Courses and Information

The Academy has gathered data showing that rectal, feeding tube, or ostomy administration of aid-in-dying medications is safe and effective when patients are carefully screened, prepared, and supported. Clinicians can minimize potential complications by specific evaluations and preparations.
The Academy highly recommends that all patients considering aid in dying enroll in hospice care, especially those who may need support for non-oral self-administration. Terminally ill patients’ conditions can change rapidly, and good palliative care and realistic contingency plans are essential.
Monitoring and preparing patients for non-oral routes of administration requires expert clinical attention and collaboration between attending/prescribers and bedside clinicians. Non-oral routes of self-administration require a doctor or (hospice) nurse to be present to manage this more complex medical procedure. End-of-life doulas can provide additional and often essential support but are not licensed to help with this procedures. Some hospices permit and train their nurses to insert rectal catheters when needed and ordered by a provider.
Please use this link for referrals to hospices or other providers who can manage non-oral routes.
The patient must self-administer the aid-in-dying medications to themselves by pushing the medications into their GI tract using a feeding syringe or by releasing a clamp orally or manually. As a reminder, per the laws, the patient must have mental capacity on the planned day of death and must depress the feeding syringe plunger or release the clamp without assistance.
Detailed Information and Guidance for Clinicians:
Supplies are generally available from hospices or online medical supply stores. We recommend having two complete sets on hand in case the first clogs or malfunctions.
Please note:
We do not recommend using Macy catheters or any feeding pump for this procedure. Aid-in-dying medications are a thick suspension of powders, which have clogged the narrow 14Fr lumen of Macy catheters and the tubing on the kangaroo pumps.
Supplies needed:
two 60mL catheter-tip syringes (one for medications, one for pre-test water flush)

30mL Luer-lock syringe (to inflate balloon).
Foley clamp or Kelly clamp

Lubricating jelly

Gloves

clear (filtered) apple juice

Chux and paper towels

tall container, like a graduated cylinder (to hold filled syringes tip-up)

And bring a plastic bag to clean up at the end.

additional for rectal administration:
26-30Fr Foley catheter with a 30mL balloon. (choose the largest size tolerable and available)

30mL leur lock syringe to inflate balloon

saline enemas (NOT bisacodyl suppositories!)

additional for ostomy administration:
Narrow-orifice procedure wafer – with a small hole that will cover the stoma and tightly fit the catheter to prevent the aid-in-dying medications from refluxing into the bag. Do not cut smaller.

