PEG or Feeding Tube Administration of Aid-in-Dying

• Remind the patient that they are never required to take the medications to die, and can change plans at any point and choose not to proceed with the procedure, and that it is perfectly normal to adjust plans. 
• Prepare solid contingency plans in case the patient loses capacity or aid in dying is not clinically advisable. These plans should outline who will provide bedside attendant care, the typical signs and symptoms to expect, the care that may be needed, and which medications might be beneficial.
• Ensure that facility staff or caregivers are sufficiently informed; SNFs can legally prohibit aid in dying on their premises, but other facilities may have different requirements. If the patient intends to use a short-term rental, the owner/operators should be notified and, at a minimum, informed that the patient is ill and likely to die soon, on the premises. (A friend’s or family member’s home may be a viable alternative if needed)
• Remind the patient that to proceed, they must be sufficiently oriented to communicate an understanding of their terminal disease, prognosis, and their end-of-life options, including aid-in-dying.
• The patient must be able to administer the liquid medications through their PEG tube independently, either by pressing the syringe plunger or by releasing a clamp using their teeth or another preferred method. They should practice self-administration beforehand to confirm they can complete the process comfortably and without difficulty.
• NOTE: We do not recommend using a pump of any kind due to the high risk of clogging and jamming.
• Constipation or loose stools should be carefully managed using medications if necessary, with the goal of achieving a soft but formed, easily passed bowel movement every 3-5 days to ensure the aid-in-dying medications are readily absorbed.
• Any nausea or vomiting must be well-managed for 72 hours, preferably with non-sedating medications. Before proceeding, the patient should have been able to tolerate small amounts of intake in the past 24 hours.  
• Continue all medications, including comfort medications, unless otherwise ordered by the attending provider.
• The patient should stop intake after midnight the night before the procedure, except for clear liquids.
• Ideally, the procedure should be initiated in the morning to allow time for attendance.
• Patients may feel more comfortable wearing an incontinence brief in case of urination, but are unlikely to pass stool. 
• The patient should stop eating after midnight the night before the procedure and consume only clear liquids thereafter.
• Discuss who will prepare the medications. If staff are not allowed to manage this complex task, consider referring to end-of-life doulas or volunteers who may. If loved ones must manage this, explain how to do so safely. (See below.). Another person can legally assist with preparing the medications and anchoring the catheter if needed.
• The 2-4 oz of liquid medication can cause a slight burning sensation, which will pass quickly once sedation begins.
• Once the sedation takes effect, the patient can be gently laid on their left side (to enhance absorption), and the family can come close for comfort. Typically, the time to sleep and enter a deep coma is 5-10 minutes, and the time to death is around 2 hours, but may range from 1 day to 10 minutes.
• After administration, the patient’s lips may become blue, their face may become pale, and their jaw may relax. There may be slight stiffening and relaxation of the body, followed by sudden deep breathing, which can then stabilize and become shallow for several hours. Reassure patients and families that once in a deep coma, the patient will not experience any discomfort.
• Discuss who may remain at the bedside during the ingestions until the patient is deeply comatose. If staff are required to leave the room during these critical moments, consider referring to end-of-life doulas or volunteers for this essential care.
• The patient’s heart and lungs will slow down and stop. Death can be determined once there is no detectable neck pulse and no breath for over 10 minutes.
• Typically, a hospice nurse visit can be provided whenever needed, including after the patient has died, for post-mortem care.

Bring supplies to the home.

Tip: Check the prescriber’s order to determine whether a 60 mL or 100 mL catheter-tipped syringe is required:

2 x 60mL or 100mL catheter-tipped syringes (with cap)

2x small clamp

graduated cylinder (to hold filled syringes upright)

8 oz clear filtered apple juice

PPE: chux, gloves, mask

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. Prepare and update contingency plans.
3. Manage constipation, nausea, or vomiting, and use of comfort medications to optimize GI and cognitive functions.
4. Bring supplies, in duplicate, to the home.
5. Assess GI function: intake, output, symptoms (N/V, 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 self-administer by depressing the plunger on a feeding syringe or releasing a clamp, using their teeth or another preferred mechanism.
8. Call the attending provider to review the assessment findings, and (ideally) to receive a verbal order. Discuss:

• The patient’s plans for ingestion (if any)
• Assessment findings and  Clinical factors associated with prolonged or complicated aid-in-dying
• indications to change the aid-in-dying prescription dose or route of administration, or other medications.
• Review the pre-procedure instructions, particularly any comfort medications to be continued or discontinued, and the volume of apple juice to be added to the aid-in-dying medications.
• Promptly notify the prescriber and do not proceed with aid in dying if the patient:
  • Has uncontrolled nausea, vomiting, or signs of bowel obstruction or gastroparesis, including severe nausea and vomiting.
  • Is not tolerating intake for at least 24 hours, or has no bowel sounds, and has had no BM in over 5 days.
  • The patient appears not to have capacity, such that they cannot communicate an understanding of their terminal disease, prognosis, and end-of-life options, including aid-in-dying.
  • The patient appears not to have sufficient strength to self-administer.

