Medical aid in dying: Clinical considerations

INTRODUCTION — Many parts of the world have seen the emergence of discussions regarding end-of-life care, with increasing pressure for the legalization of varying forms of medical aid in dying (sometimes abbreviated as MAID). Although there remains variation in legal status internationally, as well as within in the United States, a substantial population of patients have access to legal medical aid in dying. Information on US state laws is available on the Death with Dignity website.

As a result, many clinicians, particularly those in the fields of oncology palliative care, and hospice, will care for patients considering a hastened death. Given the advances in the bedside practice of medical aid in dying, those clinicians who choose to participate must be well educated in the clinical details to provide their patients with appropriate care.

This topic describes the clinical practice of self-administered medical aid in dying, which is the only form allowed in those parts of the United States where medical aid in dying is legal. Self-administration is also an option in all other countries where medical aid in dying is permitted, although clinician administration is far more common. Due to the paucity of published data on the practice of medical aid in dying, much of the recommendations in this topic are based on the contributors' experience, as well as data from the self-reported experiences of other clinicians.

Ethical and legal considerations, including those outside of the United States, are discussed in further detail elsewhere. (See "Medical aid in dying: Ethical and legal issues".)

DEFINITION AND TERMINOLOGY

Definition — Medical aid in dying refers to the legal practice where a clinician cares for a terminally ill patient who considers and potentially follows through with hastening their imminent death through the use of medications prescribed for that purpose. Earlier descriptions of medical aid in dying have characterized it as writing a prescription, at the patient's request, for a lethal medication. Clinical best practices have since discouraged this limited focus and now emphasize the evaluation and care of terminally ill patients considering the option of a physician-assisted death.

Terminology - Medical aid in dying is one of the most commonly used expressions for the practice. Other terms include aid in dying, physician aid in dying, medically assisted deaths, physician-assisted deaths, and hastened deaths. The term "assisted suicide" is misleading. The American Association of Suicidology "…recognizes that the practice of physician aid in dying… is distinct from the behavior that has been traditionally and ordinarily described as 'suicide'… legal physician assisted deaths should not be considered to be cases of suicide" [1]. Similar policy statements have been presented by the American Academy of Hospice and Palliative Medicine [2], the American Public Health Association [3], the American Psychiatric Association [4], the American Medical Women's Association [5], and the American Academy of Family Physicians [6,7], although these organizations' policy statements vary in their support of medical aid in dying.

The clinician must consider carefully what terminology is appropriate to use, ideally reflecting (and understanding) the terminology used by the patient [1-7]. Terminology is discussed in more detail elsewhere. (See "Medical aid in dying: Ethical and legal issues", section on 'Terminology'.)

LEGAL REQUIREMENTS FOR MEDICAL AID IN DYING — The legal status and requirements of medical aid in dying in other countries are discussed in detail elsewhere. (See "Medical aid in dying: Ethical and legal issues".)

In the United States, the legal requirements for aid in dying vary between states and change frequently. Clinicians should remain aware of their individual state laws. In general, as of July 2023, these laws require that the patient [8]:

●Is over 18 years of age.

●Lives (or has established residency) in a state where medical aid in dying is legal (no residency requirement in Multnomah County, Oregon, and Vermont).

●Is terminally ill, with a prognosis of less than six months to live. This determination must be made by two independent physicians or, as in New Mexico and Washington (and potentially other states in the future), by an advanced practice registered nurse or physician assistant with confirmation by a physician, or when the patient is already enrolled in a Medicare-certified hospice program.

●Has the mental capacity to make their own medical decisions and is not suffering from a mental health condition that negates that capacity. (A mental health evaluation is mandatory in Hawaii.)

●Has two doctors who concur that they are eligible:

•The attending/prescribing clinician, who assumes primary responsibility for the patient's aid-in-dying care.

•A consulting/second-opinion doctor, who evaluates the legal criteria above but has no further aid-in-dying care responsibilities (although these are not forbidden).

●Has the physical ability to self-administer the medications without assistance (except in New Mexico).

●Makes two verbal requests (one in New Mexico) and signs a written request expressing their consideration of medical aid in dying. In most states, there is a waiting period between the two verbal statements which varies by individual state law.

Further requirements include the following:

●The clinician must advise the patient about other options, including palliative and hospice care, and must tell the patient that their request may be withdrawn at any time for any reason.

●If either clinician suspects that depression or mental illness is distorting the patient's judgment or decisional capacity, the patient must be referred for psychological or psychiatric evaluation.

●The clinician, typically within 30 days of writing a prescription, must file with the designated state health agency: the patient's written request, an attending clinician checklist and compliance form, and (if applicable) a consulting clinician compliance form. The identity of the clinician and of the patient are not matters of public record.

INITIAL EVALUATION

Clarify patient intentions and discuss options — Clinicians should have a conversation with the patient to explore their reasons for considering medical aid in dying, including fears of how they may otherwise die. Patients interested in medical aid in dying may have difficulty initiating such discussions and may not use precise language. They may use language like "I want that choice, so I don't suffer" or some equivalent. In these situations, the clinician must explore seemingly vague requests to fully understand their patients' wishes and to address underlying fears and concerns. The clinician should not put off these conversations for later visits, since these patients are often quite ill and seeking prompt information and clarity. An exploratory discussion with the patient doesn't commit you or the patient to any particular course of action. However, it is important to be clear and honest with the patient as to whether you are making a promise regarding future actions.

Many aid-in-dying statutes are clear that "coercion or undue influence" to direct a patient toward medical aid in dying is a felony. As such, the clinician should have a conversation with the patient, alone, that specifically addresses the question as to whether the patient has been coerced into this decision. The "no-coercion" clauses do not state and should not be interpreted by a clinician to signify that they cannot bring up the legal right to medical aid in dying if a patient doesn't mention it themself. The decision about if or when to bring up the right to medical aid in dying should be made by each clinician after careful consideration of the end-of-life milieu and the entirety of conversations with the dying patient. Some clinicians consider it always inappropriate to bring up the possibility of medical aid in dying if not initiated by the patient. Others consider responding to a patient's nonspecific requests, such as "Doctor, I'm ready to die, can't someone help me?", as an indication of the patient's right to be informed of the legality of medical aid in dying in their state. Whether to initiate the conversation is a question of clinical judgment, not law. However, under no circumstances is it appropriate for a clinician to bring up the subject with a patient who does not meet legal requirements or has insufficient decisional capacity, or to attempt to coerce a patient who indicates that they are not interested in pursuing this option.