28-30Fr Foley catheter with a 30mL balloon

30mL leur lock syringe to inflate balloon

1. First, review the procedure and sequence of events so everyone who will be present, including family, loved ones, and friends, knows what to expect. Please see the video enactment of an aid-in-dying day below:
Enactment of an Aid-in-Dying Day
2. Assessments, preparations, and monitoring :
- Inform the patient and their family about the necessary preparations and what to expect on the day of the procedure (refer to the resources below).
- Remind patients and their loved ones that the patient must have the mental capacity and the physical ability to self-administer without assistance to proceed.
- Prepare, update, and review contingency plans with patients and families in case aid in dying becomes not an option or clinically not advisable. Review signs and symptoms that indicate that aid in dying might soon become not an option or too unsafe to proceed.
- The patient should practice depressing the plunger and fully emptying a 60mL syringe filled with water or Ensure into a bowl to be sure they can easily do so without assistance on the day. They will need to apply pressure slowly and smoothly to release the medications while carefully avoiding forcing the plunger with so much pressure that the tubing connections open and medications spray out. (Tip: using a new syringe, with a few drops of cooking oil around the edge of the plunger, can make this easier.)
- Patients planning to use other mechanisms, such as manually or orally releasing a clamp, should also practice the planned self-administration.
- NOTE: feeding pumps, such as kangaroo pumps or Macy catheters, should NOT be used with non-oral routes, as they clog too easily.
- Constipation or loose stools should be carefully managed using medications if needed, with the goal of a soft but formed, easily passed bowel movement every 3-5 days to ensure the aid in dying medications are easily absorbed.
- NOTE: Bisacodyl (stimulant) suppositories should NOT be used in the 48 hrs before a rectal procedure to minimize the risk of rectal stimulation and expelling the aid-in-dying medications.
- Nausea or vomiting must be thoroughly controlled for at least 72 hours before the procedure (yes, even for non-oral administration), ideally with non-sedating, non-agitating medications that don’t inhibit gut function or movements, such as ondansetron, metoclopramide, or low-dose dexamethasone (which has additional positive effects such as improved mood, energy, and appetite). Patients should be taking and tolerating at least small amounts of food for 72 hours before a non-oral aid-in-dying procedure.
- Inspect the medications, confirm the Rx (DDMAPh), and check all supplies to ensure everything needed for the aid-in-dying procedure is there.
3. Contact the attending/prescribing provider
- Review the patient’s plans to proceed with the specifics of their non-oral route.
- Report gastrointestinal assessments, ability to self-administer, and capacity evaluation findings.
- Review signs and symptoms to monitor that would indicate that it is unsafe for the patient to proceed with the planned aid-in-dying non-oral route and patient contingency plans.
- Review medication and NPO orders for the night before.
- Ask about the best way to contact them or their backup if urgent needs arise, especially during the procedure and afterward, to provide information for their required DPH forms.
The Academy has a hotline for clinicians in the field with questions or even urgent needs!
Note:
- Bisacodyl (stimulant) suppositories should not be used in the 48 hrs before the rectal procedure to minimize the risk of rectal stimulation and expelling the aid-in-dying medications from the rectum.
- Macy catheters should not be used for aid-in-dying medications, as they clog too easily with the thick suspension.
Additional care, three to seven days before the procedure:
- Perform an initial rectal exam, assessing for stool quality and quantity, obstructions, sphincter tone, and general tissue condition (warm, moist, non-friable).
- Administer a saline enema. Assess for leakage during administration and ability to retain the enema for 10 minutes. May repeat as needed to empty the rectal vault.
- Report findings to the attending/prescribing provider
24 hours before the procedure:
- Review instructions, requirements, and what to expect during the procedure with the patient and family. Patients should have nothing by mouth after midnight, clear liquids only, but continue comfort medications. For more details, check with the attending/prescribing provider.
- Remind patients and their loved ones that the patient must have the mental capacity and the physical ability to self-administer without assistance to proceed. If needed, review contingency plans, and indications that they might be necessary.
- Perform an additional rectal exam, assessing for stool quality and quantity, obstructions, sphincter tone, and general tissue condition (warm, moist, non-friable).
- Administer a saline enema. Assess for leakage during administration and ability to retain the enema for 10 minutes. May repeat as needed to empty the rectal vault.
- Contact the attending/prescribing provider to report assessment findings, review plans and contingencies, medications, and confirm contact information for which provider to call if urgent needs arise during the procedure.
On the Day of Aid in Dying:
- Upon arrival, assess and verbally confirm that the patient has sufficient capacity and hand strength to depress the plunger and empty the syringe, has no nausea or vomiting, and has maintained NPO/clear liquids only after midnight.
- Review what to expect during the procedure with the patient and loved ones, and remind them that the patient must self-administer without assistance.
- Repeat the rectal exam and, if needed, administer another saline enema to empty the rectal vault. Move the patient to their chosen bed, provide some privacy, and help them get into a comfortable side-lying position for the exam. A small amount of firm stool high in the rectal vault will not significantly interfere, but ensure the vault is mostly empty and not filled with soft, pasty stool.
- NOTE: Wait at least one hour after the last enema before proceeding with self-administration to ensure that the rectum does not continue to contract, which might expel the medications.
- Insert the catheter: Lubricate a 26-30fr catheter with a 30mL balloon and insert it 3-4 inches into the rectum. Then, with a 30mL luer lock syringe, inflate the balloon fully and tug it back against the internal sphincter to seal it. Thread the catheter up between the legs along the peritoneum, tuck it into the clothing waistband, and clamp it. The patient can now sit upright.

- Help the patient to flush the catheter with 10-15mL water to check patency and the patient’s hand strength. Fill 60mL catheter tip syringe with 15mL water. Unclamp the catheter and insert the syringe. Anchor the catheter if needed, and have the patient depress the plunger to flush it. Check the anal area for any fluid leakage. (again, report finding if clinically indicated).

Note:
- Do not use any feeding pump, such as a kangaroo pump, for non-oral administration of aid-in-dying medications. The tubing is too narrow and clogs too easily with the thick suspension of medications.
- An upright position helps prevent medications from refluxing into the esophagus during self-administration. Remind patients and families that any burning sensations will quickly pass with sedation.
If the patient is too weak to depress the plunger on a 60mL catheter-tip syringe, there may be alternative means to self-administer.
- Patients commonly understand their own strengths and may be able to strategize other mechanisms. One method is to use a gravity bag with a slightly kinked tube to block the flow of medications, which can then be released by the patient’s hand or mouth. The patient will need to practice this several times before the procedure. Please discuss these issues with the prescriber.