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. Ensure all necessary supplies are on hand. (see above)
3. Review what to expect on the day of the procedure. (see above)
4. Reassess GI and cognitive function, and strength/ability to self-administer.
5. Call the attending provider to review the assessment findings, and (ideally) to receive/revise verbal order. Discuss:
   • The patient’s plans for ingestion (if any)
   • Assessment findings and  Clinical factors associated with prolonged or complicated aid-in-dying
   • indications for needed changes to the prescription dose or route of administration.
   • Review the pre-procedure instructions, particularly any comfort medications to be continued or discontinued, and the volume of apple juice to be added to the aid-in-dying medications.
   • Promptly notify the prescriber and do not proceed with aid in dying if the patient:
     • Has uncontrolled nausea, vomiting, or signs of bowel obstruction or gastroparesis, including severe nausea and vomiting.
     • Is not tolerating intake for at least 24 hours, or has no bowel sounds, or no BM in over 5 days.
     • Is unable to easily administer medications into their PEG tube by depressing a syringe plunger or releasing a clamp.  
     • The patient has permanently lost capacity and cannot communicate a clear understanding of their disease, prognosis, end-of-life options, including aid-in-dying.

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 what to expect during the procedure (see above).

Review the order, which typically calls for medications to be mixed to a total volume of 60mL or 100mL. Prepare the medications to the total volume ordered, being careful not to overfill the syringe:

1. Place a barrier, put on masks, and gloves.  

2. Draw up and decant roughly ½ to ¾ of the ordered volume (30-50mLs) of clear, filtered apple juice directly into the medication bottle, cap it, and shake it for at least 30 seconds.  

3. Then, pour this suspension from the bottle into a cup and draw it up into the catheter-tipped syringe.  

4. Next, pour an additional amount of filtered apple juice into the cup and draw it into the syringe, filling it to the total volume ordered, being very careful not to overfill the syringe.  

5. Cap the syringe and place it tip/cap-side up into the graduated cylinder, keeping the tip upright to prevent blockage, as medications tend to clump in the tip.  

7. Clean up and dispose of any contaminated materials in a plastic bag and store it out of easy reach for later cleanup.   

8. Bring capped tip-up medications in the graduated cylinder, along with an additional water-filled catheter-tipped syringe (for flush), to the bedside.  

1. Have the Patient sit upright or lie on their left side.
2. Just before self-administration, flush the catheter with 10- 15 mL of water (using a second syringe) to check the catheter for clogs and discreetly check for any anal leakage. If any are observed, remove the catheter and insert the second/spare catheter, then flush to reassess.
3. Hold the filled capped syringe tip up and shake vigorously for 30 seconds.
4. Uncap the syringe and insert it into the catheter.
5. Unclamp the catheter and anchor for the patient if needed.
6. Instruct the patient that they may proceed and depress the plunger.
7. Once the patient has depressed the plunger, clamp the line, remove the syringe, and place it in a safe location.
8. No further flush is required. If any concerns, check discreetly for any leakage of medications.
9. Note the time of ingestion and the time of full sedation to report later to the attending provider.
10. Once sedation has begun, lie the patient down on their left side (to improve absorption).
11. Support the family by encouraging them to gather close for comfort, normalize signs of the dying process, and reassure them that the patient is deeply in a coma and is comfortable. 
12. Once the patient has been unconscious for 15 minutes and the family is settled, consider leaving the bedside to clean up. Gather the syringes, rinse any contaminated containers, including the medication bottle, and remove any labels. Dispose of the bottle, syringes, graduated cylinder, and other contaminated materials in a plastic bag, then place it in the outdoor bin (not in the kitchen trash). 
13. If staff must depart, family should be notified who to call if they have any questions or concerns, or once the patient has died.
14.  Death can be confirmed once neck pulses and breathing have stopped for at least 10 minutes.
15. Leave the catheter in the rectum post-mortem to contain residual medications and ensure staff safety.