Family Medicine Specialist Template

Medical Assistance in Dying (MAID Assessment)

A professional Family Medicine Specialist template for healthcare professionals.

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Specialty

Family Medicine Specialist

Used

104 times

Type

Note

Last edited

11/18/2024

Created by

Joshua Tracey

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About this template

The Medical Assistance in Dying (MAID) Assessment template is a comprehensive tool designed for family medicine specialists and other healthcare providers involved in evaluating patients' eligibility for MAID. This detailed template ensures that all necessary criteria are assessed, including patient consent, medical condition, and decision-making capacity. It also provides a structured format for documenting patient history, current medications, and allergies. The template is particularly useful for clinicians in Canada, where MAID is legally regulated, and helps ensure compliance with legal and ethical standards. This template is ideal for creating thorough and accurate MAID assessments using Heidi, the AI medical scribe.

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Medical Assistance in Dying (MAID) Assessment Name: John Doe DOB: 15 March 1950 Medicare: 1234-567-890 PPRN: 987654321 Family Practitioner: Dr. Emily Smith Assessor: Dr. Thomas Kelly, Family Medicine Specialist Second Assessor: Dr. Sarah Johnson Diagnosis: Metastatic pancreatic cancer Date of Diagnosis: 10 January 2024 MAID request date: 15 October 2024 CRITERIA: ☑ eligible to receive health services funded by the Government of Canada ☑ over 18 years of age ☑ capacity to make decisions with respect to their own health ☑ voluntary request for MAID that is not the result of external pressure ☑ grievous and irremediable medical condition: a serious and incurable illness, disease, or disability ☑ advanced state of irreversible decline in capability ☑ enduring physical or psychological suffering, caused by either the illness, disease, or disability, or by the advanced state of decline in capability, that is intolerable to the patient and cannot be relieved under conditions that they consider acceptable ☑ informed that they can withdraw their request for MAID at any time, in any manner ☑ I have informed of the risks associated with taking the medication to be prescribed; and the result of taking or being administered the medication prescribed TRACK: 1, Reasonably Foreseeable Death OPTIONS: mediation route: IV location of administration: Home organ donation: Not specified waiver of final consent: Not specified Patient History and Status: John Doe is a 74-year-old male with a diagnosis of metastatic pancreatic cancer. He has been experiencing severe abdominal pain, significant weight loss, and profound fatigue. Despite aggressive treatment, his condition has continued to deteriorate. Mr. Doe states, "I am in constant pain and have no quality of life left." He has expressed a clear and consistent desire for MAID, emphasizing his wish to die with dignity and end his suffering. Past Medical History: - Metastatic pancreatic cancer, diagnosed 10 January 2024 - Hypertension, diagnosed 2010 - Appendectomy, 1995 Medications: - Morphine 30 mg PO q4h - Lisinopril 20 mg PO daily Allergies: - Penicillin (rash)