24 hours before the procedure:
- Review instructions, requirements, and what to expect during the procedure with the patient and family. Patients should have nothing by mouth after midnight, clear liquids only, but continue comfort medications. For more details, check with the attending/prescribing provider.
- Remind patients and their loved ones that the patient must have the mental capacity and the physical ability to self-administer without assistance to proceed. If needed, review contingency plans and indications that they might be necessary.
- Assess GI function (intake, output, N/V), capacity, and ability to self-administer.
- Contact the attending/prescribing provider to report assessment findings, review plans and contingencies, medications, and confirm contact information for which provider to call if urgent needs arise during the procedure.
On the Day of Aid in Dying:
- Upon arrival, assess and verbally confirm that the patient has sufficient capacity and hand strength to depress the plunger and empty the syringe or can manage their chosen mechanism to self-administer the medications, has no nausea or vomiting, and has maintained NPO/clear liquids only after midnight.
- Review what to expect during the procedure with the patient and loved ones, and remind them that the patient must self-administer without assistance.
Note: The ostomy route requires more clinical information and medical support than other non-oral routes.
The attending/prescriber should review all pertinent surgery notes and scans to better understand the ostomy’s placement, utility, mechanics, and potential absorptive function, as well as which direction and area the catheter should be aimed towards.
Follow the prescriber’s suggestion about medications and intake the day before aid in dying, as well as choosing the best time of day to proceed. Many patients know the time of day that their stool is least likely to flow, which will help plan the best time for the procedure.
2-3 days before the planned procedure
The clinician should perform a test run, accessing and flushing the ostomy with a small amount of water. This will allow any issues to be identified and hopefully resolved before the actual procedure.
Procedure:
1. Prepare medications in the 60mL syringe (see below).
2. Remove the existing wafer (and bag), and clean around the stoma. Apply skin prep all around peri-stoma and stoma, and allow to dry as much as possible, so entire area is sticky with adhesive.
3. Apply the narrow-orifice procedure wafer, covering as much of the stoma as possible. Leave just enough room to pass the catheter. Use the warmth and gentle pressure of your palm to mold and stick the wafer in place.
4. Lubricate and then insert the tip of the catheter through the narrow-orifice procedure wafer, past the stoma, and into the intestine (in the direction ordered) as far in as it will comfortably go, at least 4-6 inches. Inflate the balloon fully to 30mLs. Do not pull back against the wafer.
5. Flush the catheter using 10-15 mL of plain water in a catheter-tip syringe to ensure the line is patent, then clamp.
6. Bring the family in close and prepare pt for self-administration.
7. Unclamp the catheter, attach the syringe, and allow the patient to self-administer while you anchor the catheter and syringe.

8. After self-administration, clamp the catheter as close to the ostomy as possible, and remove the syringe.
9. Using your gloved palm, occlude the exit as much as possible by gently but firmly pressing down on the opening in the wafer, covering the clamp and protruding end of the catheter.
10. After 15 minutes, release the pressure and apply the bag, sealing in the clamp and the protruding end of the catheter.
11. Do not remove the catheter post-mortem so any remaining medications do not leak out. Regular post-mortem care can be provided.
Prepare medications to a total volume of 60 mLs, being very careful not to overfill the syringe. Then, cap the syringe and bring it cap-side up to the bedside.
- Choose a clear area that is free of children or pets. Put down a barrier, don gloves and a mask, and use a fresh 60mL syringe.
- If needed, put a few drops of cooking oil around the edge of the plunger to help the patient depress and empty the syringe.
- Pour 45 mL clear filtered apple juice into the medication bottle, re-cap it, and shake to mix the powder and juice into a suspension.
- Decant the suspension into a cup and draw all of it up into the 60 mL catheter-tipped syringe.
- Add 10-15 mL more filtered apple juice to the cup and slowly draw small increments of juice into the syringe until it reaches 60 mL.
- Then, cap the syringe and put it cap-side up into a graduated cylinder or other tall container.
- Bring this container to the patient’s bedside, carefully keeping the tip upright. The medications clump up easily in the tip and can cause a plug.
Once the patient is ready for self-administration.
- Shake the filled capped syringe vigorously for 30 seconds.
- Uncap and insert the syringe into the catheter.
- Unclamp the catheter and anchor for the patient if needed.

- Instruct the patient that they may proceed and depress the plunger.
- Once the patient has depressed the plunger, clamp the line, remove the syringe, and place it safely out of reach.
- Once sedation onset begins, lay the patient down.
- For rectal administration patients, lay the patient on their left side and discreetly check for medication leakage.
- Support the family to move in close for comfort and then normalize signs and symptoms of the dying process.
- Once the patient has been unconscious for at least 30 minutes and the family is comfortable, the clinician can clean up and possibly depart.
- Carefully rinse the cup and medication bottle. Remove the label from the bottle and dispose of the bottle syringes and any contaminated materials in a plastic bag brought to the outside bin.
- Instruct the family that once the patient has had no neck pulses and no breath for over 10 minutes, the patient has died, and hospice can be called.
- For staff and loved one’s safety, we recommend the catheter remain in place until the mortuary picks up the body.
Each patient’s death is an opportunity to improve the care of the next patient.
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