The Oral MAiD Option in Canada

Part 2: Processes for Providing

Review and Recommendations

Harty C, Chaput AJ, Buna D, Trouton K, & Naik VN

A Canadian Association of MAiD Assessors and Providers (CAMAP) White Paper on

Oral MAiD

April 18, 2018

!1 April 18, 2018

Contents

1. Executive summary

2. Improving access to oral MAiD for Canadians

a. Providing options for Canadians

b. Improving access to MAiD across Canada

3. Key collaborations in the provision of oral MAiD

a. Practitioner and patient

b. Practitioner and pharmacist

c. Pharmacist and patient

4. Safe acquisition and administration of oral MAiD medications

a. Safe compounding

b. Dispensing

c. Administration

5. Optimizing the patient and family experience for oral MAiD

a. Preparations for a successful process

b. Obtaining final consent prior to MAiD provision

c. Preparing for a delayed or failed oral medication process

6. Oral MAiD provider experience in Canada

!2 April 18, 2018

Executive Summary
Medical Assistance in Dying (MAiD) has been legal in Canada since Bill C-14
received royal assent in June 2016. Following approval against eligibility criteria, MAiD
can be provided in the majority of Canadian provinces and territories, by either
intravenous administration of medications by physicians or nurse practitioners, or self-
administration of oral medications by the patient themselves. The main advantage of
offering patients an oral option is the autonomy it provides for patients to take the
medications themselves, and re-establish some control during a challenging time in
their disease or illness.

The purpose of this paper is to outline best practices for the safe dispensing,
administration, and evaluation of the plausibility of an oral MAiD provision. Guidance
will be provided for both clinicians and pharmacists in the provision of oral MAiD. The
medications recommended for oral MAiD are covered in Part 1 of this guideline.

The following are summary recommendations:

1. Clinician presence is currently recommended for all oral MAiD provisions in

order to be able to evaluate success and effectiveness and, if needed,
intervene with intravenous medications in the case of delay or failure.
2. With greater experience with oral medications in Canada and greater
knowledge of the effectiveness of oral regimens, there may come a time when
clinician presence need not be required for oral MAiD provisions.
3. Clinicians should write prescriptions for both oral and IV medications for
patients requesting oral MAiD.
4. Regular communication with the patient should be maintained to confirm that
the patient’s preference and the ongoing appropriateness for an oral route has
been preserved for the planned date/time.
5. To optimize absorption, patients should refrain from eating 6 hours prior to
taking the coma-inducing medications. Clear, non-carbonated fluids can be
continued.

6. The patient is recommended to take an anti-emetic regimen at least 1 hour

before consumption of the coma-inducing agent.

7. Secure delivery of the medication is important to prevent harm to others from

this lethal dose of medication. Secure delivery of the medication could be
accomplished by dispensing the medication directly to the providing clinician,
either on their way to the provision or by a participating pharmacy to a
clinician already present at the site of provision.
8. In preparation for potential delay or failure of the oral medication, ease of vascular access
should be assessed, as with all patients requesting MAID. If vascular access may be
difficult, clinicians, in consultation with the patient, may opt to start an IV prior to oral
ingestion.

!3 April 18, 2018

9. Clinicians should come to an agreement with patients prior to the MAiD procedure on an
agreed upon time (for example, 1 hour) that if death has not occurred, there will be IV
supplementation with standard IV MAiD medications to cause death.

10. Where applicable, instructions from pharmacies should be followed explicitly

with respect to reconstitution of the oral MAiD regimen.

11. Immediately prior to the start of the procedure clinicians should obtain final
consent for MAiD, which should include both the oral MAiD procedure as well as
consent for potential IV MAiD supplementation.

12. Clinicians should witness the ingestion of the medication. The patient should
assume a standard Fowler’s position (60 degrees) when consuming the
medication and remaining sitting for at least 20 minutes, even if unconscious,
to optimize absorption and prevent regurgitation.

13. The patient should consume all of the medication within 4 minutes. Use of a
straw should be avoided as its use can slow the rate of consumption. Clear
fluids between swallows are allowed as long as it does not prolong duration of
consumption.

14. After consuming all the medication, the aftertaste can be mitigated by
consumption of a strong liquor (1/4 cup of vodka or whiskey), or a room
temperature non-carbonated beverage (1/2 cup). Creamy and milky liquors or
beverages should be avoided.

