British Columbia Medical Assistance in Dying Prescription

Transcription

1 British Columbia Medical Assistance in Dying Prescription Date: Page 1 of 6 Upon completion of MAID: 1) to provide copy of MAR to Pharmacist for reconciling the return of unused and partially used medications in Prescription Accountability section of Prescription; 2) Pharmacist to provide copy of completed Prescription (including Prescription Accountability section) to ; 3) to fax completed Prescription (all sections, including MAR) with all other MAID forms to BC Coroners Service, Attention Deputy Chief Coroner, fax ; 4) For cases involving a health authority (HA), to fax or mail an additional copy of Prescription (all sections) to applicable HA (see bottom of page 4 for HA fax numbers and mailing information); 5) to retain a copy of Prescription (all sections) in patient s health record. Identification and Declaration Patient Information Name: Address: Medical Information (pertinent to medical assistance in dying - allergies, etc.): Medical / Nurse Practitioner Information () Name: CPSID #: CRNBC #: Address: Telephone Number: Signature: Medical / Nurse Practitioner Declaration () The will initial each statement to declare it is true. The Pharmacist will initial the first statement to acknowledge discussion and confirmation with. The intention is NOT that the Pharmacist performs an assessment of the patient s eligibility criteria or obtains consent from the patient these functions are to only be performed by the. I confirm the medications prescribed on this form are intended for the purpose of medical assistance in dying, and patient s drug therapy has been discussed. I have determined the patient is capable to consent to medical assistance in dying. I have determined the patient is suffering from a grievous and irremediable medical condition and meets the eligibility criteria. I have received informed consent from the patient authorizing medical assistance in dying. Name of other Medical / Nurse Practitioner who confirms that the patient meets the eligibility criteria. Pharmacist

2 Intravenous Protocol Administered by Medical / Nurse Practitioner Patient Name: Page 2 of 6 The following are the components of the Medical or Nurse Practitioner-Administered medical assistance in dying intravenous drug protocol. Initial to confirm the selected drug for each protocol component. Sign the form at the bottom to prescribe the selected medications. Indicate by checkmark whether IV Regimen is: midazolam (1 mg/ml) Local Anaesthetic lidocaine (20 mg/ml) Primary IV Kit x 2 (Pharmacist must dispense 2 identical IV kits of all drugs in a sealed / tamperproof container.) or Back-up IV Kit for Oral Regimen Dispensed Quantity Dosage Notes (Mitte) Anxiolytic (Initial to confirm anxiolytic is being ordered.) 10 mg x mg to 10 mg IV over 2 minutes. May repeat additional dose x 1 PRN. midazolam 1 mg/ml is preferred formulation. 40 mg 40 mg IV over 30 seconds. lidocaine 20 mg/ml is preferred formulation. COMA Inducing Agent (CHOOSE one of the two alternatives. Initial to indicate selected agent.) propofol (10 mg/ml) phenobarbital (120 mg/ml) Neuromuscular Blocker rocuronium (10 mg/ml) OR IV Line Flush Solution sodium chloride 0.9% solution 1 g x 1 1 g IV over 5 minutes. May repeat additional dose x 1 PRN. 3 g x 1 sodium chloride 0.9% 10 ml x 3 for injection (for dilution) 3 g (dilute to 50 ml with sodium chloride 0.9%) IV over 5 minutes. May repeat additional dose x 1 PRN. 200 mg 200 mg by rapid IV injection. 1 st line agent Obtain additional PRN from back-up IV kit, if required. 2 nd line agent phenobarbital 120 mg/ml is preferred formulation. Confirm deep medically-induced coma before administration. 10 ml x 6 Flush IV line after each medication to ensure entire dose is given AND to. Medical / Nurse Practitioner Signature () My signature serves to prescribe the medications initialed above for this patient. Signature Date CPSID # or CRNBC #

3 Oral Protocol Self-Administered (Supervised by Medical / Nurse Practitioner) Patient Name: Page 3 of 6 The following are the components of the Self-Administered medical assistance in dying oral drug protocol. Initial to confirm the selected drug(s) for each protocol component. Sign the form at the bottom to prescribe the selected medications. For controlled prescription drugs (e.g. morphine), provide an additional prescription written on a duplicate prescription form and attach to this form. Dispensed Dosage Notes Quantity (Mitte) Gastric Motility / Anti-Emetic metoclopramide 20 mg (tablets) ondansetron 8 mg (tablet) haloperidol 5mg (5 mg/ml) 10 mg tablets x 2 20 mg (2 tablets) orally one hour prior to ingesting comainducing agent. 8 mg tablet x 1 8 mg (1 tablet) orally one hour prior to ingesting comainducing agent. 5 mg intravenous vials x 2 Anxiolytic (Initial to confirm anxiolytic is being ordered.) LORazepam 0.5 mg (sublingual tablets) 0.5 mg sublingual tablets x 8 5 mg subcutaneous or IV over 1 minute PRN for emesis during procedure. May repeat additional dose x 1 PRN. 0.5 mg to 2 mg (1 to 4 tablets) sublingually, 5 to 10 minutes prior to ingesting coma-inducing agent, if needed for anxiety. May repeat additional dose x 1 PRN. COMA Inducing Agent (Initial to confirm each ingredient is being ordered.) Powder Mixture: phenobarbital powder* 20 g Shake well. Ingest the entire prescription in less chloral hydrate powder* 20 g than 4 minutes. morphine sulphate powder** [Note: Omit morphine if patient has significant morphine allergy (i.e. anaphylaxis)] ORA-Plus / ORA-Sweet (50/50) or Distilled Water for feeding tube 3 g qs to 120 ml *Active ingredients required for coma induction. **Optional, depending on patient factors (e.g., adverse effects, tolerance). Stable for 72 hours. Use haloperidol 5 mg/ml intravenous formulation Patient to follow with a small amount of nonfat, non-carbonated drink. If compound is to be administered via PEG or NG tube, replace ORA- Plus /ORA Sweet with 120 ml of water. Flush feeding-tube with 60 to 90 ml of water after medication. Notes: 1) must complete the Intravenous Protocol section of the prescription form to prescribe the specific contents of the back-up IV kit. 2) Pharmacist must dispense 1 po kit plus 1 IV kit as backup in sealed / tamperproof container. The backup IV kit should include a second dispensed quantity of propofol or phenobarbital (i.e., total dispensed quantity of propofol 1 g x 2, or phenobarbital 3g x 2 ). Medical / Nurse Practitioner Signature () My signature serves to prescribe the medications initialed above for this patient. Signature Date CPSID # or CRNBC #