If the patient is considering medical aid in dying and appears to be qualified, the clinician may move the conversation forward:

●Address avoidable causes of suffering – For all patients considering aid-in-dying, the first task of the clinician is to address all avoidable causes of suffering. In addition, the patient should be made aware of all appropriate treatment options, from purely palliative care to potentially life-prolonging treatments.

●Recommend palliative and hospice care – All patients considering medical-aid-in dying should be referred to palliative care and/or hospice care, in part to make sure that their consideration of a hastened death is not driven by treatable distress. For most patients, there's a months-long journey from considering the option to engage in medical aid in dying and eventually following through on it. During that interval, it is essential they receive skilled end-of-life palliative care, which is often most readily available with hospice. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)

Some hospices, especially those with strong religious affiliations, may disapprove of medical aid in dying and choose not to participate in any way. However, in the experience of the American Clinicians Academy on Medical Aid in Dying (ACAMAID), most hospices in aid-in-dying states now support open, nonjudgmental discussions with patients contemplating a hastened death and continue to provide care for such patients.

●Offer to discuss the likely dying process – For patients to thoroughly understand their options, they must first know how they are likely to die. This conversation should be tailored to their specific situation, which is dependent on their disease(s) and their present condition and symptoms, as well as the treatments they've received and their support systems.

Although some clinicians fear that a "how you die" conversation eliminates hope, patients who are contemplating a hastened death must be offered truthful and thorough information about the potential scenarios of their deaths so they can decide whether to end their lives or continue with other approaches to dying. Information a patient clearly indicates they do not want to hear (eg, vivid details of the death process that is likely to occur) must not be forced on a patient. Asking what questions the patient has or noting that some patients want all the details and others just the big picture may help titrate the information.

●Respond to psychosocial, housing, and financial needs – If the clinician detects that a significant driving force toward medical aid in dying might be family conflict, housing difficulties, financial needs or other psychosocial difficulties, the clinician should immediately involve the full resources of social workers and others who can provide such support. However, a patient who is terminally ill and choosing medical aid in dying because of a personal decision that they have "no additional quality of life" should not be denied medical aid in dying if they have been offered all available resources but still choose medical aid in dying as the route to their approaching death. Lack of resources should not be the cause of an aid-in-dying death; neither should lack of resources be a reason to deny an aid-in-dying death. It is the job of the clinician, with the aid of others on their team, to evaluate these complex decisions.

ASSESS PATIENT SUITABILITY FOR MEDICAL AID IN DYING

Review legal requirements — The clinician must first determine whether the patient meets the legal requirements for medical aid in dying. (See 'Legal requirements for medical aid in dying' above.)

Assess prognosis

Prognostic requirements — In the United States, the criteria used to establish a less-than-six-months prognosis for medical-aid-in-dying eligibility are similar to those of the Medicare requirements for hospice [9]. This linkage to hospice precedents in establishing prognoses is so firm that in New Mexico, if a patient is in hospice, a consulting/second-opinion doctor is not required for the patient to qualify for medical aid in dying [10].

Prognostic challenges — Cancer is the most frequent underlying condition for medical aid in dying, and prognoses should be discussed with the patient's oncologist, especially if the patient is receiving experimental or advanced treatments. For many patients, prognostication can be difficult, especially for illnesses that have variable trajectories. In situations where the attending/prescribing clinician is uncertain about the prognosis, they can reassure the patient that they will follow them over time, and as their illness progresses they will become eligible for medical aid in dying and can then move forward should they wish. (See "Survival estimates in advanced terminal cancer" and "Communication of prognosis in palliative care".)

Certain clinical situations present specific prognostic challenges:

●Neurodegenerative diseases – Neurodegenerative diseases are the second most common diagnostic group linked to aid-in-dying requests, after cancer. Such patients who are considering medical aid in dying pose specific challenges, including difficult-to-establish prognoses and the potential difficulty or inability to self-administer medications. (See 'Self-administration in patients with neurodegenerative disease' below.)

For these patients, a single evaluation often does not provide adequate prognostic clarity. The clinician must obtain medical records and review prognostic indicators such as progressive declines in respiratory function, aspirations, and weight loss. If prior records are incomplete or nonexistent, the aid-in-dying prognostic assessment continues forward over time, measuring respiratory and other variables to establish the pattern and velocity of decline.

Among the neurodegenerative diseases, amyotrophic lateral sclerosis (ALS) tops the list of aid-in-dying requests. While ALS forms only 0.3 percent of annual United States mortality figures [11], ALS patients comprise some 10 percent of requests for hastened deaths. Hospices make the determination of a less-than-six-months prognosis for patients with ALS quite regularly, using Medicare admissions criteria. The Medicare requirements include benchmarks such as pulmonary function tests and swallowing/aspiration evaluations. A lengthy list of clinical assessments also applies, with the conclusion that "…no single variable deteriorates at a uniform rate in all patients. Therefore, multiple clinical parameters are required to judge the progression of ALS" [9].

When a prognostic evaluation for a patient with ALS or other neurodegenerative disease shows they have not yet reached the less-than-six-months window, it is essential for the clinician to avoid contributing to a sense of abandonment or hopelessness. Many patients with ALS express fear about possible death by suffocation, which is often the driving force for considering medical aid in dying. The clinician should acknowledge this fear and reassure the patient that the lack of a less-than-six-months prognosis indicates that suffocation is not impending. Assure the patient that their evaluation and care are continuing, and ensure they are aware of available treatments. (See "Disease-modifying treatment of amyotrophic lateral sclerosis" and "Symptom-based management of amyotrophic lateral sclerosis".)

●Patients receiving experimental or advanced treatments – Cancers are the underlying illness for roughly 80 percent of patients who consider or complete medical aid in dying. For this great majority, prognoses tend to be straightforward, given extensive clinical experience and actuarial tables [12]. (See "Survival estimates in advanced terminal cancer".)

Usually as the patient gets sicker, prognostic accuracy increases. This is especially true for patients in whom multiple therapies have failed, or those who have rejected additional life-prolonging treatments.

It is more complex to reach prognostic conclusions for cancer patients who are accessing advanced, targeted, or experimental therapies. However, if even with these treatments the patient is still more likely than not to die within six months, the aid-in-dying qualifying process can move forward. This may provide the patient with emotional relief and the courage to enter into higher-risk therapies, since they have a back-up plan if the therapy is too difficult to continue [13]. Their aid-in-dying eligibility provides reassurance that they are qualified and will receive the medications if and when they are needed. However, for safety reasons, aid-in-dying medications should not be delivered to the patient's home until they are clearly ready to be used. This also provides for additional conversations with the aid-in-dying clinician before the patient ingests the medications.