15. Any unused medications should be returned to the pharmacy for proper
disposal.

!4 April 18, 2018

Improving Access to Oral MAiD for Canadians
Providing options for Canadians
The provision of MAiD through the administration of intravenous (IV)
medication by a provider, while safe and highly effective, for many patients may feel
“institutionalized” and/or “proceduralized”. While providers always strive for a
patient centred experience through provisions in the home, an intravenous MAiD can
be perceived by some patients as very clinical. The clinical perception is somewhat
unavoidable given the requirement for vascular access and the necessary bedside
participation of a clinician with IV MAiD, which can extend the intimacy of the
moment beyond a circle of friends and family. Some patients may want to feel
empowered to control this final act of their life. The availability of oral medications
for MAiD may facilitate a more intimate and empowered process for a patient by
lessening some of the procedural aspects and a need for bedside clinician intervention
through IV medications.

Improving access to MAiD across Canada

Currently there is no accurate or stable data for the number of clinicians
providing MAiD services in Canada. In a pre-legislation survey by the Canadian Medical
Association (CMA), only 29% of physicians surveyed said that they would consider
providing MAiD, and as many as 63% said that they would refuse (Vogel, 2015). No
differentiation was made between providing the prescription or IV medications and
completing a consultation for MAiD. Increasing the complexity of accurate data is that some
physicians opt to only be involved in the assessment portion of the process, and not be involved
in the actual provision of MAID. While this data may have shifted since Bill C-14 was
legislated, it can be inferred that at the time there are far fewer physicians providing
MAiD services than those who conscientiously object.

While an oral option has existed in most provinces and territories since Bill C-14
was legislated, almost all provisions in Canada to date have been through the
administration of IV medications. The proportion of those clinicians willing to
complete assessments and to physically provide MAiD versus those only willing to
complete MAiD assessments is probably multifactorial and includes the psychological
burden of being a more active participant in the death as well as a lack of comfort
with vascular access and knowledge of the medications used. With an estimated
0.3-4.6% of all deaths provided by MAiD in countries with a longer history and greater
experience (Health Canada, 2017), we can safely assume that there are currently not
enough practitioners willing to provide MAiD in Canada. Recent polling has suggested
that the introduction of reliable oral medications for the provision of MAiD may
increase access by increasing the comfort for “assessor-only” practitioners to expand
their practice to provisions by mitigating some of the concerns outlined above. This
assumption may be incorrect, at least short term, as prescribing physicians should still
need to be present to obtain final consent and ensure the lethal dose of medication is
delivered securely and successfully. This will also mean that clinicians will still need
to be prepared to obtain vascular access, or otherwise have an IV established before

!5 April 18, 2018

the oral provision, and administer IV medications in the case of failure or excessive
delay in death.

Geographically, Canada is the largest country where physician assisted death is

legal. As a result, the population is widely distributed. While MAiD is a legislated right
of all Canadians, access to it, from both an assessment and provision point of view, is
very likely inequitable, with most service providers concentrated in the urban centres.
Appropriate referral of any patient requesting MAiD has been mandated by medical
regulatory authorities. Unfortunately, without consultant MAiD clinicians available in
all communities, most referrals must be directed to the aforementioned urban
centres. While we acknowledge that this can be similarly true of many medical and
surgical services, a major goal of any MAiD service is to remain patient-centred. Due
to the nature of the eligibility criteria many MAiD patients are unable to travel.
Alternatives (ie. phone or e-consultation) to in person consultations, to mitigate
inability to travel, vary depending on provincial regulation. However, the provision of
MAiD will, at least in the short term, require travel by either clinician or the patient.
With greater experience with the effectiveness and reliability of oral medications, as
well as regulations to guide safe dispensing practice, there may come a time when the
oral medications can be offered to patients for administration in the absence of
clinicians and increase equitable access across Canada.

!6 April 18, 2018

Key Collaborations in the Provision of Oral MAiD
The planning and provision of an assisted death with oral medication requires
communication and collaboration with the patient, their family, the practitioner, the
pharmacist and potentially other supportive healthcare professionals such as nursing
and social work. Once a patient is assessed as eligible and the decision is made to
choose the oral option, a date for the provision is made that is agreeable to patient,
practitioner and pharmacist. This date should take into account the 10-day mandatory
reflection period unless there is concern that the patient will either lose the capacity
to provide informed consent within that time frame or the patient is at imminent risk
of death before the end of the 10-day waiting period (House of Commons Canada,
2016). However, in the interval between confirmation of eligibility and selection of the method,
the clinical condition may change, and should be regularly assessed. The patient may prefer the
IV option if unable to ingest an oral dose on the planned date.

