Rectal 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 for those requiring rectal administration. Bedside clinicians, such as hospice nurses, and recent medical records, including imaging studies, 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 imaging 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.

Please don’t hesitate to contact our hotline if you have questions:

We recommend that prescribers collaborate, when possible, with bedside RNs to gather assessment information and to help determine the dose and route of administration.

If the rectal route is indicated, we encourage prescribers to provide an order for the insertion of a rectal catheter for self-administration.

Conduct thorough assessments and coordinate with bedside staff:
Do not proceed if the patient presents with any of the following:
• Palpable rectal obstruction due to stool or tumor, or extremely thin, friable rectal tissue
• Severely weakened rectal sphincter tone such that an enema cannot be retained for 10 minutes
• Permanent or temporary loss of decision-making capacity
• Insufficient strength to self-administer medication

Note: Macy catheters are wonderful, but do not work for aid-in-dying; the lumen is too narrow (14fr), and the one-way valve is prone to clogging with aid-in-dying medications, which tend to clump easily

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

Instruct the patient that the rectal catheter is a small, flexible tube inserted 2 inches into the rectum, anchored internally by a small water-filled balloon. The tubing is threaded up between the legs to the waistband. Patients can be fully dressed for the procedure and usually do not feel the catheter or experience discomfort once it is inserted. Patients self-administer 2-4 oz of medication by depressing the plunger and emptying a syringe into the tubing, which is roughly half the volume of a typical saline enema. (Consider bringing these supplies to demonstrate to the patient and family.)

The patient should practice depressing the plunger and fully emptying a 60mL or 100mL syringe filled with water into a bowl to ensure they can easily do so on the day.

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.

Patients should be encouraged to continue eating or taking at least small amounts of food, unless they are NPO, 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 the rectal vault is empty, allowing medications to be absorbed through the rectal mucosa. Laxatives or antidiarrheals should be used to ensure the patient produces a soft but formed, easily passed bowel movement approximately every 3-5 days.

Bisacodyl (stimulant) suppositories should not be used in the 48 hrs. before the rectal procedure to minimize the risk of rectal stimulation expelling the aid-in-dying medications from the rectum. 

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

Bring supplies (in duplicate) to the home.

Tip: Check the prescriber’s order to determine whether a 60 mL or 100 mL catheter-tipped syringe is required:
4x saline enemas
2x 26-30fr foley w/30mL balloon
3 x 60mL or 100mL catheter-tipped syringes (with caps).Check the order!
2 x 30 mL Leur (screw-on) syringe for balloon
2x small foley clampShort glass cup (to mix the medications in)
Graduated cylinder (to hold the filled syringes upright)
Lubricant
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. Bring necessary supplies, in duplicate, 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 self-administer by depressing the plunger on the syringe.

8. Perform a rectal exam, assessing for stool quality and quantity, obstructions, sphincter tone, and general tissue condition (warm, moist, non-friable).

9. Administer a saline enema. Assess for leakage during administration and the ability to retain the enema for at least 10 minutes.

10. Call the attending provider, or their backup, to review the assessment findings, review pre-care instructions, prescription, plans for the procedure, and to receive order to insert a rectal catheter for self-administration.

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

5. 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.

6. Assess the patient’s ability to self-administer by depressing the plunger on the syringe.

7. Perform a rectal exam, assessing for stool quality and quantity, obstructions, sphincter tone, and general tissue condition (warm, moist, non-friable).

8. Administer a saline enema. Assess for leakage during administration and the ability to retain the enema for at least 10 minutes. May repeat as needed to empty the rectal vault. (NOTE: do not use bisacodyl suppositories or any rectal stimulant laxative).

9. Call the attending provider, or their backup, to review the assessment findings, review pre-care instructions, prescription, plans for the procedure, and review/revise the order to insert a rectal catheter for self-administration.

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.
4. Perform a rectal exam to ensure the rectum is empty; administer an enema if necessary.
   • NOTE: Wait at least one hour after the last enema before proceeding to minimize the risk of expelling medications.
5. Insert a 26-30Fr catheter with a 30mL balloon into the rectum. Then, inflate the 30 mL balloon fully and tug it back against the internal sphincter to create a seal. Thread the catheter between the legs along the peritoneum, tuck it into the waistband of the clothing, secure it, and clamp it.

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. Choose an uncluttered area, away from others, especially pets or children. 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.
3. Cap the bottle and shake it for at least 30 seconds. Check to be sure all the medication is mixed, especially from the bottom of the bottle.
4. Uncap the bottle and pour the suspension from the bottle into a cup, then draw it up into the catheter-tipped syringe.
5. 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.
6. 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 pre-flush), to the bedside.

1. Have the Patient sit upright or lie on their left side.
2. 5-15 minutes before self-administration, flush the catheter with 10-15 mL of water (using the second syringe) to check for clogs and discreetly assess for anal leakage. If any are observed, remove the catheter and insert the second/spare catheter, and 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 30 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 or other accessible area). 
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.