MAiD ASSESSMENT
Address: |
Phone numbers: |
Email: |
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MRP: |
Paris ID: |
Other contacts (e.g. partner): |
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Assessor contact info: |
Specialty: |
Prior involvement with patient: |
Date referral received: |
Referral for assessment as:
Provider / assessor |
Other assessor: |
Assessment status at referral date: |
Care Coordinator: |
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Preparation
Other preparation (e.g. telephone calls) and times: |
MAiD assessment
Location(s): |
Telemedicine witness/profession/college ID: |
People present (incl. interpreter): |
Patient’s ID confirmed? |
Witness (1632) not will beneficiary? |
Request (1632) meets requirements? |
Life story: |
Social situation: |
Patient’s understanding of medical condition(s): |
Informed of grievous and irremediable medical condition? |
Background to and reasons for request. How and when was MAiD decision made? |
Intentions re MAiD (when?): |
Details of (a) current symptoms and (b) suffering (BC forms list: loss of ability to engage in activities making life meaningful; loss of dignity; isolation or loneliness; loss of ability to perform ADLs; loss of control of bodily functions; perceived burden on family, friends or caregivers; inadequate pain control/concern about it; inadequate control of other symptoms/concern about it; emotional distress/anxiety/fear/existential suffering; loss of independence; other): |
Functional status (BC forms list: unable to do most/all ADLs/IADLs; reduced/minimal oral intake/difficulty swallowing; dependence on life-sustaining treatments; significant dependence on aids for interaction/mobility; severe SOB; persistent extreme fatigue/weakness; cachexia; persistent, significant, escalating chronic pain; other): |
Mental health:
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Discussion of means to relieve suffering, including palliative care: |
Palliative care received? Duration? |
Disability support services/care? Duration? |
Discussion of alternatives to MAiD including hospice palliative care, continuous palliative sedation: |
Others in life, involvement, views, children affected: |
Relevant spiritual, religious, ethical beliefs: |
Coercion assessment: |
Feelings of burden? |
Mental state (subjective/objective): |
Capacity assessment (communication; understanding (circumstances); appreciation (options); reasoning (pros/cons); note collateral info): |
Understanding that request can be withdrawn at any time and in any manner? |
Understanding of effect of MAiD medication (death)? |
Current medications: |
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Allergies: |
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Previous reaction to anaesthetic? |
Coronary bypass? |
Heart valve replacement? |
Pacemaker? |
ICD? |
Surgery within last 28 days? |
Environ./occup./lifestyle? |
Organ transplant? |
Hx difficult venous access? |
Long-term venous access? (e.g. Port-a-Cath or PICC) |
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Relevant physical examination: |
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Conclusions
Advanced state of irreversible decline in capability (ASIDC)? |
SIIDD or ASIDC causing subjectively intolerable suffering that cannot be relieved acceptably (meaningful activity, dignity, isolation/loneliness, ADLs, bodily functions, burden, pain/concerns, other symptoms/concerns, other)? |
Need for further expertise (note track 2 requirements): |
Track 2 cases: fully informed of means available to relieve suffering, offered relevant consultations, discussed with both assessors, and given serious consideration to those means: |
Conclusion on eligibility: |
Reasonable foreseeability of natural death (RFND): |
Conclusion on track: |
Discussion of eligibility and track: |
If ineligible, discussion of right to further assessment: |
Next steps
Discussion of process (medications, continence, etc.): |
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Discussion of waiver (explanation, date, additional terms, non-binding): |
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Conclusions on waiver: |
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Anticipated date of MAiD: |
Anticipated location of MAID: |
Specific wishes (people, music, etc.): |
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Will in place? |
Funeral home arrangements: |
DNR (explain still required, suggest keep on fridge door): |
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Wishes re MAiD document copies (e.g. emailed to patient; consider waiver on fridge door)? |
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Discussion re organ donation (where appropriate, < 80 years, not metastatic cancer): |
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Further discussion: |
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Next steps: |
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Complex cases: further steps
Time tracking
Times: with patient: |
Times: documentation, MAiD forms, communication with program: |
Times: complex cases — further steps: |
Template by Adam Sandell. Last updated 2023-03-03. Suggestions? adam@adamsandell.com.
February 27, 2022
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