●Patients who lack a firm terminal diagnosis but are clearly dying – Some patients, when told they have a potentially terminal illness, refuse diagnostic evaluations. This is more typical at the extremes of age, often with the presentation of a mass, unexplained weight loss, or severe and demonstrably progressive weakness, anorexia, and "failure to thrive." Rather than undergo invasive diagnostic evaluations when they are unlikely to permit therapeutic interventions, these patients often request a hospice referral. They also may ask for medical aid in dying. Depending on how advanced their illness is, the clinician may accept the prognosis on clinical grounds alone and conclude that the patient is aid-in-dying eligible. Prognostication tools can be useful in this setting. Available prognostic tools for use in clinical decision-making for older adults are available through ePrognosis by the University of California, San Francisco.

●Extreme old age – It is important to recognize that extreme old age in and of itself does not necessarily coincide with a prognosis of less than six months to live. Life expectancy at 107, for example, is to still have 1.45 additional years to live. If you make it to 110, the statistical bet is for 1.21 additional years [14]. When these patients do die, it is commonly without a particular disease to blame. So when people at the extremes of age request an aid-in-dying evaluation, their clinicians face a prognostic dilemma. These patients do, however, eventually enter their final six-month window. Clinician observations (and family information) often show a pattern of rapidly progressive weakness, anorexia, weight loss, lethargy, and prolonged sleep. As above, prognostic tools are available through ePrognosis by the University of California, San Francisco.

Assess capacity to make medical decisions — The clinician must confirm the patient's ability to make decisions about their health care. In all US aid-in-dying states except Hawaii, laws only require a single capacity evaluation before the prescription is written. However, best aid-in-dying practices require ongoing clinical evaluation, since the crucial moment of a patient's fully-informed consent is at the time of taking the medications if the ingestion is medically supervised. The patient must have the capacity to understand this action and its consequence (death). Capacity evaluation is discussed in detail elsewhere. (See "Medical aid in dying: Ethical and legal issues", section on 'Assessing decisional capacity'.)

Mental health disorders, in particular depression, do not negate capacity unless the disorder is severe enough to impair comprehension. However, capacity is a condition that can significantly change as patients approach death, making it essential for clinicians to follow their patients until the final aid-in-dying decision is at hand. Hawaii is the only US state that mandates a psychiatric evaluation. (See "Assessment of decision-making capacity in adults".)

Address family and religious/spiritual concerns — Even patients who are certain about their aid-in-dying request are often troubled about the spiritual and religious implications of the act, or they face family concerns and conflicts. Clinicians can offer support and information as the patient works through these issues.

●Family conflicts – The first role of a clinician working with family conflicts about medical aid in dying is to offer guidance if requested and only intercede if the family dynamic is so toxic there is concern for elder abuse. Since these patients are commonly receiving hospice care, it is wise to bring in the hospice social worker or chaplain to help.

The question of coercion by family members is somewhat unique to aid-in-dying evaluations. Many United States laws require the clinician to meet with the patient alone to specifically ask if anyone has coerced them into hastening their death. This part of the aid-in-dying evaluation is straightforward. But another concern, not addressed by the laws, is when families use physical or emotional manipulations to stop a patient from taking medications to die. If a clinician ascertains or senses coercion in either direction, they must intercede and bring in appropriate counselors to work with family conflicts.

In our clinical experience, actual coercion is extremely rare. Most family conflicts about medical aid in dying are resolved by compromise, patient acquiescence to family desires, or family acceptance of the patient's wishes.

●Religious/spiritual concerns – The most common apprehension entails the question of suicide, which is prohibited by many religious groups. Medical groups have concluded that medical aid in dying is distinct from suicide (see 'Definition and terminology' above). It is helpful to review this fact with the patient and, with permission, family members or chosen religious figures. The clinician can begin the conversation by agreeing that suicide is to be avoided before reviewing the varied reasons why assisted dying is not considered a suicide, while fully acknowledging that some religions have come to different conclusions. Encourage patients to have open discussions about their aid-in-dying questions with their spiritual counselors.

Assess the patient's ability to absorb aid-in-dying medications — Many United States aid-in-dying laws use the language of "ingestion." While some statutes use the language of "take" or "administer" the medications, they are almost universally interpreted to permit only ingestion. Ingestion mandates involvement of the gastrointestinal tract and precludes injections (eg, intravenous, intramuscular, subcutaneous). Of the five medications in the American Clinicians Academy on Medical Aid in Dying (ACAMAID)-recommended aid-in-dying protocol, all except one (phenobarbital) have no gastric absorption and must be transported rapidly to the duodenum to be absorbed. Since transport and absorption of extremely large doses of medications by the gastrointestinal tract is essential for oral, feeding-tube, or rectally administered medical aid in dying, the clinician must carefully evaluate the gastrointestinal tract for the ability to fulfill this function if medical aid in dying is to proceed.

Oral administration — The oral route is the most common in the United States. However, common end-of-life conditions may include several conditions that make this route difficult. These may include severe general weakness, swallowing difficulties, nausea, intractable vomiting, gastroparesis, abdominal masses, bowel obstructions, tense ascites, intraabdominal scarring and/or metastases, constipation/obstipation, and, for the anorexic/cachectic patient, duodenal villous atrophy. Thus, clinicians must thoroughly evaluate their patient's alimentary tract and do their best to maintain its functionality.

●The oropharynx – Aid-in-dying medications prepared in the United States are usually a total of 2 to 4 ounces of a thick, liquid suspension of powders. Most commonly, these are ingested by swallowing. The full ingestion must be completed within two minutes, since the sedative components are so potent that the patient may fall asleep mid-dose if it takes longer.

Clinical evaluation must confirm nonobstructed swallowing without aspiration adequate for the two-minute interval. Any oropharyngeal obstruction (tumors, lymph nodes, abscesses, swelling), severe xerostomia, or oropharyngeal weakness (usually neurologic) can disqualify the patient from a safe oral aid-in-dying procedure. ("Safe," in this unusual context, means that death will occur, not partial-dose damage.) Note that patients can use a straw if needed. Consider a wide-bore boba or bubble tea straw, given the thickness of the suspension.

The best way to evaluate the adequacy of swallowing is to observe the patient rehearsing the procedure using a thick (or thickened) nutrition drink. This also reassures patients, who are often extremely anxious about whether they can complete the act.

