details of aid in dying (mixing medications, checking for side effects or complications, worrying about breathing patterns near death, and having to conclude when the patient has moved from a deep coma to death).     

• One week before the aid-in-dying date:
  • Notify your care providers: Let hospice and your attending doctor know that you are planning to take aid in dying medications, and when. 
  • Notify your attending doctor: If you have or develop any difficulty with swallowing, nausea, vomiting, or significant constipation. These issues may need to be managed before you take aid-in-dying medications.  
  • Practice swallowing: At least every other day, practice swallowing 4 ounces (1/2 cup) of slightly thickened liquids (the consistency of Ensure or other liquid food supplements) in two minutes. This practice helps 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: Be sure your bowels are moving regularly, at least every other day, even if you are eating very little. The Academy recommends that if you are planning to take aid-in-dying medications by mouth, you should try to continue to eat at least small amounts of food 2-3 times a day. This ensures your digestive tract continues to function and can easily absorb the aid in dying medications. 
  • Medications: Continue all of your usual medications unless you receive other specific instructions.  
  • Finalize plans for your remains: Contact a local mortuary and make arrangements for your body to be removed from the home after your death. Do not wait until the day of your death to make these arrangements.
  • Death Certificate: Your underlying disease will be listed 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 after being signed by your doctor.  

• Step four: The aid in dying procedure
  • Preparing the medications.
    • For an aid-in-dying death attended by a professional, the Academy has prepared this short video “Aid in Dying at the Bedside” for both the family and attending professional or volunteer.  Instructions for mixing the medications are at 2:30 into the video.
      
• Step Five: Bereavement
  • Your hospice will have specific bereavement counseling available for all who were close to the patient. The hospice social worker will have details about this.
  • For patients who are not in hospice care, most hospices will still provide bereavement counseling for these patients’ loved ones. Contact a local hospice to ask about this or obtain a referral for bereavement counseling.

NOTE: The American Clinicians Academy on Medical Aid in Dying is available to answer questions from patients, their loved ones or care providers, and professionals who might have any questions about the process. Please contact us at [email protected] with any questions or concerns.

The American Clinicians Academy on Medical Aid in Dying provides this service free of charge, but we welcome donations to support our activities.