Oral Administration of Aid-in-Dying

Beyond assessing a patient’s prognosis and decision-making capacity, additional clinical evaluations are necessary to ensure a safe and effective aid-in-dying process. Bedside clinicians, such as hospice staff, doulas, and volunteers, often play a critical role in completing these assessments.

The effectiveness of aid-in-dying medication relies on intestinal absorption, systemic circulation, and receptor activity. Adequate oral intake and bowel management should be encouraged to maintain gastrointestinal function. Clinicians should review recent medical records and gastrointestinal evaluations to verify absorptive capacity. Concurrent use of opioids or benzodiazepines should also be assessed, with medication plans adjusted as needed.

Clinical risk factors that may contribute to prolonged death:
When multiple risk factors are present, an increased dosage or alternative aid-in-dying medication regimen or route may be necessary.
See our detailed list of contributing factors here.
Refer to our pharmacology page for dosage guidance.
If indicated, see our non-oral routes of administration.

Conduct thorough assessments and coordinate with bedside staff:
Do not proceed with planning oral aid in dying (call prescriber) if the patient
• has any uncontrolled nausea or vomiting
• indications of bowel obstruction or gastroparesis:
• severe nausea and vomiting
• not tolerating oral intake for 24 hours
• bowel sounds, and no BM in over 5 days.
• Cannot easily swallow the ordered volume of liquid medication
• has clearly lost capacity

Review patient information: Planning, Preparing, and the Aid-in-Dying Day.

Discuss who will provide bedside care on the day of aid-in-dying. If staff are not permitted to prepare the medications or remain bedside during ingestion, consider referring the patient to doulas or volunteers who may do so. (contact the academy at aadm@aadm.org for information).

Prepare solid contingency plans in case the patient changes plans, loses capacity, or aid in dying becomes clinically inadvisable. These plans should outline who will provide bedside attendant care, the typical signs and symptoms to expect, and medications that might be required.

The patient should practice swallowing 2 to 4 ounces (1/4 to 1/2 cup) of slightly thickened liquid to ensure they can easily do so on the day.

Patients should be encouraged to continue eating or taking at least small amounts of food to maintain motility and absorptive function. 1-2 tablespoons of ice cream or yogurt, 1-2 times per day, will suffice.

Constipation or loose stools should be carefully managed to ensure that the medications are absorbed effectively. Laxatives or antidiarrheals should be used to ensure the patient produces a soft but formed, easily passed bowel movement approximately every 3-5 days.

Nausea and vomiting should also be managed, preferably with non-sedating medications, to support the patient’s capacity.

Tip: Check the prescriber’s order to determine how many ounces of apple juice will be mixed with the medications.
Short glass cup (to mix the medications in)
measuring cup (with 1/4 and 1/2 cup markings)
non-fat popsicles or sorbet, per patient preference (of course!)
8 oz clear filtered apple juice
straw, if needed
spoon for stirring
PPE: chux, gloves, mask, small plastic trash bag

1. Inspect the medications, confirm the Rx (DDMAPH, patient’s name, and DOB), and ideally put them in the lockbox until needed, for safety.

2. Bring necessary supplies to the home.

3. Review what to expect during the procedure. Prepare and update contingency plans.

4. Manage constipation, nausea, or vomiting, and use of comfort medications to optimize GI and cognitive functions.

5. Assess GI function: intake, output, symptoms (nausea, vomiting, bowel sounds, constipation, diarrhea, ascites), and medications.

6. Assess cognition: orientation, use of comfort or other sedating medications, ability to understand and communicate terminal disease, prognosis, and end-of-life options, including aid-in-dying.

7. Assess the patient’s ability to swallow the ordered volume of fluid.

8. Call the attending provider, or their backup, to review the assessment findings, review pre-care instructions, prescription, and plans for the procedure, including who will provide bedside care.

1. Verbally confirm that the patient wishes to proceed with plans to take the medications to die, and that they understand they can change plans at any time.

2. Review what to expect during the procedure.

3. Manage constipation, nausea, or vomiting, and use of comfort medications to optimize GI and cognitive functions.

4. Assess GI and cognition functions and the patient’s ability to swallow the medications.

5. Call the attending provider, or their backup, to review the assessment findings, review pre-care instructions, prescription, and plans for the procedure, including who will provide bedside care, and whom the patient or family should call with questions or concerns, and after the death.

The day of the planned death, upon arrival:
1. Verbally confirm that the patient wishes to proceed with plans to take the medications to die, and that they understand they can change plans at any time, including today.

2. Also verbally confirm that they have the strength to self-administer, are sufficiently oriented, and have maintained NPO/clear liquids only after midnight.

3. Review who will provide bedside care, what to expect during the procedure, and after the death.

Review the prescription, which typically specifies mixing medications with 2–4 ounces (¼ to ½ cup or 60–100 mL) of liquid.

1. Set up in a clean, quiet area away from others—especially pets and children. Place a protective barrier and put on a mask and gloves.

2. Measure the prescribed amount of clear, filtered apple juice. Pour it directly into the medication bottle. If the bottle cannot hold the full volume, pour the remaining juice into the short glass cup.

3. Secure the bottle cap and shake for at least 30 seconds. Check that the medication is fully mixed (it will not dissolve completely, but will form a suspension), including at the bottom of the bottle.

4. Clean up and dispose of any used or contaminated materials in a small plastic bag, keeping it out of reach until you can discard it properly.

5. Bring the capped medication bottle (and any remaining apple juice), the short glass cup, straw (if needed), spoon, and popsicles or sorbet to the bedside.

1. Have the patient sit upright or recline on their left side.

2. When the patient expresses readiness to begin, shake the medication bottle thoroughly for 30 seconds.

3. Remove the cap and pour the entire contents into the short glass, adding any remaining apple juice as directed. Stir the mixture with a spoon if it settles.

4. Offer the medication to the patient promptly. You may support the glass or straw if needed.

5. Instruct the patient that they may proceed with taking the medication.

6. After ingestion, place the glass in a secure location, out of reach of others.

7. Record the time of ingestion and the time of deep sedation for documentation and provider reporting.

8. Once sedation has started, position the patient on their left side to support absorption.

9. Encourage family members to gather close, offer reassurance, and normalize the natural signs of the dying process, emphasizing that the patient is deeply unconscious and comfortable.

10. After the patient has been unresponsive for about 30 minutes and the family feels settled, you may begin cleanup. Rinse and remove labels from used containers, including the medication bottle. Dispose of the bottle and other contaminated supplies in a plastic bag, then place it directly in an outdoor bin—never in household or kitchen trash.

11. If staff are leaving, ensure the family knows whom to contact for questions, concerns, or to report the patient’s death.

12. Death may be confirmed once there has been no pulse or breathing for at least 10 minutes.