●The esophagus – Clinically significant esophageal obstruction or motility abnormalities can contraindicate the oral administration of aid-in-dying medications. In addition, prolonged contact of the medications with the esophageal mucosa may increase the risk of a burning pain associated with the amitriptyline component of the medications, usually felt deep to the sternum.

●The stomach – Many patients approaching death have some component of gastroparesis. This impairment of gastric emptying can be more severe if there is a history of diabetes, chemotherapy-induced neuropathies, or intraabdominal tumors (especially pancreatic cancers). Gradual transport of aid-in-dying medications from the stomach to duodenum can be detrimental to the rapid absorption needed for reliable lethality.

Symptoms suggestive of clinically significant gastroparesis include rapid satiety, epigastric bloating/pressure, gastroesophageal reflux, nausea, and vomiting. Delayed gastric emptying may also be asymptomatic, so a high index of suspicion is necessary. Not all gastroparesis causes nausea, but all nausea is associated with gastroparesis. Treatment modalities for gastroparesis are discussed below. (See 'Pre-aid in dying symptom management' below.)

●The duodenum – Aid-in-dying medications are almost all absorbed across the duodenal mucosa, requiring mechanical transport and transmucosal absorption. Bowel obstructions, even if incomplete, can impede effective duodenal peristalsis and thus contraindicate the oral administration of these medications.

The duodenal mucosa is nourished as much by luminal nutrients as by vascular supply. Prolonged lack of eating causes significant duodenal villous atrophy. If a patient is significantly cachectic, with loss of muscle and connective tissue, the duodenal mucosa will also be atrophied and rapid medication absorption impaired.

Rectal administration — In patients for whom the oral route is compromised, the clinician must assess the capacity to utilize non-swallowing methods of self-ingestion. For the first 19 years of medical aid in dying in the United States (1997 to 2016), oral self-administration was the standard, and it was not known if rectal (enema) self-administration was legal or whether the rectal mucosa could adequately absorb the large doses of aid-in-dying medications. This changed in 2016 when California's End of Life Option Act specifically used the term "ingestion" as the route of administration. Clinicians were unclear what the legally mandated "ingestion" meant and wrote to the Medical Board for its opinion. In an informal reply from the Executive Director, ingestion was interpreted, essentially, as anything involving the gastrointestinal tract [15,16]. This unlocked the possibilities of nasogastric tube, percutaneous endoscopic gastrostomy (PEG) and jejunostomy tubes, ostomy, and rectal administration methods. Since then, all of the above routes have been utilized, and clinician-reported data collected by the ACAMAID suggest that times to death are not substantially different from those for oral administration [17]. Once safety and efficacy were established in California, other states rapidly followed suit. Today, some 16 percent of medically assisted deaths reported to the ACAMAID are by the rectal route [17].

Self-administration in patients with neurodegenerative disease — All aid-in-dying states except New Mexico forbid anyone to assist the patient in the self-administration. Patients with ALS and other neurodegenerative diseases face the uncertainty of whether they will have the strength to self-administer aid-in-dying medications. Some patients who choose medical aid in dying, then, feel a pressure to take the lethal medications sooner than they would otherwise desire, in fear of later losing strength for self-administration without assistance. For patients with ALS, it is helpful to consider the specific characteristics of their disease, dividing it into predominantly bulbar onset, which can limit swallowing, versus spinal onset, with predominantly limb weakness, or some mixture of symptoms from both.

●Spinal-predominant ALS, with profound limb weakness – These patients may maintain significant swallowing ability, enabling assisted-dying medications to be taken through a straw (assistants are allowed to hold the straw, providing the patient provides the suction). As long as swallowing function is preserved, the patient considering medical aid in dying can wait until their quality of life or other physical symptoms have deteriorated to the point where they choose to end their life. A note of caution, however, is that even patients who maintain oropharyngeal swallowing ability will eventually have significant enough respiratory compromise that they can no longer create the suction to take liquid medications through a straw. Patients should be monitored for this progression and advised about their declining aid-in-dying potential.

●Bulbar-predominant ALS, with loss of swallowing but some maintenance of limb function – Since these patients have lost their ability to swallow, the only options for taking aid-in-dying medications are by PEG (or jejunostomy) tube or rectal catheter. In light of the United States legal requirement of self-administration, in most cases without assistance, it is crucial to understand that ordering a PEG tube, placing a nasogastric tube, inserting a rectal catheter, or attaching medication-filled syringes to these tubes is not considered to be assistance. Self-administration without assistance refers to the "final act" of ingesting the medications, ie, pushing the plunger or physically releasing a valve occluding the tubing, etc. Legally, only the patient can perform this final act, which requires some strength of hands, fingers, limbs, or even head-turning or forehead pushing to depress a syringe-plunger, or hand- or jaw-clenching/unclenching to release a valve or kinked tube.

PROVIDE ONGOING CARE

Importance — In the early years of medical aid in dying in the United States, it was a common practice for the practitioner to legally qualify the patient, then write a prescription for a lethal medicine with instructions to "take the medications when ready." As the practice has evolved, the emphasis has shifted from the medications to the patient. As noted above, a dying patient's condition (everything from mental capacity to gastrointestinal function) alters over time. Between the initial clinical evaluation and the date the patient takes medications to die (often a months-long interval), everything from the medication doses used to the route of administration may need to be changed, or even whether the medical aid in dying should go forward at all. Insufficient follow-up over time can cause significant errors and potential complications of the procedure.

Coordinate with hospice clinicians — Often, the patient is receiving hospice care as the hastened-death process evolves, but the hospice staff may or may not be knowledgeable about or experienced with medical aid in dying. The medical-aid-in-dying clinician, then, must work with hospice physicians and nurses in an open manner, sharing information about the patient's needs that are unique to a potentially hastened death and helping to integrate those specifics with the patient's palliative care. In that sense, the aid-in-dying clinician becomes part of the end-of-life team, working in collaboration toward the patient's desires, best interests, and safety.

Anticipate clinical changes — A patient's clinical situation can change in the interval between deciding to pursue aid in dying and the actual administration of the medication. Changes in bowel function are particularly important. For example, a patient may develop a bowel obstruction or other complication necessitating a change from oral to rectal administration of aid-in-dying medications. Although this is not a legal requirement, it is best practice not to provide aid-in-dying medications as soon as the patient qualifies. Rather, the medications can be held at the pharmacy, ready for pickup or rapid delivery, and the patient or patient's representative can contact the prescribing clinician when they have a specific plan and date to take them. That provides the clinician with an opportunity for a quick check-in before the patient proceeds, allowing for adjustments in dosage, route of administration, final instructions, and, especially, aggressive control of gastrointestinal symptoms.