Practitioner and patient

Patients who choose oral MAiD often have the desire to plan their assisted
death as more of an event. This may take some coordination among various people,
and likely requires some flexibility on the part of the clinician, as this type of
medically assisted death may require more time. Depending on the illness, disease or
disability, the clinical status of the patient may change between the decision to have
oral MAiD and the date set to ingest the medication. If the patient is unable to
tolerate oral MAiD, but wants an assisted death, the practitioner should discuss the
option of starting directly with the IV MAiD medications.

Clinicians should discuss pre-medication with an anti-emetic to help prevent or

treat any nausea or potential regurgitation. Ideally, the patient should refrain from
eating 6 hours prior to the provision. This optimizes the absorption of the coma-
inducing medication.

Clinicians should discuss the approximate time to coma and death with the
patient and family, and should explain to the patient that the oral route has a higher
risk of failure. Clinicians should discuss the time frame for an intravenous (IV)
intervention in the case of a delayed or failed oral provision. The pre-determined
time frame should ideally be established prior to the day of the MAiD provision (for
example, 1 hour or 2 hours as a time frame). An IV may be started prior to the oral
procedure or only after the oral procedure has failed. This decision should be made
taking into account the clinician’s comfort in starting an IV, the predicted ease in
establishing IV access, and the patient’s desire or comfort in having an IV prior to the
start of oral ingestion.

Emphasis should be placed on continuing usual medications right up to the

time of the provision, especially pain and anti-emetic and pro-motility medications.
While the continuation of some cardiac medications may not seem to be necessary,
clinicians do not want the patient experiencing chest pain or shortness of breath prior
to the provision as this will only contribute to their suffering. To prevent any
prolonging of time to death, pacemakers and defibrillators should be deactivated if
possible. If such access to cardiology services is not available, you should be able to

!7 April 18, 2018

obtain a magnet from a local hospital for placement over the device to turn off the
ICD function. Oxygen should be discontinued immediately after the person loses
consciousness. The family should be prepared for signs and symptoms that the dying
person may exhibit such as snoring, gurgling, changes in rate of breathing, and
increased paleness or greying or duskiness of skin. As in all MAID cases, the events for
after the procedure, such as body disposition should also be clarified and confirmed
with the family prior to start.

Practitioner and pharmacist

Prior to offering MAiD, and particularly oral MAiD, practitioners should identify
pharmacies that are willing and competent to provide the service. The specific
pharmacy standards around MAiD are governed by the provincial colleges of pharmacy
and vary from province to province. Some pharmacies do not offer collaboration with
practitioners providing MAiD, or with the MAiD coordinating service due to
conscientious objection or the lack of facilities to properly compound products.
Compounding pharmacies are undergoing more regulation as a result of cases of
inaccurate potencies and contamination in compounded products (Riley, 2017). There
are variations in multiple aspects of MAiD provision including drug protocols,
preparations of medications, storage, dispensing, destruction, documentation and
inclusion of regulated pharmacy technicians in preparation (Verweel L et al., 2018).
Each practitioner must be familiar with individual provincial medical and pharmacy
standards.

Early communication between the practitioner and the pharmacist about the
anticipated date of the provision is key to success. This allows the pharmacy to have
all the appropriate medications and ingredients available to compound the
prescription and have the agreeable staff available to carry out the compounding.
Formulations that are compounded into suspensions or solutions have a limited expiry
date and should not be prepared until immediately before the scheduled assisted
death. The practitioner and the pharmacist must discuss the appropriate antiemetic
regimen, as well as the need and format of the IV back-up kit. This should be done
prior to writing the MAiD prescription.

The security chain of these lethal medications should be clearly delineated

and transfer of medications should be understood by physician and pharmacist. Ideally,
the medication should be prepared and then picked up immediately prior to the
scheduled provision so there is no need to secure it for extended periods of time after
dispensing. Alternatively, arrangements could be made to have the medications
delivered to the site of MAiD provision. In such circumstances the clinician would need
to be present to receive the medications to maintain the chain of security.

Pharmacist and patient

Bill C-14 (House of Commons Canada, 2016) outlines the pharmacists’ role in
dispensing the medications and does not include direct participation in administering
medications. However, pharmacists do have to provide the dispensing service and if
they do not have the ability to compound the medication or are conscientious

!8 April 18, 2018

objectors, they have the responsibility to help the physician and/or the patient find an
alternative pharmacy that can provide this service.

