Patient’s full name: PHN: DOB: Age (years):
Address: Phone numbers: Email:
MRP: Paris ID: Other contacts (e.g. partner):
Assessor name: MSP number (if applicable): College ID:
Assessor contact info: Specialty: Prior involvement with patient:
Date of request (1632): Witness (1632): Date witness signed request:
Date referral received:

Referral for assessment as:

Provider / assessor

Other assessor:
Assessment status at referral date:


Review of medical records and times:
Other preparation (e.g. telephone calls) and times:

MAiD assessment

Date(s): F2F / video / telephone:
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?
Details of suffering and current symptoms:
Intentions re MAiD (when?):
Discussion of means to relieve suffering, including palliative care:
Palliative care received? Duration? Disability support services? Duration?
Relevant spiritual, religious, ethical beliefs:
Others affected, including children, and significance of that:
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Understanding that request can be withdrawn at any time and in any manner?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)?
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:


Serious and incurable illness, disease or disability (SIIDC) other than mental illness?
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/preferences re IV or oral MAiD:
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: preparation, review of medical records (from above):
Times: with patient:
Times: documentation, MAiD forms, communication with program:
Times: complex cases — further steps:

Template by Adam Sandell. Last updated 2022-09-05. Suggestions?

February 27, 2022

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