Planning, Preparing and the Aid-in-Dying Day

Stay in close contact with your care team
Please stay in close contact with your prescribing provider and your hospice or palliative care team for support and guidance. Patients are never obligated to take their aid-in-dying medication, and it is entirely normal to change one’s mind. Many people are surprised to find that their natural dying process is more peaceful than expected, especially with quality hospice care. In these cases, patients often continue on their natural course and die without using the prescribed medication.

Understanding your “window of opportunity”
There is a specific window of opportunity for aid in dying. It opens once a patient is determined eligible and closes if the patient permanently loses decision-making capacity or the ability to safely ingest and absorb the medication. Your attending prescribing provider, working closely with the hospice or palliative care team, can help guide you about whether and when to proceed. While no clinician can predict exactly when a person will begin to die, clinical updates can help you stay informed about your condition and timing considerations. When patients become weaker, bedbound, sleep most of the time, lose appetite, show changes in alertness or vital signs, or experience worsening symptoms, these may be signs that the body is preparing for death and that the opportunity for aid in dying may be closing soon.

Managing symptoms so you do not feel rushed
Any uncomfortable symptoms can and should be well managed, so that the decision to proceed with aid in dying is not driven by unmanaged discomfort. Hospice or palliative care teams can help ensure that symptoms such as pain, nausea, or shortness of breath are well controlled. Some hospices fully train and support their staff to provide attentive care for patients considering aid in dying. For referrals, please fill out our intake form at this link.

Your reasons are your own
Patients are not required to justify their decision or prove that they are suffering. While it is important to discuss your thoughts with a trusted provider, your reasons for proceeding may be entirely private and personal.

Planning for all possibilities

It is important to have detailed plans and good bedside care, such as hospice, in case you lose the mental capacity or physical ability to safely proceed with aid in dying. If needed, your loved ones or other bedside attendants should be prepared to provide comfort and vigil care, including repositioning, cleaning, and administering comfort medications. Ask your hospice team or healthcare provider to help you develop this plan.

Arranging bedside support for the aid-in-dying day

This can be a very tender and stressful day, and having the right support can make it easier for everyone. If your hospice team cannot provide bedside care, privately hired doulas or volunteer organizations may be able to offer calm, experienced presence. The patient must be able to self-administer the aid-in-dying medication, but others can still help with the surrounding tasks. A nurse, end-of-life doula, family member, or friend may prepare the medication, offer reassurance, and provide practical bedside support. Whenever possible, arrange this help well before the aid-in-dying day so everyone knows their role and feels prepared.

Medications and symptoms in the days before the aid-in-dying day

Constipation, diarrhea, nausea, and vomiting should be proactively managed, ideally with non-sedating medications, to help maintain alertness and decision-making capacity. However, comfort medications should never be withheld, and all distressing symptoms should be well controlled.

Keep the aid-in-dying medication safely at the pharmacy until needed

For safety, the aid-in-dying medication should be kept at the pharmacy until your plans are finalized, and the date is near, typically just a few days beforehand. This helps ensure the medication does not pose a risk in your home and prevents loved ones from having to dispose of it. Pharmacies can typically deliver the medication promptly when needed, and you will not be charged while it is being securely held.

If you live in a facility or are using another location

Make sure that facility staff or caregivers are sufficiently informed in advance. Skilled nursing facilities may legally prohibit aid in dying on their premises, while other facilities may have different requirements. If the patient intends to use a short-term rental, the owner or operator should be informed, at a minimum, that the patient is seriously ill and may die on the premises. A friend’s or family member’s home may be a workable alternative if needed.

Practice swallowing or using non-oral routes

Once your plans are set, practice swallowing two to four ounces of a slightly thickened liquid, such as a smoothie, each day. This helps ensure that you can swallow comfortably when the time comes. If you plan to use a non-oral route, practice pressing the plunger and emptying a 60 mL or 100 mL syringe filled with water into a bowl. This practice can help you feel more confident and prepared for the aid-in-dying day.

The day before and the morning of the procedure

Scheduling the procedure in the morning can help ensure there is adequate time for attendance and support. Consider saying goodbye to loved ones in the days leading up to the planned day, while keeping only your closest companions nearby for your final moments. The night before, stop taking all solid food after midnight and consume only clear liquids afterward. Many patients choose to wear an incontinence brief for comfort, although passing stool is uncommon.

Support on the day of death
The aid-in-dying procedure is generally very peaceful when you and your loved ones know what to expect and feel well supported. Having knowledgeable hospice staff or another experienced bedside attendant can help ensure a calm process and allow your loved ones to focus on being with you.

Preparing the medications
The medications come in powder form and must be carefully mixed with clear, filtered apple juice. For detailed step-by-step instructions, please see our handout “Preparing the Aid-in-Dying Medications.” The Academy strongly recommends having an experienced clinician manage this preparation, which can reduce stress during this tender time and minimize the amount of medical detail your loved ones have to handle.

Taste and physical sensations
When swallowed, the medication may cause a burning sensation or a bitter taste. This can be soothed by a non-fat popsicle or a few teaspoons of non-fat sorbet before and after taking it. Sitting upright during swallowing can help prevent coughing, and it is best to remain upright until sedation begins to take effect.