Be aware of potentially treatable crises — For the patient who is considering medical aid in dying, the decision of when or if to actually take the medications is often complex. This is one of the most consequential decisions of the patient's life, and aid-in-dying clinicians should be available to provide expert guidance about the details. Patients, for example, may decide to hasten death because their pain or other symptoms have gone out of control. However, a pain crisis or other escalation of symptoms may be treated with increased palliative care rather than lethal medications. The aid-in-dying clinician, when contacted to obtain the aid-in-dying medications, can explore these issues with the patient, in conjunction with the patient's hospice and/or palliative care team to be certain their final decision is an informed one.

Pre-aid in dying symptom management — The patient's decision about if or when to proceed with medical aid in dying is often influenced by symptom burden and treatment; therefore, it is essential for the clinician to maintain open communication with the hospice team. Some symptoms may require an intervention different than typical hospice care, so guidance from the clinician focusing on the assisted death is crucial, especially for managing the pre-aid-in-dying gastrointestinal tract.

●Eating – Most patients approaching death eventually develop anorexia. Modern palliative care principles avoid the older practice of encouraging a dying patient to eat "to keep up your strength." Rather, the family is advised to offer food only if the patient requests it. But since the duodenum receives nutritional support mainly from luminal content, prolonged lack of eating can lead to villous atrophy, which may impair rapid absorption of the very large doses of aid-in-dying medications. While there is no definitive evidence that low-level food intake can prevent duodenal atrophy in the anorexic end-of-life patient, logic says that encouraging small amounts of food, if tolerated, may improve duodenal absorption and thus the efficacy of the procedure. The aid-in-dying clinician should work with hospice to assess the feasibility of maintaining gut absorptive function in this manner.

●Nausea, vomiting, and gastroparesis – For aid-in-dying efficacy, rapid gastric clearing and transport of the medications to the duodenum is essential. Aggressive treatment of all nausea or vomiting is essential. If nausea and/or vomiting are not controlled, the clinician should consider delaying the procedure until aggressive symptom relief is achieved.

Based on our clinical experience, we avoid the commonly prescribed antiemetics of the antimuscarinic group (prochlorperazine, haloperidol) since their anticholinergic effect can delay gastric emptying. 5-HT3 receptor antagonists (most commonly ondansetron) are often effective, but if any nausea persists, move quickly to a glucocorticoid (dexamethasone, 4 to 8 mg and higher). We find this has a high rate of success, with the added benefit of increasing the patient's mood, energy, and appetite. Experience with NK-1 receptor antagonists (aprepitant, rolapitant, casopitant) is too limited in the aid-in-dying context to comment on their use.

Establish a "Plan B" — Some patients who are initially eligible for aid-in-dying experience a change in condition that negates that possibility. This can include loss of mental capacity for medical decision-making and/or loss of physical ability to self-ingest the medications. It is crucial when planning a medically assisted death to establish a parallel plan that closely follows the patient's wishes should they become ineligible to take life-ending medications.

The underlying assumption behind a request for a clinician-assisted death is the patient's desire not to sustain severe or prolonged suffering. As such, when a patient considering a hastened death is no longer eligible, they commonly request aggressive palliation, even to the point of significant sedation. In case the patient should lose mental capacity, this potential for assertive symptom management should be discussed while they can still express their wishes. When possible, that conversation should be attended by the patient's health care proxy, who can express the patient's desires if/when they can no longer do so. However, the health care proxy is not legally permitted to continue with medical aid in dying if the patient has lost decision-making capacity. (See "Palliative sedation" and "Palliative care: The last hours and days of life".)

PHARMACOLOGY

Common regimen — It is pharmacologically complex to achieve a reliable, rapid, and comfortable aid-in-dying death, especially with the stipulation that all medications must be administered into the gastrointestinal tract. The most commonly used regimen is a combination of sedative and cardiotoxic medications. The present medication protocol recommended by the American Clinicians Academy on Medical Aid in Dying (ACAMAID) is as follows, abbreviated as DDMAPh [18]:

All medications must be sourced as powder, not crushed tablets (which contain a large amount of filler material):

●Diazepam 1 g

●Digoxin 100 mg

●Morphine 15 g

●Amitriptyline 8 g

●Phenobarbital 5 g

Powdered medication in these quantities are only available through compounding pharmacies.

Avoiding prolonged medical aid-in-dying deaths — Although improvements in the recommended pharmacology have substantially improved both the speed and reliability of gastrointestinally-administered aid-in-dying deaths, 1.2 percent still exceed 10 hours, and 4.1 percent are between 5 and 10 hours. In general, deaths of over five hours' duration are considered to be problematic for the families (the patients remain in coma). The most frequent risk factor for prolonged dying is gastrointestinal dysfunction due to cachexia/anorexia, gastroparesis, severe constipation/obstipation, partial or complete bowel obstructions, or tense ascites. Other concerns are medication-related, such as opiate and/or benzodiazepine tolerance or a history of extreme athletic conditioning. These conditions may necessitate a change in dosing or route of administration. For a complete list of risk factors, refer to the ACAMAID "Red Flag" checklist.

Clinicians should warn families in advance that while a fairly rapid demise is likely, some may take longer.

Insurance coverage — In US states where medical aid in dying is legal, many private health insurers claim to cover the cost of necessary medications, but in our experience rarely do so. Factors limiting coverage include the fact that medical aid-in-dying protocols require compounded medications which are usually not covered by insurance and that there is no ICD-10 code for aid in dying. Coverage involving federal funds (including Medicare and the Veterans' Administration) cannot be used for medical aid in dying. Medicaid is a state-run program, and the decision to cover the cost of the medications is variable among states that have authorized medical aid in dying.

PREPARING FOR THE AID-IN-DYING DAY

Clinician-attendants and others at the bedside — In the United States, the American Clinicians Academy on Medical Aid in Dying (ACAMAID) strongly advises patients not to take their medications while alone. For a weakened patient at the end of life, mixing and taking lethal oral drugs without assistance is mechanically difficult and potentially unsafe. Most patients arrange for family members and/or others close to them to be present on a preset death day. Clinical attendants can be a physician, an advanced practice nurse, a hospice nurse, a non-hospice nurse, a social worker, a chaplain, an aid-in-dying-trained volunteer, or an end-of-life doula. They can mix or supervise mixing the medications, inform about self-administration details, and answer patient and family questions and concerns as they come up. Clinical experience has shown that the presence of a knowledgeable clinician on the death day aids not only the immediate procedure but also subsequent bereavement.

