Patient to End-Of-Life Doula or Bedside Attendant Intake Form – American Clinicians Academy on Medical Aid in Dying

Over the many years that the Academy and its clinicians have been providing aid-in-dying care, we have found that having an experienced attendant at the bedside, in the days before and during the aid-in-dying procedure, is crucial.

Patients who have knowledgeable attendants have more peaceful deaths, and their loved ones have less complicated grief. Having a trained, knowledgeable person throughout the process and at the bedside helps prevent complications, frees loved ones from having to take on this complex clinical role, and ensures that patients safely have the peaceful death they so deeply desire. The preparations and procedures around aid in dying can be complex and more easily managed by a knowledgeable clinician, rather than a stressed-out but well-intentioned loved one. And, well supported loved ones who don’t have to manage medications or make clinical decisions, can keep their attentions on each other more fully during these tender moments.
There are many trained professionals who can help provide this care. Ask your prescribing doctor about their availability to attend. Also, be sure to ask your hospice if they allow their nurses and other staff to be present. Hospices have a wide variety of policies, so be sure to ask specifically about what their staff can and can’t do to support you and your loved ones.
There are also end-of-life doulas experienced with aid-in-dying care who provide this service.
Many states have trained volunteers who can be there for this important day.

If your hospice staff or doctors cannot attend on your aid-in-dying-day, or if you feel you need further support, fill out the form below for a referral to an Academy-trained and verified bedside attendant.

Patient Name*
First Last
Date filling out this form
MM slash DD slash YYYY
Patient is a resident of a state where medical aid in dying is legal, or is moving to such a state.*
- Yes
Patient has been diagnosed with a terminal illness, and can make their own medical decisions*
- Yes
Terminal Illness (please be specific, not just "cancer," etc.)*
Age*
Please enter a number from 18 to 120.
Patient's address*
Street Address City State / Province / Region ZIP / Postal Code
Best Phone # to reach patient*
Best email to reach patient*
Person filling out this form (if not the patient)
First Last
If not the patient, please let us know your relationship to the patient
Best email to reach person filling out this form
Best phone number to reach person filling out this form
Other Contact (just in case we have difficulty contacting you)*
First Last
Other contact's relationship to the patient*
Other Contact's Phone Number*
Other Contact's email*
Is this patient enrolled in hospice care*
- Yes
- No
Name of the hospice?
Does this patient have an attending/prescribing physician for medical aid in dying?*
- Yes
- No
Name of attending/prescribing physician for medical aid in dying
What steps has the patient taken for becoming eligible and/or planning for medical aid in dying? (Given a first verbal request? Still in the waiting period? Are the medications prescribed and waiting in the pharmacy? Are the medication in the home?)*
Urgency of Aid in Dying Consideration? Days, weeks, or months away? (If you are filling out this form for the patient and do not know the answer to this, please talk with the patient about it.)*
Does the patient have any special communication needs?
How did you learn about this form and referral system?
Consent to the ACAMAID Patient-to-Doctor Referral Program*
The patient has reviewed and agrees to ACAMAID's Referral Policy as noted below
ACAMAID and/or its representatives do not vet or review these end-of-life doulas or bedside attendants. We are not in any way responsible for the care they provide, and our role ends with the completion of the referral. By checking that you have consented to our referral system, you agree that you will not hold ACAMAID or its representatives responsible for any actions or omissions of the referred provider. ACAMAID's role is solely that of a referral system and not that of a health care provider. Submitting this form is your permission for us to share your information with potential end-of-life doulas or bedside attendants.