4 Page 4 of 6 Prescription Planning Patient Name: Planned Date and Time of Prescription Release and Return of Unused Medications Planned Release Date (YYYY/MM/DD): Planned Return Date (YYYY/MM/DD): Planned Release Time (00:00 am/pm): Planned Return Time (00:00 am/pm): Plan for Concluding Medical Assistance in Dying Process Procedures have been established for the return of any unused and partially used medication(s) within 48 hours to the Pharmacy for secure and timely disposal. Any Pharmacist within the dispensing pharmacy can receive back unused and partially used medications from the. Completed Prescription Accountability Medication Administration Record The has been instructed on how to complete the Medication Administration Record for medical assistance in dying medications. Dispensing Sign-Off Completed Printed Name Signature College ID Date Time Dispensed by: (Pharmacist) Received by: () CPBC License #: CPSID # / CRNBC #: Confirmation of photo ID of, if applicable: Completed Return of All Unused and Partially Used Medications to Pharmacist for Disposal The will return all unused and partially used medications to the pharmacy within 48 hours of the patient s death. The Pharmacist will reconcile and document the return of unused and partially used medication(s) below. Medication Name(s) Form Strength Quantity Printed Name Signature College ID Date Time Returned by: () Received by: (Pharmacist) CPSID # / CRNBC #: CPBC License #: Health Authority fax numbers for submission of forms: For mailing addresses of Health Authorities, FHA: Fax: NHA: Fax: VIHA: Fax: see Document Submission Checklist, HLTH IHA: Fax: VCHA: Fax: PHSA: Fax:

5 Page 5 of 6 Medication Administration Record (Provide copy of completed MAR to Pharmacist) Medical Assistance in Dying Intravenous Protocol (Administered by Medical / Nurse Practitioner) Date: Name of Patient: PHN: Name of Medical / Nurse Practitioner (): CPSID #: CRNBC #: Signature: : Dose Administered Time Given Anxiolytic midazolam 2.5 to 10 mg IV over 2 minutes Anesthetic lidocaine 40 mg IV over 30 seconds Coma-inducing Agent - Choose propofol OR phenobarbital propofol 1 g IV over 5 minutes phenobarbital 3 g (dilute to 50 ml with sodium chloride 0.9%) IV over 5 minutes Neuromuscular Blocker Confirm patient is in deep medically-induced coma* prior to administration rocuronium 200 mg by rapid IV injection * Deep medically-induced coma: No response to verbal stimuli, unable to rouse; serious depression of circulation, evidenced by weak pulse; serious depression of ventilation, evidenced by slow, shallow breathing; no protective reflexes, such as eyelash reflex.

6 Page 6 of 6 Medication Administration Record (Provide copy of completed MAR to Pharmacist) Medical Assistance in Dying Oral Protocol (Supervised by Medical / Nurse Practitioner) Date: Name of Patient: PHN: Name of Medical / Nurse Practitioner (): CPSID #: CRNBC #: Signature: : Dose Administered Time Given Anti-emetic (prior to procedure) metoclopramide 20 mg (10 mg tablets x 2) 1 hour prior to the coma-inducing agent ondansetron 8 mg (1 tablet) 1 hour prior to coma-inducing agent Anxiolytic LORazepam 0.5 mg sublingual tablets 0.5 to 2 mg (1 to 4 tablets), 5 to 10 minutes prior to coma-inducing agent, as needed for anxiety Coma-inducing Agent phenobarbital powder 20 g chloral hydrate powder 20 g morphine sulphate powder 3 g (cross-out morphine, if not given) ***Shake well. *** Ingest entire mixture in less than 4 minutes, followed by a glass of water or non-carbonated, non-fat liquid of patient s choice. For PEG or NG tube administration, flush feeding-tube with 60 to 90 ml of water after medication. Anti-emetic (during procedure) haloperidol 5 mg SUBCUT or IV over 1 minute as needed for emesis