Pharmacists do have the responsibility of providing patients and families with

information around MAiD when enquiries are made including which drugs are used,
maintaining security of the medications and correct administration procedures.

!9 April 18, 2018

Safe Acquisition and Administration of Oral MAiD
Medications
Safe compounding
The preparation of oral MAiD formulations requires adherence to strict
compounding procedures to protect the safety of staff preparing the product and to
ensure an accurate, stable and palatable product. In the absence of MAiD specific
published literature, these recommendations rely on references such as the US
Pharmacopeia Non-sterile Compounding Guidelines (US Pharmacopeia, 2016) and the
Canadian Society of Hospital Pharmacists Guidelines on Non-sterile Compounding
(Canadian Society of Hospital Pharmacists, 2014) These references recommend using
compounding monographs from standardized pharmacopeia’s or peer-reviewed journal
articles. It is also recommended that a regulated health professional, either a
pharmacist or a regulated pharmacy technician, are primarily involved in the
compounding procedure. Some provinces do not allow the involvement of a regulated
pharmacy technician in the MAiD preparation and dispensing.

Since the preparation of oral MAiD formulations often requires manipulation of

powders with strong pharmacological actions, compounders should wear personal
protective equipment (PPE) such as a clean gown, powder-free gloves, mask, beard
guard (if necessary) and eye protection to avoid inhalation or absorption through the
skin. An `independent double check’ of all measures is advisable to ensure accuracy to
the weighted powders/doses.

Safe Dispensing
There are some general practices of safe dispensing that will be applicable to
all oral preparations. Ideally, formulations should be dispensed in a ready-to-use
format that can be easily consumed by a person in less than 4 minutes. The preferred
format is a suspension or solution of less than 120 mL. This ensures a tight security
chain and minimizes time that is required to store the medication at home. The
disadvantage of this format is that the stability of the medication cannot be
guaranteed beyond a certain period of time. If oral MAiD prescriptions are dispensed in
powder format, there is a need for the person to mix the powder with water and juice
prior to consumption, increasing the risk of complications such as decreased
palatability, failure to consume total dose and failure of completion. In those
situations, it is recommended the compounding of the product should not happen until
immediately prior to the scheduled assisted death.

The phenobarbital, chloral hydrate and morphine combination must be

compounded into a suspension as the phenobarbital has some solubility in water and
alcohol, but the aqueous solution is not stable (Gerald, 2018). The chloral hydrate is
quite soluble in water, but easily volatizes when exposed to air, and decomposes when
exposed to light. Therefore, it is recommended to dispense this formulation in an
amber glass bottle with minimal air space at the top. Since this formulation is a
suspension, it must be shaken well prior to administration. There is no standardized
pharmacopeia formulation that guides us on an expiry date so the determination is

!10 April 18, 2018

based on the US Pharmacopeia (2016) approach of aqueous preparations of moderate
compounding complexity. It advises that water containing oral formulation could have
a `beyond use date’ of 14 days from preparation if stored at controlled cold
temperatures and 7 days if stored at room temperature. The British Columbia MAiD
protocols have opted for a 72 hour expiry date to ensure the stability and potency of
the preparation and discourage the dispensing of the preparation too far ahead of the
schedule date of the assisted death (MAID BC Pharmacy, 2018) The formulation should
include auxiliary labeling to “shake well prior to administration”, “lethal Dose”, and
“protect from extreme temperature fluctuations”.

Dispensing of secobarbital will differ from other agents and practices are
largely based on Dutch experience. The Dutch protocol provides a compounding
procedure for pentobarbital and secobarbital (KNMG/KNMP, 2012) It advises a beyond
use date of 1 month for the unopened bottle if stored at room temperature. This
formulation should NOT be stored in the fridge. Secobarbital solution should NOT be
shaken as the high pH of the solution causes it to form bubbles in a soapy manner.
Therefore, auxiliary labeling should include “lethal dose”, do NOT shake, and do NOT
store in fridge. Keep at room temperature.

