**<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.
**<u>Medical Assistance in Dying Eligibility Assessment</u>**
I have been asked to assess [patient name]'s eligibility for Medical Assistance in Dying (MAiD). [patient first name] goes by [goes by name] (Only include if patient's preferred name differs from their first name as explicitly mentioned in transcript or context, else omit entirely.)
I met with [him/her] in [location where the patient was seen] (Only include if explicitly mentioned in transcript or context, else omit entirely.) on [date].
I introduced myself. I gained the patient's consent to use Heidi AI Scribe to generate this report and to record [his/her] voice.
[The patient showed me photo ID] (Only include if explicitly mentioned in transcript or context. If clearly stated that the clinician has previously met the patient before, instead record "I have previously met [patient name] so did not require [him/her] to show me photo ID.")
[patient first name]/[goes by name] (Use goes by name preferentially instead of first name throughout the rest of the note.) is [job or retirement status] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[He/She] is [marital status and spouse name if married, or state if divorced or widowed] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[The following family member was present:
[name of family member]
[name of family member]
[name of family member]
[name of family member]
[name of family member]]
(Only include if family member in attendance is named in transcript or context, else omit entirely.)
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. [describe any discussion of family member's feelings about MAiD or other family members or friends who have had MAiD] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[The following friend or supporter was present:
[name of friend or supporter]
[name of friend or supporter]
[name of friend or supporter]]
(Only include if explicitly mentioned in transcript or context, else omit entirely.)
**<u>Primary condition</u>**
[Diagnosis] (Only include if explicitly mentioned in transcript or context, else omit entirely. Include discussion of prognosis if this occurred.)
**<u>Patient's story of disease and symptom progression</u>**
[patient first name] explained [patient's description of the course of their illness since symptoms started or first visit to physician or hospital with the problem] (Only include if explicitly mentioned in transcript or context, else omit entirely. This section should be comprehensive and include considerable detail given by patient and family members concerning their medical conditions and their progression. Write in paragraphs.)
**<u>Previous medical history</u>**
[list patient's other diseases and diagnoses] (Only include if explicitly mentioned in transcript or context, else omit entirely. Write as list.)
**<u>Medications</u>**
[list current medications] (Only include if explicitly mentioned in transcript or context, else omit entirely. Write as list.)
**<u>Symptoms - physical</u>**
**Pain**
[describe pain symptoms and effects] (Only include if explicitly mentioned in transcript or context. If no pain is mentioned, record "[patient name] has no pain.")
**Gastrointestinal**
[list appetite, nausea, vomiting, problems with eating and drinking, weight loss] (Only include if explicitly mentioned in transcript or context. If no gastrointestinal symptoms are mentioned, record "[patient name] has no GI problems and no weight loss.")
**Respiratory**
[describe any respiratory symptoms] (Only include if explicitly mentioned in transcript or context. If no respiratory symptoms are mentioned, record "[patient name] has no respiratory symptoms.")
**Mobility**
[describe any mobility issues such as use of cane or walker] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[describe how far the patient can walk and speed of walking] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Toileting and incontinence**
[describe whether patient needs assistance with toileting] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[describe any incontinence] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Care needs**
[describe the care that patient receives from other people especially with dressing, bathing, showering, feeding] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Other physical issues**
[describe any physical issues not so far described] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**<u>Symptoms - emotional/spiritual</u>**
**Depression/sadness**
[describe any symptoms of depression or sadness] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Anxiety**
[describe any symptoms of anxiety] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Spiritual/religion**
[record any discussion around spirituality and religious belief] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**<u>Vulnerabilities</u>**
(Only include this section heading and content below if any vulnerability topics are discussed in transcript or context, else omit section entirely.)
**Financial:** [record any discussion of financial or income issues] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Housing:** [record any discussion of housing or accommodation issues] (Only include if explicitly mentioned in transcript or context, else omit entirely. Do not add discussion of Long Term Care here.)
**Mental health and supports:** [record any discussion of mental health issues] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**<u>Previously enjoyed activities</u>**
[describe activities the patient enjoyed but now cannot do] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**<u>Medical Assistance in Dying discussion</u>**
**Eligibility**
[patient name] is [record whether or not the patient is eligible or not eligible for MAiD] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[transcribe the discussion about whether the patient is eligible or not for MAiD including discussion of serious and incurable illness, disease or disability, advanced state of irreversible decline in capability, and suffering] (Only include if explicitly mentioned in transcript or context, else omit entirely. Write in paragraphs.)
