MAiD ASSESSMENT
Address: |
Phone numbers: |
Email: |
MRP: |
Paris ID: |
Other contacts (e.g. partner): |
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: |
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:
|
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Understanding that request can be withdrawn at any time and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: |
Allergies: |
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) |
Relevant physical examination: |
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.): |
Discussion of waiver (explanation,
date, additional terms, non-binding): |
Conclusions on waiver: |
Anticipated date of MAiD: |
Anticipated location of MAID: |
Specific wishes (people, music,
etc.): |
Will in place? |
Funeral home arrangements: |
DNR (explain still required, suggest
keep on fridge door): |
Wishes re MAiD document copies (e.g. emailed to
patient; consider waiver on fridge door)? |
Discussion re organ donation (where
appropriate, < 80 years, not metastatic cancer): |
Further discussion: |
Next steps: |
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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