The digoxin/Diazepam/Morphine/Propranolol (DDMP2) combination was

developed in Washington state and has now been adopted by some Canadian
provinces. There has been no formulation that guides the compounding of this into a
suspension or solution. Therefore it is dispensed as a mixture of the four drug powders
with directions to mix powder into 100-125 mL of water, clear juice, or alcoholic
beverage. The mixture must be shaken or stirred well until smoothly mixed and milk-
like. The entire contents should be consumed within 1-2 minutes. The requirement to
mix it immediately prior to consumption makes this option less desirable in that the
powders can be aerosolized and inhaled by providers or surrounding family and
friends. The patient also may have trouble consuming the full amount in 1-2 minutes
as it also has a bitter taste. This increases the risk of incomplete dosing, extended
dying periods and/or failure to achieve death.

The antiemetic agents may be dispensed in tablet format anytime prior to the
scheduled date and consumed as directed. There may be a need to dispense a solution
format, depending on patient specific factors. This requirement can be discussed with
the pharmacist during the planning phase.

IV backup kits can be provided in a ready-to-use format (medication drawn up

in syringes), appropriately labelled to minimize the delay in administration when the
decision is made to complete the provision with one or more IV medication. This
eliminates possible mistakes on site and minimizes the time needed to draw-up the
medications.

In order to maintain the security chain, oral MAiD medications should be passed
from pharmacist to practitioner who provides it to the patient at time of MAiD
provision. This will minimize any concern of the medication being used or
administered by another person, and maximize the effective and timely use of the
medication by the still competent person for whom it was intended. The practitioner

!11 April 18, 2018

then should return any unused portions to the pharmacy for documentation and
destruction. This will ensure no residual amounts are consumed by others at the
patient’s location, or by pets or animals.

Safe Administration
Safe administration of these medications will optimize absorption, which is
crucial to maximizing the effectiveness of the regime. To optimize absorption,
patients should refrain from eating 6 hours prior to taking the coma-inducing
medication if possible. Clear non-carbonated fluids can be continued. Ensure the anti-
emetic regimen is taken at least 1 hour before consumption of the coma-inducing
agent. Usual medications should be continued right up to the time of the provision,
especially pain and anti-emetic/pro-motility medications. In particular, while the
continuation of some cardiac medications may not seem to be necessary, experiencing
chest pain or shortness of breath prior to the provision will only contribute to
suffering.

Read the directions on the bottle of the coma inducing medication: some
formulations such as suspensions need to be shaken well before administration and
some should NOT be shaken. Patients should remain in a Fowler’s position (60 degrees)
when consuming the medication and for at least 20 minutes after consumption, even if
becoming unconscious, to optimize absorption of the medication and prevent
regurgitation. After that time, they can be lowered to a semi-reclined position.

Patients should consume the medication as quickly as possible to ensure they

have consumed the entire dose before becoming sedated or losing consciousness. Use
of a straw may slow down the rate of consumption. Sips of water or clear juice may
be taken in between swallows as long as it is done quickly and does not prolong the
consumption of the coma inducing medication.

MAiD medication is often bitter tasting. To help rinse away the bitter aftertaste
and enhance the effect of the medication, ¼ cup of strong liquor such as vodka or
whiskey OR ½ cup of room temperature, non-carbonated beverage can follow the
consumption of the MAiD medication.

!12 April 18, 2018

Optimizing the Patient and Family Experience for Oral MAiD
Preparations for a successful process
Individuals eligible for MAiD may indicate a preference for oral medication,
however, their commitment to that route of administration may change at anytime up
to the provision of MAiD. Furthermore, their preference may be altered by a change in
their status which renders them incapable of either holding a container or swallowing
effectively. In preparation for these potential changes, oral and IV medications should
always be concurrently ordered and preparations taken so that both are options at the
time of provision. As with any MAiD provision, regular and timely communication
ensures capacity and consent to proceed with a planned date and time.

On the day of the oral MAiD provision, individuals often spend their final moments
with family and friends. Events may include wishes to consume food, beverages,
alcohol, and/or other substances. As with any MAiD provision (oral and IV routes), any
consumption must be balanced against maintaining capacity for final written and/or
verbal consent to proceed with the planned provision. If an oral route is preferred,
individuals should be informed of enhanced efficacy of medications on an empty
stomach, and as such, should ideally avoid solids and full fluids in the preceding 6
hours. Clear fluids can be continued up to the planned provision. Individuals should
also be informed of the risks of nausea and vomiting associated with these bitter
medications, and if applicable, burning associated with chloral hydrate. Antiemetic
regime adherence is crucial to promoting a successful oral procedure.

