What medications are used in Ontario's Medical Assistance in Dying (MAiD) program for end of life procedures?

Medications Used in Ontario's Medical Assistance in Dying (MAiD) Program

In Ontario's MAiD program, the standard medication protocol includes midazolam for initial sedation, followed by propofol for coma induction, and rocuronium as a neuromuscular blocker to complete the procedure. 1

Standard Medication Protocol

The typical medication sequence used in Ontario's MAiD program includes:

• Initial sedation: Midazolam is administered first to sedate the patient 1
• Coma induction: Propofol is used as the primary coma-inducing agent (typically >1000mg) 1, 2
• Neuromuscular blockade: Rocuronium is administered to complete the procedure 1

This three-medication protocol is consistent with the Canadian national approach to MAiD, which has been documented in large cohort studies showing that 98.5% of cases used propofol, 91.4% used midazolam, and 90.8% used rocuronium 2.

Procedural Details

The MAiD procedure in Ontario typically follows this sequence:

• The MAiD provider initiates the procedure with midazolam sedation, allowing the patient to have final moments with loved ones 1
• After initial sedation, propofol is administered to induce a coma-like state 1
• Rocuronium is then administered as a neuromuscular blocker 1
• Death is confirmed after 5 minutes of monitoring for cardiac and respiratory cessation using ECG and assessment of apnea 1

Setting and Timing

• The median time from first injection until death is approximately 9 minutes 2
• MAiD procedures in Ontario occur in various settings:
  • Hospital settings (approximately 39% of cases) 3
  • Patient homes (approximately 38-45% of cases) 3, 4
  • Other healthcare facilities for the remaining cases 3

Complications and Considerations

• Complications are rare, occurring in only about 1.2% of cases 2
• Most complications relate to:
  • Difficulties with venous access 2, 5
  • Need for administration of a second medication 2
  • Prolonged time until death (particularly with high-dose propofol >1000mg, which can paradoxically extend time to death by approximately 3 minutes) 2

Special Considerations for Organ Donation

For patients who have chosen to be organ donors after MAiD (known as organ donation after medical assistance in dying), additional procedural steps may be taken:

• The standard protocol is still used, but with additional monitoring 1
• After death declaration by the MAiD provider (using permanent death criteria), a 5-minute observation period is observed 1
• For lung donation specifically, intubation may be performed after the waiting period 1

Patient Demographics in Ontario

• The median age of MAiD recipients in Ontario is approximately 70 years 3
• Slightly more males (55%) than females receive MAiD 3
• Cancer is the most common underlying diagnosis (64-70% of cases) 3, 4

This standardized approach to medication administration in Ontario's MAiD program reflects careful consideration of effectiveness, predictability, and patient comfort during the end-of-life process.