If you cannot swallow the medication
Some patients are unable to swallow but can self-administer the medication by pushing it into the GI tract through a tube, such as a PEG, ostomy, or small rectal catheter. Non-oral routes require significant clinical support. If you need a provider who can manage a non-oral route, please fill out our referral form at this link.

What to expect after taking the medications
After taking the medication, most people become sleepy within five to ten minutes and then enter a comfortable coma. Their breathing may slow and seem to pause, and their skin color may change; they may also take a few very deep, sudden breaths that can look alarming, but they will not be aware of these changes and will not feel discomfort. For many, breathing and the heart slow down and stop over the next two hours; for some, this can take longer if their body absorbs the medication more slowly. They will remain comfortable during this time. Once there have been no breaths for 10 minutes, and there are not heartbeat in their neck, the patient has died.

This can be a very tender and stressful day, and having a knowledgeable clinician at your bedside can make it easier for everyone. A nurse, end-of-life doula, or volunteer can help prepare the medication and offer reassurance. If your hospice staff is not permitted to provide this support, ask for them or your attending prescriber for referrals.
(PDF of these instructions is at the bottom of this page)

What you will need
• Paper towels or a chux pad
• Gloves, mask, and a small plastic trash bag
• A short glass cup (easy to drink from without tipping back too far)
• A measuring cup with ounce and cup markings
• 8 ounces of clear, filtered apple juice
• A straw, if needed
• A spoon for stirring
• Non-fat popsicles or non-fat sorbet (kept in the freezer until needed)

Important notes before you start
• Check the label on the medication bottle for how much apple juice to use (for example, 2 ounces [about 1/4 cup] or 4 ounces [about 1/2 cup]).
• These medications are dense powders and will not fully dissolve; some powder will always sink to the bottom.
• Because they settle quickly, you will need to shake the bottle several times to keep the powder mixed into the juice.
• The mixture can taste bitter and may cause a burning feeling in the mouth and throat.
• Practicing drinking 2–4 ounces from the short cup within 2 minutes, once or twice a day for a few days before, can make the actual day easier.
• A non-fat popsicle or small spoonful of sorbet just before and just after the medications can help numb the mouth and add a bit of sweet comfort.

Step 1: Set up the space

• Choose a clean, quiet area away from pets and children, ideally near a sink for easy clean-up.
• Lay down paper towels or a chux pad on your work surface.
• Put on your mask and gloves. Place the small plastic trash bag nearby.

Step 2: Mix the medications with apple juice

1. Measure and pour the apple juice into the measuring cup and set it aside.
2. Pick up the medication bottle and, while it is still capped, gently tap the bottom so the powder settles away from the cap.
3. Keeping the bottle on the counter, remove the cap and slowly pour about half of the measured apple juice into the bottle, then recap it.
4. Shake the capped bottle strongly for at least 30 seconds.
5. Uncap the bottle and pour in the rest of the apple juice. If the bottle cannot hold all of it, pour the extra juice into the short glass.
6. Recap the bottle and shake again, checking the bottom of the bottle to be sure the powder is mixed in; keep shaking if you still see powder.

Step 3: Clean up and go to the bedside

• Put any used paper towels, gloves, or masks into the small plastic trash bag and keep it out of reach until you can throw it away.
• Take the capped medication bottle (and any extra apple juice), the short glass, straw (if needed), spoon, and the popsicles or sorbet to the bedside.

Step 4: Right before the patient takes the medications

1. Have the patient suck on the cold popsicle or have a few spoonfuls of non-fat sorbet to cool their tongue.
2. When the patient is ready, shake the capped bottle again for at least 30 seconds.
3. Uncap the bottle and carefully pour the mixture into the short glass. Offer it to the patient, using a straw if that is easier for them.
4. If they need more time, gently stir the mixture with the spoon to keep the powder mixed into the juice.
5. Encourage them to drink all of the mixture within 2–3 minutes, if possible.
6. Once the patient has finished the medication, place the cup, spoon, and bottle somewhere out of reach.
7. Offer sips of juice or a non-fat popsicle or sorbet to help with any lingering bitterness or burning in the mouth

What your loved ones should do right after death
Loved ones or bedside attendants should call hospice or the attending provider once no breaths or neck pulse have been detected for at least 10 minutes.

Death certificate and life insurance
According to the law, the death certificate will officially list the patient’s underlying medical condition as the cause of death, not medical aid in dying. Life insurance companies are legally prohibited from canceling policies for patients who pursue aid in dying.

Grief support
In general, families are not at higher risk of complex grief simply because their terminally ill loved one took aid-in-dying medication and died. Hospices and various nonprofits offer specialized grief support for families. Contact us for details.

Plan extra time for evaluation and support

If you decide to travel to another state and choose to proceed, arriving at least three to seven days in advance of your planned death is strongly recommended. A patient’s condition is very likely to deteriorate, which may mean increased fragility and the need for more care. Arriving early allows time for thorough evaluation and preparation, helps minimize risks of adverse outcomes, and supports a more peaceful experience for both you and your loved ones.