Obtaining final consent prior to MAiD provision

In all provinces and territories in Canada, the MAiD process requires both a
written request from an individual and 10 “clear” days between the written patient
request and the date of the event. A final consent is obtained prior to the
administrations of IV medications, and the same should obtained prior to the ingestion
of any oral medications. These requirements ensure that there is no coercion and full
capacity of the individual to receive medications that will result in death. We suggest
that a MAiD provider must be present at the time of an oral provision to confirm
capacity and consent. Presence is also highly recommended to witness actual
ingestion of the medication, as the provider is ultimately responsible for the
prescription of the medication.

Preparing for a delayed or failed oral medication process

Examining the Canadian experience of using phenobarbital, chloral hydrate and
morphine, coma typically occurs in 15 and 20 minutes, and death between 45 and 75
minutes (Trouton, 2018). The variability in the onset of death is well documented in
the literature. Unarousable coma was followed in a stepwise fashion by slow and
shallow breathing, agonal breathing, obstructed breathing, apneic spells, and death.
These latter stages can take several minutes and can be very difficult for families to
observe. Considering these factors, final MAiD consent prior to oral administration
should include the insertion of an IV either prior to ingestion or within reasonable time
frame post ingestion. Securing vascular access can ensure that all MAiD provisions in

!13 April 18, 2018

Canada are successful, and that any potential failure in our system has been reduced
to the lowest acceptable risk. This will also ensure the most compassionate provision
of MAiD for patients and their families.

!14 April 18, 2018

Oral MAiD Provider Experience in Canada
There have been 11 cases of oral MAID provision in Canada – one in Ontario, 1 in
Saskatchewan, 1 in the Yukon and 8 in British Columbia. The summary of the 8 cases in
BC is as follows:

Oral medication Time from Pre medication Diagnosis

used drink to death

1 Phenobarbital, 60 Ondansetron Glioblastoma

morphine and
chloral hydrate

2 Phenobarbital, 60 Ondansetron and lorazepam Spinal stenosis,

morphine and CAD
chloral hydrate

3 Phenobarbital, 45 Marijuana End stage

morphine only COPD

4 Phenobarbital, 75 * Marijuana End stage

morphine and COPD
chloral hydrate

5 Phenobarbital, n/a none Metastatic

morphine and breast cancer
chloral hydrate patient was too
ill to hold or
ingest

6 Phenobarbital, 60* none Frailty, CAD

morphine only and COPD

7 Phenobarbital, 83 Ondansetron Progressive

morphine only supranuclear
palsy

8 Phenobarbital, 90* none Hepatocellular

morphine only carcinoma

* IV was started and process completed with propofol and rocuronium

Case 5 included as on the day prior to MAID, the patient still expressed strong desire to do oral,
and clinician arrived with that medication, and IV back up kit. The 4 medications were
administered, as for IV-MAID.

Patients were contacted approximately one hour prior to clinician arrival. On

arrival, the patient’s consent was re-affirmed, and they were offered a chance to
withdraw consent for the provision, and if they expressed a desire to continue, then to

!15 April 18, 2018

reconfirm their desire for the oral versus the IV route. In all cases, they proceeded to
take the drink directly from the medicine bottle, rather than a separate vessel.

A physician was present for all eight cases. All patients were strongly motivated
to not have an IV but consented to having an IV inserted if prolonged death was
observed. The first 3 cases presented did not have any IV intervention. An IV was used
in case 4, 6 and 8, as agonal breathing persisted longer than 60 minutes. 6 of the 7
patients noted bitterness, and 6 of 7 patients successfully took the entire volume
under 4 minutes. The one who was not able to take it in 4 minutes had pre-medicated
with alcohol as part of the event, and continued do take alcohol between sips of the
oral medication. Regurgitation or vomiting were not observed in any of the cases. In
case 2, a trial of Benzocaine spray (Hurricaine ©) was used, but did not seem to
improve the bitterness significantly. There was no loss of bladder or bowel control at
any time for any patient. In all cases, the coma inducing medication was brought by
the attending physician and would not have been able to be picked up by any of the 7
patients themselves because of physical decline.

In this short case series, the patients and families gave positive feedback
regarding the oral experience as a whole. Between the coma and death, the family
discussed suffering, reflected on a life well spent, and shared condolences. The total
time with the patient and family was not significantly longer than IV, but the time was
organized differently. 


!16 April 18, 2018

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Canadian Society of Hospital Pharmacists. Compounding guidelines for pharmacies. Ottawa, ON.
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KNMG/KNMP. Guidelines for the practice of Euthanasia and Physician-Assisted Suicide 2012.
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!17 April 18, 2018