If a patient or family desires a clinician attendant but their care providers are unable to be there, ACAMAID has a national attendant referral form to connect the patient with a local, knowledgeable nurse, doula, or trained volunteer. Some states have organizations that provide skilled attendants for the aid-in-dying day.

Clinician visit a few days before medical aid in dying — Once the patient has decided on a date to take aid-in-dying medications and that day is approaching, a specific clinician check-in is essential to establish the continued efficacy of the procedure and to answer remaining patient and family questions. Telehealth or a home visit is recommended, since these patients are almost uniformly too ill to attend an office appointment. Note that for patients planning rectal administration, an in-person digital rectal examination is necessary one to five days prior to the medical aid-in-dying day. (See 'Rectal catheter self-administration' below.)

During this visit:

●Note any changes in gastrointestinal function, from gastric emptying to constipation.

●Aggressively treat any nausea or vomiting.

●Use laxatives to alleviate significant constipation.

●Review the medication list. If extreme opiate or benzodiazepine tolerance has developed, consider increasing the phenobarbital in DDMAPh from 5 to 10 g, and diazepam from 1 to 2 g.

●Speak directly with the patient to be sure they've maintained capacity for medical decisions. Patients must fully understand what they are about to do: take medications to die. The final decision to take the medications, or not, must be made by the patient, not by any proxy.

●Reaffirm the ability to self-administer the medications.

●Encourage the patient to rehearse the self-administration (using thickened nutritional supplement liquids) to be sure they are capable of and at ease with completing the procedure. For the patient's understanding and comfort, it is helpful to perform three or four rehearsals of swallowing the necessary amount over a few days. It is very difficult, and potentially dangerous, for a patient to try this for the first time with lethal medications on the aid-in-dying day.

●Direct the patient and family to additional written and video information:

•Preparations and instructions for the aid-in-dying day [19]

•Video enactment of medical aid in dying at the bedside [20]

•Instructions for mixing aid-in-dying medications [16]

●Discuss the immediate preparations for the patient's assisted death. The essentials are:

•The day itself will be filled with distracting medical events and details. Therefore, long goodbyes, living memorial ceremonies, "celebrations of life," family meals, etc work better the day before. The emotional and mechanical complexity of the aid-in-dying day is much easier if not accompanied by intricate family or social plans.

•Continue all medications unless otherwise advised by hospice and/or the attending/prescribing clinician.

•Nothing by mouth (NPO) after midnight, except for clear liquids in small amounts. (Or, if the patient is not taking the aid-in-dying medications in the morning, NPO for at least eight hours before aid-in-dying ingestion.)

THE AID-IN-DYING DAY

Initial considerations for all patients — In the experience of the American Clinicians Academy on Medical Aid in Dying (ACAMAID), the best time to take aid-in-dying medications is around 11 AM or noon. That way, patients can have a quiet morning with their families and others and still have ample time for the procedure. Late-afternoon or evening ingestions are not recommended, since prolonged deaths are possible, and it is challenging for the family to stay awake through the late night.

Family members and others may be timid about or frightened by the impending procedure. They often stand at a distance from the patient, at times across the room. Advise them that the day is about caring for their loved one, so move in closer and pull up some chairs. Frequently, once the patient is unconscious, loved ones cradle them and say their final goodbyes.

On the morning of medical aid in dying, clear liquids, tea, or coffee (with no dairy added) are fine, but not solid foods and especially no fat at all (delays gastric emptying). Large volumes of liquid that may fill the stomach should be strictly avoided. Frequent small sips are allowed.

Many patients inquire about a last cocktail or a (small) glass of wine. As long as they are accustomed to these drinks without experiencing nausea, and will not be sedated to a level that may impair self-administration, a final alcoholic beverage is fine. (Contrary to assisted-death mythology, times to sleep or death are not improved by this amount of alcohol.)

Administration details

Premedication and preparation of medications — One hour before a planned oral or feeding tube ingestion, the patient takes ondansetron 8 mg and metoclopramide 20 mg. Note that for ostomy or rectal administration, ondansetron is still necessary (when serum digoxin levels increase, this prevents the associated nausea/vomiting) but metoclopramide is not needed.

There is nothing in any United States aid-in-dying laws that prohibits a clinician or anyone else from mixing aid-in-dying medications. Rather, many laws specifically state it is permissible. There is a common misperception that hospice personnel are legally prohibited from mixing the medications. For details of the safe preparation of aid-in-dying medications, refer to the ACAMAID mixing instructions.

●Preparation of medications

•The medicines come as powders in a bottle, mixed to a suspension in water or clear apple juice, to a final volume of 2 to 4 ounces (60cc for non-oral administration). We suggest preparing the aid-in-dying medications no more than 30 minutes before they are to be taken. It is crucial to understand that the final product is a suspension, not a solution. If prepared too long before ingestion, the suspended powders will settle and may form concretions in the container/syringe. A crucial practice is to add the diluent (apple juice or water) to the bottle containing the powders. Pouring dry powder from the bottle to be mixed in a glass risks aerosolizing the powders, with potential inhalation of toxic medications by attendants or family members.

•The medications are preferably mixed in the kitchen or a bathroom near the patient's room. For safety, it is best to prepare the medicines in the bottle, then cap the bottle and bring it to the bedside. That way, if you trip on the way to the patient's bed, the medicines will not spill. Decant the suspension of medicines into a drinking glass at the bedside. (Or, some patients prefer to drink directly from the bottle.) For non-oral administrations, draw up the medications into the 60cc catheter-tip syringe, then cap the syringe and bring it to the bedside (holding the tip up so that the powders don't settle into it and clog the tip).

•Some settling of the suspended powders may occur during even a brief delay before the patient ingests the medications. If the patient is using a glass for oral administration, keep a spoon at the bedside to stir the suspension if any settling is noted. If the dose is taken directly from the bottle, shake it before ingestion. If the medications are in a catheter-tip syringe, rapidly and repeatedly invert the syringe to fully suspend all the powders. Anyone present can legally stir the liquids in the glass, shake the bottle, or agitate the syringe; it is not considered part of self-administration.

•Be sure that all pets and young children are safely secured while you mix the medications and bring them to the beside. Once the drugs have been ingested, rinse the bottles, glasses, and spoons. Pets and children can then freely join the patient and family.

Oral self-administration — For oral administration, the patient is typically sitting up in bed or in a comfortable, stable armchair (commonly a cushioned recliner). If the patient takes the medications while in a chair, no attempt should then be made to move to a bed. The risk of falling is extreme. It is fine to remain in the chair until death.

