Medical Assistance in Dying - Assessment Checklist

**<u>Medical Assistance in Dying Eligibility Assessment</u>** I have been asked to assess John Doe's eligibility for Medical Assistance in Dying (MAiD). John goes by Johnny. I met with him in his home on 1 November 2024. I introduced myself. I gained the patient's consent to use Heidi AI Scribe to generate this report and to record his voice. I have previously met John Doe so did not require him to show me photo ID. Johnny is retired. He is widowed. The following family member was present: Jane Doe (daughter) I explained that the law is not interested in whether or not a family member is supportive of or against MAiD but it is helpful for me to know. Jane expressed sadness but also understanding for her father's decision, stating that she has witnessed his prolonged suffering. **<u>Primary condition</u>** Metastatic pancreatic cancer, diagnosed 8 months ago, with widespread hepatic and peritoneal metastases. Prognosis is less than 3 months. **<u>Patient's story of disease and symptom progression</u>** Johnny explained that his symptoms started approximately 10 months ago with generalised fatigue and indigestion. He initially dismissed these as age-related but sought medical attention when he developed persistent abdominal pain and jaundice. A CT scan revealed a pancreatic mass, which was subsequently biopsied, confirming adenocarcinoma. Despite palliative chemotherapy attempts, the disease has aggressively progressed. He describes a significant decline in his quality of life over the last two months, including profound weakness, constant nausea, and an inability to participate in previously cherished activities. He feels he is a burden to his daughter and wishes to maintain some control over his final days. **<u>Previous medical history</u>** * Hypertension, controlled with medication * Type 2 Diabetes Mellitus, managed with diet and oral agents * Osteoarthritis, knees and hips **<u>Medications</u>** * Lisinopril 10mg daily * Metformin 500mg twice daily * Oxycodone 5mg every 4 hours as needed for pain * Ondansetron 4mg every 8 hours as needed for nausea * Docusate Sodium 100mg daily **<u>Symptoms - physical</u>** **Pain** Johnny describes chronic, dull abdominal pain, rated 6/10 at its worst, often radiating to his back. It is somewhat relieved by oxycodone but never completely absent. The pain significantly impacts his sleep and ability to sit comfortably. **Gastrointestinal** Johnny reports poor appetite, constant nausea, and occasional vomiting, especially after eating solid foods. He estimates a weight loss of 15 kg over the past 3 months. He struggles to keep down fluids and reports significant early satiety. **Respiratory** Johnny has no respiratory symptoms. **Mobility** Johnny uses a walker for ambulation. He reports needing assistance to stand up from a seated position. He can walk approximately 10 metres slowly before needing to rest, due to profound weakness and dyspnoea on exertion. **Toileting and incontinence** Johnny needs assistance with toileting due to weakness and instability. He reports occasional faecal incontinence due to poor bowel control and urgency, and urinary incontinence at night. **Care needs** Johnny receives comprehensive care from his daughter, Jane, who assists him with dressing, bathing, and preparing soft foods. He requires help transferring from bed to chair. **Other physical issues** Johnny notes significant fatigue that limits all his daily activities. He experiences peripheral oedema in his ankles bilaterally. **<u>Symptoms - emotional/spiritual</u>** **Depression/sadness** Johnny expresses profound sadness about his declining health and loss of independence. He denies clinical depression but admits to feeling hopeless about his prognosis. He states he wants to avoid further deterioration. **Anxiety** Johnny reports mild anxiety related to future suffering and the burden he feels he places on his daughter. **Spiritual/religion** Johnny is not religious but considers himself spiritual. He finds peace in nature but is no longer able to access it. He discussed a desire for a peaceful and dignified end. **<u>Vulnerabilities</u>** **Financial:** Johnny expressed concerns about the financial strain his illness is placing on his daughter due to lost income from her caregiving. **Housing:** Johnny lives in his own home and wishes to remain there for MAiD. **Mental health and supports:** Johnny has been offered counselling services but declined, stating he prefers to discuss his feelings with his daughter. He has no prior history of mental health disorders. **<u>Previously enjoyed activities</u>** Johnny previously enjoyed gardening, walking his dog, and playing chess with friends. He can no longer participate in any of these activities due to his physical limitations and fatigue. **<u>Medical Assistance in Dying discussion</u>** **Eligibility** John Doe is eligible for MAiD. I discussed with Johnny that he meets the criteria for MAiD as he has a serious and incurable illness (metastatic pancreatic cancer), is in an advanced state of irreversible decline in capability, and is