**Capacity**
I explained to [patient first name] that [he/she] must have capacity at the time of an assisted death or must have signed a Waiver of Final Consent - see below.
**Consent**
I made [patient first name] aware that [he/she] may rescind consent at any time. On the agreed day of an assisted death I will attend [him/her] wherever [he/she] is and I will bring a consent form. [He/She] may decline to sign it. If [he/she] gives [his/her] consent, immediately prior to commencing the intravenous injections I will ask again if [he/she] is sure [he/she] wishes me to proceed. [He/She] may remove [his/her] consent.
**Life insurance**
In 2016, all the major Canadian insurers declared that MAiD would not affect life insurance policies. Nonetheless, I made [patient first name] aware that [he/she] should check this with [his/her] insurer if [he/she] does have life insurance.
**Administration of MAiD drugs**
I informed [patient first name] 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. [patient first name] confirmed that [he/she] 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 [patient first name] that from [his/her] point of view this means that MAiD takes about 20-30 seconds.
The second drug is Lidocaine. This, plus the fact that [patient first name] 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 [patient first name] into a coma and then stop [his/her] breathing. I told [patient first name] that because [he/she] will be in a coma [he/she] will not be aware that [he/she] is not breathing and will not have any sensations at all of any type.
The last drug is Rocuronium. I explained to [patient first name] 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**
[describe whether patient first name has received any palliative care consults] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Palliative care options**
[describe options discussed and any discussion about palliative sedation and the differences between palliative sedation and MAiD] (Only include if explicitly mentioned in transcript or context, else omit entirely. Include that the decision to use palliative sedation is made by the treating physicians not the patient or their family, that it is only used if there is no remaining option for the management of suffering, and that it is only used in the last 1-2 weeks of life.)
[describe any discussion about hospice] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Patient request**
[patient first name] has correctly completed a 1632 Request form with an independent witness. (Only include if explicitly mentioned in transcript or context. If patient has not completed the form, instead record "[patient first name] has not yet completed a 1632 request form.")
[record any discussion and explanation about the 1632 form if patient has not completed it] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[record any discussion if the patient's 1632 form was incorrectly completed] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[record whether or not a 1633 form or second assessment has already been carried out or if eligibility has been confirmed by another clinician and record the clinician's name] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[record details of the discussion with the patient about whether or not their request was voluntary and whether or not they have experienced any coercion to request MAiD] (Only include if family members and friends were asked to leave the room and this discussion occurred as explicitly mentioned in transcript or context, else omit entirely.)
**Waiver of Final Consent**
[record the discussion about the Waiver of Final Consent] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Track 2 patients: Safeguards checklist explained**
(Only include this section if the patient is Track 2 as explicitly mentioned in transcript or context, else omit section entirely:
"I explained that as [patient first name] is on Track 2 the following Safeguards are required:
i. one assessor must have expertise in the condition causing suffering or must consult with a clinician who has such expertise
ii. the patient must have been informed of the means available to relieve suffering including, where appropriate, counselling services, mental health and disability support services, community services, palliative care; and consultations with relevant professionals have been offered
iii. both assessors have discussed these means with the patient, and agree that the patient has given serious consideration to these means
iv. an assessment period of 90 clear days from the start of the first assessment must have passed before an assisted death may take place
v. a Waiver of Final Consent is not permitted.")
[record any discussion about Safeguards] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Going ahead with MAiD**
[patient first name] said that [describe what the patient said about symptoms or problems in the future that might make them decide to set a date for MAiD] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[He/She] said that if [describe what the patient said about what would mean that they might not choose MAiD or if their mind is made up to have it] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
**Timing of MAiD**
[record the discussion concerning the timing of MAiD] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
I gave [patient first name] my business card which includes my cell and home phone numbers. I drew [his/her] 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**
[patient first name] wishes to have MAiD [record if the patient said home or hospital or hospice or elsewhere] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[He/She] [record whether the patient stated a day they wish to have MAiD or record that the patient is not yet ready to set a date] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
[record any discussion about arrangements the patient and family might make to personalize the assisted death including inviting other people to be present, any mention of alcohol or cannabis or marijuana, and any discussion about ceremony] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
On the agreed day I will attend [patient first name]. 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 [patient first name]'s veins. I expect [record whether there probably will or will not be a problem with cannulation] (Only include if explicitly mentioned in transcript or context, else omit entirely.)
