For Medical Professionals
The MAID Prescription
All of the DWDA qualifying requirements must be completed to write the MAID Rx:
Both oral requests have been documented.
Both qualifying physicians have completed their patient evaluation and determined that the patient meets all of the qualifications of the law.
The Consulting Physician Compliance Form has been turned into the Attending Physician.
The Request to End My Life in a Dignified and Humane Manner form has been turned in to the Attending Physician 48 hours prior to writing the MAID Rx.
The Psychiatric/Psychological Consultant’s Compliance Form has been completed and turned into the Attending Physician, if required.
Immediately, before writing the MAID Rx, verify the patient is making an informed decision.
Guidance for Medical Professionals
EOLCOR can provide information from experienced participating physicians, including participating pharmacies and prescribing Information
Once the qualifying steps have been fulfilled and the MAID Rx has been written, the Attending Physician should call and notify the pharmacists of the incoming MAID Rx. Pharmacists will often have questions or suggestions specific to the patient’s condition or diagnosis.
The name of a designated contact person should be included on the MAID Rx so the pharmacist can make arrangements for payment and dispense the medications to the designee.
The Attending Physician may fax the MAID Rx ahead of time but, the Attending Physician must directly deliver the MAID Rx to the participating compounding pharmacy either in person, by courier, or mail in order for it to be filled. This is a requirement of the law. A family member may not deliver the MAID Rx, but may pick up the MAID medication.
Contact EOLCOR for participating pharmacies and prescribing information.
The Recommended MAID Rx
The Death with Dignity Act does not specify the medications to use in the MAID Rx, but they should be affordable, available, predictable, and comfortable. The most common MAID Rx has a combination of sedating and cardiotoxic medications that are used for a reliable, comfortable death.
Premedication
Prophylactic antiemetics are recommended an hour before ingestion:
Metoclopramide 20 mg
Either haloperidol 2 mg or ondansetron 8 mg
Haloperidol promotes additional relaxation in anxious patients.
Ondansetron 8 mg is an alternative to the haloperidol, especially for a very weak or somnolent patient.
The Life-ending Medication (DDMA-Ph)
Currently the most commonly used combination is:
Digoxin 100 mg
Diazepam 1 gram
Morphine sulfate 15 grams (or hydromorphone 3 grams)
Amitriptyline 8 grams
Phenobarbital 5 grams (optionally)
Phenobarbital can be added as a third class, especially for patients who are not globally debilitated, have opioid tolerance, or GI tract limitations such as villous atrophy, dysmotility, or gastroparesis. Phenobarbital may shorten the time to death and anecdotally is associated with a more “peaceful” death.
Concentrated powder forms of the component drugs should be used rather than ground tablets to avoid excess filler and allow the smallest volume of diluent to be used.
The compounded mixture should be dispensed in a light protective glass bottle.
The recommended formulation in current practice changes from time to time.
Factors For Prolonged Deaths
Although the average death takes less than two hours, longer deaths do not indicate anything wrong. There are several factors that can account for longer times to death.
Adding phenobarbital to the MAID Rx may be beneficial in these cases:
Impaired gut motility and/or absorptive capacity
The MAID medication is absorbed primarily through the small intestine though some absorption of the phenobarbital may occur through the gastric mucosa.
Gastroparesis
From cancers of the pancreas or upper GI tract, diabetes, partial obstruction of the upper GI tract, or severe constipation.
Intestinal villi
Must be functioning well, with good blood supply. Small bowel resection, malabsorption syndromes, or villus atrophy due to cachexia and minimal intake can cause slow absorption of the MAID Rx.
Relative tolerance
Individuals with high-dose opiates, sedatives, drug or alcohol abuse, can have cross-tolerance to morphine, diazepam, and phenobarbital.
Young and generally healthy
Especially athletes and former athletes have longer times to death.
Weight
Over 300 lb regardless of BMI.
Increased volume of distribution
From ascites or third spacing.
To request more information about the MAID Rx, a fillable Rx blank, and participating pharmacy contact information, please submit a contact form.
The MAID Rx is valid for six months. If an individual survives longer than the validity of the MAID Rx, the Attending Physician may renew it without restarting the DWDA qualifying process.
Insurance does not typically cover the MAID Rx, with the exception of some Oregon Health Plans and Kaiser Permanent.
Advise the patient:
Not to fill the MAID Rx until they plan to use it, to avoid waste, cost, and disposal issues, they can keep it on file at the pharmacy until they want to use it.
The pharmacy will contact the patient/caretakers to arrange payment and pickup/delivery plans.
A pharmacy consultation is highly advised if there are any special circumstances.
Pharmacies
Only a compounding pharmacy may fill the MAID Rx.
Advance notice for filling the compounded Rx is helpful. The medications may not be in stock, or insurance may need to be confirmed, which can delay delivery or pickup.
Once a pharmacists fills a MAID Rx they must submit the Pharmacy Dispensing Record form to the Oregon Health Authority within 10 calendar days of fulfillment.
Written instructions for taking the MAID Rx are provided by EOLCOR, pharmacies, and Attending Physicians. They cover mixing the powder, positioning the patient, and what to expect after the MAID medication is ingested.
The presence of experienced EOLCOR volunteers and/or hospice teams are strongly recommended so the patient and their loved ones don’t have to worry about managing the MAID medications.
Reporting
After writing the MAID Rx, the Attending Physician must submit the following documentation within 7 days to the Oregon Health Authority through mail, email, or fax.
Within 10 calendar days of an individual ingesting the life-ending prescription or dying of their underlying illness, the Attending Physician must submit the Oregon Death with Dignity Act Attending Physician Follow-up Form to the Oregon Health Authority through mail, email, or fax.
Reasons Not to Use the Life-ending Medication
There may be a limited “window of opportunity” for patients to use MAID as they become progressively more ill or as sedating medications are increased. One in three patients who have the MAID Rx do not end up using it.
No longer have the ability to make medical decisions.
No longer have the ability to self-administer the MAID medication.
Have comfortable end-of-life care on hospice.