experiencing intolerable suffering that cannot be alleviated by means acceptable to him. We reviewed his diagnosis and prognosis, confirming that his natural death is reasonably foreseeable. **Capacity** I explained to Johnny that he must have capacity at the time of an assisted death or must have signed a Waiver of Final Consent - see below. **Consent** I made Johnny aware that he may rescind consent at any time. On the agreed day of an assisted death I will attend him wherever he is and I will bring a consent form. He may decline to sign it. If he gives his consent, immediately prior to commencing the intravenous injections I will ask again if he is sure he wishes me to proceed. He may remove his consent. **Life insurance** In 2016, all the major Canadian insurers declared that MAiD would not affect life insurance policies. Nonetheless, I made Johnny aware that he should check this with his insurer if he does have life insurance. **Administration of MAiD drugs** I informed Johnny that MAiD can be carried out by the MAiD Provider injecting medication intravenously or by the patient swallowing medication. I only provide MAiD using intravenous injection. Johnny confirmed that he is content with this. I described the effects of the medications. The first drug is Midazolam. This drug relaxes the patient and puts them into a deep sleep although not yet into a coma. It takes 20-30 seconds to take effect. I explained to Johnny that from his point of view this means that MAiD takes about 20-30 seconds. The second drug is Lidocaine. This, plus the fact that Johnny will now be deeply asleep, means that the slight burning that the next drug, Propofol, can cause, will not happen. The third drug is Propofol. This will put Johnny into a coma and then stop his breathing. I told Johnny that because he will be in a coma he will not be aware that he is not breathing and will not have any sensations at all of any type. The last drug is Rocuronium. I explained to Johnny that it is given in case the Propofol fails to stop the person from breathing although I have never seen this happen. Rocuronium would then stop any breathing. **Palliative care consults** Johnny has received palliative care consultations from a specialist team over the past 3 months. **Palliative care options** We discussed palliative care options extensively, including symptom management strategies that have been tried. I explained the differences between palliative sedation and MAiD, noting that palliative sedation is a physician-initiated decision for intractable suffering in the last 1-2 weeks of life, aiming to relieve suffering by inducing a state of decreased consciousness, and is distinct from MAiD where the primary intent is to end life. Johnny affirmed he understood these distinctions and found the current palliative measures insufficient to alleviate his suffering to an acceptable degree. We discussed hospice care, and Johnny indicated he wishes to remain at home rather than relocate to a hospice facility. **Patient request** Johnny has correctly completed a 1632 Request form with an independent witness. **Waiver of Final Consent** We discussed the Waiver of Final Consent. Johnny expressed his desire to sign a Waiver of Final Consent given his rapidly declining health and his fear of losing capacity before the scheduled date. I explained the implications, ensuring he understood that this would allow the MAiD procedure to proceed even if he lost capacity, provided he met all other eligibility criteria at the time of his initial assessment. **Going ahead with MAiD** Johnny said that if his pain becomes uncontrollable, or his nausea worsens to the point where he cannot ingest anything, or he loses all independence in self-care, these would be immediate triggers for him to set a date for MAiD. He said that if his condition somehow stabilised and his symptoms improved significantly, he might reconsider, but he feels his mind is made up to have it. **Timing of MAiD** Johnny initially wanted to set a date immediately but after discussion, agreed to take a few weeks to spend time with his daughter and tie up personal affairs. He indicated a preference for early December, but understands this is flexible. I gave Johnny my business card which includes my cell and home phone numbers. I drew his attention to the resources on the back of the card. These are mainly for support of patients and their family members. **Organization on the day of an assisted death** Johnny wishes to have MAiD at home. He has not yet set a definitive day but will contact me within the next two weeks to confirm. He discussed his wish for his daughter, Jane, to be present, and that he would like to listen to classical music during the procedure. He also mentioned a desire to have a small glass of whisky beforehand, which I affirmed was acceptable. On the agreed day I will attend Johnny. A nurse will also attend either before I arrive or with me. The nurse will site two IV cannulae. The second IV is in case of a problem arising in the first during the procedure. I checked Johnny's veins. I expect there probably will not be a problem with cannulation.