●Aid-in-dying medications are bitter and at times create a burning sensation. It is crucial that patients are advised of this possibility in advance, so they are not surprised and panic if it happens. Spoonsful of sorbet and/or sucking on a popsicle before ingestion cools and numbs the mouth significantly and creates a sweet taste. (This can also be repeated after the ingestion is complete, but with limited volumes so as not to overfill the stomach).

●Many patients prefer a familiar drinking glass, while others choose to take the dose directly from the bottle. If a drinking glass is used, we prefer one made of glass rather than plastic for two reasons: there is a potential risk of some medications being absorbed by plastic [21], and in our experience, it is easier to rinse out a glass container than to safely throw away a disposable plastic one. Some patients use straws (preferably wide-bore boba straws). If needed, another person may hold the straw while the patient creates the suction. (Do not use paper straws or bendable medical straws, as they tend to clog with the thick suspension of powders.)

●If the patient is at risk of aspiration, encourage them to tilt their head down to a sniff position to help protect the airway.

●Someone at the bedside should have a cell phone or other timer, set to two minutes, to provide a guide for the patient to complete the ingestion within that timeframe. Avoid a too-rapid ingestion that may precipitate coughing, which can delay completion of the dose in the timeframe needed.

Rectal catheter self-administration

●One to five days before the procedure:

•Do a thorough digital rectal examination to assure that the anus and rectal vault are patent and can accept a catheter (no obstruction/compression by masses or scarring) and that the mucosa is warm and moist to assure capability of transmucosal absorption.

•Ensure that large amounts of stool, especially pasty or impacted, are not present, and initiate laxatives and/or enemas if needed. Digital disimpaction is at times necessary.

●On the aid-in-dying morning, administer an enema to clear the rectal vault of as much stool as possible. A brief digital rectal examination should be performed immediately before inserting the catheter. Small amounts of firm stool are acceptable, while larger amounts of thick, pasty stool must be removed by repeat enema and/or digital disimpaction before the catheter is introduced.

●The catheter can be inserted by a nurse, physician, or another clinician skilled at evaluating the rectum by digital rectal examination, inserting a Foley catheter, and properly inflating the balloon.

●Use a 26 to 30Fr Foley catheter with a 30cc balloon. (Macy Catheters, commonly used during hospice care, are not safe for medical aid in dying because the thick medications may clog the narrow lumen.)

●The catheter is introduced into the rectal vault, the balloon inflated to 15cc (30cc may induce anal urge and expulsion). The balloon is then pulled back gently against the anal sphincter to assure a seal. The protruding catheter length can be threaded along the perineum and taped to the lower abdominal wall (or left to dangle free), and the patient's clothes replaced so as to cover the catheter until needed.

●Administer 10cc of water to test the patency/function of the catheter. The tube can then be clamped with a Kelly or other clamp.

●The medication powders are mixed with water or clear apple juice to a volume of 60cc and drawn into a catheter-tip syringe. (See 'Premedication and preparation of medications' above.)

●The syringe is then attached to the Foley intake port.

●The clinician or a family member can stabilize the syringe, but the patient must push the plunger to self-administer the medications.

●For a detailed video and written instructions, refer to the ACAMAID guide on non-oral administration of aid-in-dying medications.

Feeding tube self-administration (gastrostomy or jejunostomy) — Patients with feeding tubes and their caregivers are usually very familiar with using these devices. The clinician should consult with them about the methods they typically use for tube feedings: gravity bags, catheter-tip syringes, occasionally electronic pumps. (Electronic pumps should not be used for medical aid in dying, since the thick medications can clog the device.)

If a 60cc catheter-tip syringe is used, the mixed volume should be 60cc (two ounces), which is drawn into the syringe. The syringe is then attached in a manner similar to a tube feeding. Anyone can connect the medications to the feeding tube, but the patient must self-administer the liquid either by pushing on a syringe plunger or by releasing a clamp on the tubing from the gravity bag.

Ostomy self-administration — Ostomy self-administration is very similar to the rectal procedure, with subtle differences. The 26 to 30Fr Foley catheter is introduced through the stoma and threaded to its full length (not pulled back, as in rectal technique). Ideally, place a stoma wafer with a small opening over the ostomy orifice and pass the catheter through the opening. This method decreases the risk of medications flowing back out of the ostomy orifice. The balloon is inflated to the full 30cc, although even at this size there is still the possibility of slight backflow around the balloon. If a stoma wafer is not used, prevent the medicines from exiting the intestinal lumen out of the ostomy by occluding the orifice with plastic wrap or other ostomy-care materials.

As with feeding tube administrations, the volume of mixed medications should be 60cc (2 ounces), drawn into a catheter-tip syringe. Anyone can attach the catheter-tip syringe to the Foley, but the patient must depress the plunger to self-administer the medications.

Avoid use of a rectal pouch or nonfunctioning rectum — Patients with ostomies often still have an anatomic but nonfunctional rectum. There is very limited experience administering aid-in-dying medications into these structures, and the practice should be discouraged. The rectal mucosa, like the rest of the bowel, gets the majority of its nutrition from luminal contents (food and/or feces). If stool hasn't passed through these pouches for a long time, the mucosa atrophies and loses absorptive function.

Post-ingestion considerations for all patients — We advise that the clinician remain with the patient (assuming this meets with the wishes of the family or other loved ones) during the dying process to provide support and information about the dying process to the family and other loved ones.

Points to consider include:

●The patient's face and skin can take on a blue color (hypoxia) and then gray (hypoperfusion) discoloration.

●Patients are typically unconscious within 3 to 10 minutes of completing the ingestion (by any route). Frequently, loved ones cradle them and say their final goodbyes at this time. Once nonresponsive, they can remain in the seated position in bed or in the chair, or a loved one can gently lay them down.

●Breathing can vary from apnea to at times deep breaths with stridor and/or snoring; there is a high likelihood of sudden agonal breaths. When possible, we avoid repositioning the head to decrease snoring or other respiratory noise. That increases air flow, oxygenation, and carbon dioxide expulsion, which will delay death.

●Many patients are rapidly apneic immediately after ingestion, but then up to 15 minutes later they gasp deeply and begin breathing again. This pattern is so common it has been dubbed the "Lazarus effect." To avoid the shock factor, advise all at the bedside that this can happen. Following a Lazarus restart of breathing, it is uncommon for the patient to return to full apnea. Rather, intermittent small-volume breaths continue until death.

