Appendix A.

Ontario Medical Assistance In Dying (MAID) Death Data Collection Form

General Data
Date of Report	mm/dd/yyyy
Coroner
Patient Name
CIS Number
OHIP number
Attending (Pronouncing) Clinician at Time of Death Information	Type: □Physician □Nurse practitioner Clinician name: Specialties:
Assistant at Time of Medication Provision If Noted	Name: Profession:
Type of MAID	□Self-administered □Clinician-administered
Assistant at Time If Self-Administered?	□Yes □No □Unknown If yes provide relationship if known:
Patient Age
DOB
Patient Sex	□Male □Female
Province of Residence
Medical Diagnosis Prompting MAID Request
Did an Authorized Third Party or Proxy Sign on Behalf of the Requestor?	□Yes □No Additional details provided later in chart
Referral and Assessment Process
Were There Any Previous Requests for MAID That Were Denied?	□Yes □No □Unknown If yes: what was the reason the request was denied?
Eligibility Criteria	Assess if these were considered and review of records support the decisions made
Eligible for Public Health Care Funding	□Yes □No
At Least 18 Years Old	□Yes □No
Capable to Make Decisions Regarding Health	1.Understand certainty of death □ Yes □ No 2.Capacity can be fluid—must assess each time □ Yes □ No 3.Understand the process □ Yes □ No a.if NO was a consultation requested to assess capacity □ Yes □ No
Grievous and Irremediable Medical Condition
Serious/Incurable Illness-Disease-Disability	□Yes □No List:
Advanced State of Irreversible Decline in Capability	□Yes □No Supportive findings:
Illness, Disease or Disability or State of Decline Causes Enduring Physical or Psychological Suffering That is Intolerable to the Patient and That Cannot Be Relieved Under Conditions the Patient Considers Acceptable	Physical Suffering: □Yes □No List: Types of relief attempted/offered: Why not tolerable:
	Psychological Suffering: □Yes □No List: Types of relief attempted/offered: Why not tolerable:
Natural Death has Become Reasonably Foreseeable	–Note: likely interpret as natural course of the disease (not the manner) □Yes □No Provide prognosis(estimated time) if provided: Supportive findings:
Did the Attending Practitioner Have an Existing Therapeutic Relationship With Patient?	□Yes □No Type of relationship:
i. If Yes, For How Long?
ii. If No, Did the Request Result From a Referral Through the Clinician Referral Service?
Were There Consultation(s) With Other Health Providers (Other Than the Required 2nd Opinion). If So, What Other Provider(s) (e.g., Psychiatry, Psychology, Palliative Care Specialist)? (247(5.1)	Name: Specialty:
Was the Patient Receiving Palliative Care at the Time of the Request?	□Yes □No
Had the Patient Previously Received Palliative Care	□Yes □No
Date of First Voluntary Request for MAID (Oral)	Date:
	Made freely—no external pressure or coercion □Yes □No
	Free and informed □Yes □No
Date First Assessment of Eligibility for MAID Completed	Initial assessment date: MD/NP notes opinion if meets criteria □Yes □No Supportive Findings:
Informed Consent Provided by Patient	Date: Treatment options discussed: □Yes □No
	Informed of potential means to relief their suffering: □Yes □No
	Palliative Care offered: □Yes □No
Written Request by the Patient	Date:
	Signed by person □Yes □No If no: why not?	Other person if unable 1.18 years or older □ 2.Understands the implications □ 3.Not beneficiary □ 4.No financial benefit □ 5.In presence of patient □
	Date signed was after told of grievous and irremediable illness □Yes □No
	Independent witness ONE 1.18 or older 2.Understand the process 3.Not beneficiary 4.No financial benefit 5.Not care giver(health care or personal care) 6.Not own the Health care facility where treatment sought	Independent witness TWO 1.18 or older 2.Understand the process 3.Not beneficiary 4.No financial benefit 5.Not care giver(health care or personal care) 6.Not own the Health care facility where treatment sought
	Patient informed that they may at any time withdraw consent □Yes □No
Second Assessment Written	Second opinion assessment date: (Note that this is also considered the formal approval date)
	Independent □Yes □No 1.1st and 2nd assessors not mentors to each other □ 2.1st and 2nd assessors not in supervisory role □ 3.Not a beneficiary □ 4.No financial benefit □ 5.No other relationship with patient or other assessor □
Reflection Period	10 day period followed □Yes □No
	If No: 1st assessor(or provider of MAID) and 2nd assessor both are of the opinion that (1)Death is imminent □ (2)Loss of capacity to provide informed consent is imminent □ List the rationale to support a reduced reflection period:
Concerns Regarding Reflection Period (From Coroner)	List:
Notify Pharmacist of Purpose of Prescription	□Yes □No
MAID Provision
Withdrawal Opportunity Provided Just Before MAID	□Yes □No
Confirmation of Consent Given Just Before MAID (From Verbal Information During Reporting to Coroner or Documented in the Record)	□Yes □No
Date and Time of Death	Date:	Time:
Medications Provided Directly to Patient by Physician	List:
Medications Prescribed to Patient for Self-Administration	List:
Time/Dose of Medications to the Time of Death	Physician administered 1.Metoclopramide 2.Midazolam 3.Lidocaine 4.Propofol 5.Rocuronium 6.Potassium
Recorded Cause of Death by the Coroner
P/T of Occurrence of Death
Setting (e.g., Private Residence, Hospital, Nursing Home):	Hospital □ Ward □ Critical Care Unit □ Long Term Care Home □ Private Residence □
What Were the Patient's Concerns that Lead to the Request	Physical—List:
	Psychological—List:
Family Perspectives, Concerns or Other	List:
Family Member Aware of the MAID Process	□Yes □No
Were There Any Problems Accessing MAID Identified?	i.e. non-participating institution, clinician access issue □Yes □No □Unknown If yes please list:
Any Unique Issues/Concerns That Arose During the Investigation Not Captured Elsewhere But Significant to the Case	List:

CIS - Coroner's Information System

OHIP - Ontario Health Insurance Plan

DOB - Date of birth

P/T - Province/Territory