●Some drooling or overt vomiting is possible, even after unconsciousness. Although a significant volume of emesis may be observed, it consists of only some of the medications, mixed with a large amount of gastric secretions (from before the ingestion). Such vomiting is of little clinical concern. The dosages of aid-in-dying medications are calculated for the potential of losing even 50 percent of the medications without changing the success rate. Keep a towel ready to place under the patient's chin, and advise the worried family that comfort and death will proceed as expected.

●For practical reasons, some clinicians stay only until the patient is unresponsive. They then leave the home, providing contact information in case further questions arise or death is unusually prolonged. Other clinicians (commonly hospice staff, end-of-life doulas, or volunteers) stay until the patient has died. Then they assist in contacting the funeral home and provide guidance for the immediate post-death period.

After death

●Post-death care – Soon after the patient has died, many clinicians leave the family alone with the body and move to another room. It is efficient to use that interval to contact the funeral home and call hospice (if applicable) to advise of the death. If hospice staff are not already present, they often provide a post-death visit if the family wishes. Depending on who the clinician attending the procedure is, some hospices make their own visit to pronounce death before the body is removed from the home. Of note, there is no requirement that the funeral home be advised of the medical aid in dying. The body is not toxic, and the immediate cause of death is of no relevance to a burial, cremation, or science/teaching donation.

The vast majority of county coroners in US states where medical aid in dying is legal treat these deaths as they do any expected home death, especially if the patient has been in hospice care. In rare counties, coroners insist on evaluating every medically assisted death. Clinicians who are uncertain about their jurisdiction's policy should contact the local coroner to ask. It is helpful to do this before an aid-in-dying death, not after, so that efficient disposal of remains is possible and family trauma avoided. If a coroner is unfamiliar with medical aid in dying, as some still are, it is often useful to show them the applicable law and signed legal forms that permitted the death.

●Considerations for pronouncing the patient dead – Death can be difficult to differentiate from deep coma. Once breathing and pulses (or audible heart sounds) stop completely, wait a bit longer before concluding the patient has died. Aid-in-dying patients have been observed with total apnea and no pulse for up to five minutes, only to then start breathing again and their pulse returns. It is best to explain this to the family and sit quietly for at least 7 to 10 minutes before declaring the patient dead.

●The death certificate – All state aid-in-dying laws require listing the underlying disease as the cause of death, without mention of medical aid in dying. Death certificates are public records; citing medical aid in dying as a cause of death would be a violation of the patient and family's right to confidentiality. (See "Death certificates and death investigations in the United States".)

●State health department reporting requirements – State reporting requirements for tracking medical aid in dying are highly variable [22,23]. All clinicians should consider their state's requirements and respond appropriately.

SUMMARY AND RECOMMENDATIONS

●Definition and scope of topic – This topic describes the clinical practice of medical aid in dying as performed under United States laws. It is also available in selected other countries. Medical aid in dying refers to the legal practice where a clinician cares for a terminally ill patient as they consider and potentially follow through with hastening their death through the use of medications prescribed for that purpose. (See 'Introduction' above and 'Definition and terminology' above.)

●Legal requirements – There are strict legal requirements for medical aid in dying. In the United States, these requirements vary between states and change rapidly (see 'Legal requirements for medical aid in dying' above). The legal status and requirements of medical aid in dying in other countries are discussed in detail elsewhere. (See "Medical aid in dying: Ethical and legal issues".)

●Initial evaluation

•Address avoidable causes of suffering and discuss alternative treatments – The clinician should address all avoidable causes of suffering and discuss available alternative treatments. The patient should be referred to palliative and/or hospice care. The clinician should offer to provide information on the likely natural dying process. (See 'Clarify patient intentions and discuss options' above.)

●Determine patient suitability for medical aid in dying

•Assess prognosis – In the United States, a prognosis of six months or less is required for medical aid in dying. This should be confirmed. Certain prognostic challenges may exist for some patients, particularly those with neurodegenerative illness. (See 'Assess prognosis' above.)

•Confirm capacity to make medical decisions – The clinician must confirm the patient's ability to make decisions about their health care. Although most aid-in-dying laws only require a single capacity evaluation before the prescription is written, best aid-in-dying practices require ongoing clinical evaluation, since the crucial moment of a patient's fully informed consent is at the time of taking the medications. (See 'Assess capacity to make medical decisions' above.)

•Assess ability to absorb and self-administer medications – The patient must be able to absorb aid-in-dying medications via the gastrointestinal tract, usually by oral ingestion or rectal administration, and to self-administer the medications. (See 'Assess the patient's ability to absorb aid-in-dying medications' above and 'Self-administration in patients with neurodegenerative disease' above.)

●Provide ongoing care – The clinician should provide ongoing care to monitor for clinical changes such as alterations in capacity to make medical decisions or to self-administer medication, treatable symptom crises, or other clinical changes that may affect administration of aid-in dying medications. Symptom management should be coordinated with hospice clinicians. It is also prudent to establish alternative plans in case medical aid-in-dying becomes untenable. (See 'Provide ongoing care' above.)

●Regimen – For most patients, we suggest using a regimen that includes all of the following rather than other regimens (all medications must be sourced as powder) (Grade 2C) (see 'Common regimen' above):

•Diazepam 1 g

•Digoxin 100 mg

•Morphine 15 g

•Amitriptyline 8 g

•Phenobarbital 5 g

The clinician should be aware of potential causes of prolonged death and make adjustments to prevent this from occurring. (See 'Avoiding prolonged medical aid-in-dying deaths' above.)

●Clinician visit a few days prior to the medical-aid-in-dying day – A telehealth or home visit should be performed a few days before the chosen day to assess for and address potential complications due to changes in clinical status, to assure that the patient has retained capacity to make clinical decisions, and to provide final instructions to the patient. For patient planning rectal administration, a digital rectal examination is needed a few days prior. (See 'Preparing for the aid-in-dying day' above.)

●The medical-aid-in-dying day

•Premedication and preparation of the medications – Premedication is needed for both oral and rectal administration. Preparation of the medications should be performed no more than 30 minutes before they are to be taken. (See 'Premedication and preparation of medications' above.)

•Administration – Details of the best practices for administration of the medication vary between oral, rectal, feeding tube, and ostomy routes. (See 'Oral self-administration' above and 'Rectal catheter self-administration' above and 'Feeding tube self-administration (gastrostomy or jejunostomy)' above and 'Ostomy self-administration' above.)

●Post-ingestion and after death considerations – Staying with the patient through the dying process and providing support for family and loved ones is an important part of the clinician's responsibilities, along with communicating with hospice and coroners, completing the death certificate, and reporting to state health departments (if needed). (See 'Post-ingestion considerations for all patients' above and 'After death' above.)