What initial screening or conditions should be ruled out in an elderly or disabled patient with limited mobility and possible dementia, stroke, or chronic obstructive pulmonary disease (COPD), who is requesting a maid?

Initial Screening and Assessment for Medical Assistance in Dying (MAID) Requests

When a patient requests MAID, you must first conduct comprehensive screening for depression, cognitive impairment, and ensure they have been offered and understand palliative care options, as these are critical reversible or modifiable factors that may be influencing their request.

Mandatory Psychiatric and Cognitive Screening

Depression Assessment

• Screen for depression using a standardized tool at the initial MAID request visit 1
• Depression is a common, treatable condition in elderly patients that can profoundly affect end-of-life decision-making 1
• If depression is identified, evaluate whether current medications may be contributing to depressive symptoms 1
• Document specific target symptoms if depression treatment is initiated, and reassess within 6 weeks to determine treatment effectiveness 1
• Depression screening is particularly critical because untreated depression can distort a patient's perception of suffering and quality of life 1

Cognitive Impairment Evaluation

• Perform structured cognitive testing using the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) at the first MAID request visit 1, 2
• Patients with dementia, stroke, or COPD are at significantly elevated risk for cognitive impairment that may affect decision-making capacity 1, 3
• Document baseline cognitive performance across all domains: memory, executive function, visuospatial abilities, language, and behavior 2
• Assess functional impact on instrumental activities of daily living (managing finances, medications, transportation, household tasks) using tools like the Pfeffer Functional Activities Questionnaire 2
• A score below 24 on the MMSE indicates significant cognitive impairment that raises questions about capacity for MAID consent 1

Laboratory Workup for Reversible Causes

Order the following tests to identify treatable conditions that may be contributing to suffering:

• Thyroid function tests (TSH, free T4) to rule out hypothyroidism 1, 2
• Vitamin B12 and folate levels to identify deficiency states 1, 2
• Complete blood count (CBC) to assess for anemia or infection 2
• Comprehensive metabolic panel to evaluate electrolyte imbalances, renal function, and glucose control 2

Palliative Care Assessment

Documentation of Palliative Care Involvement

• Determine whether the patient has had any palliative care involvement before the MAID request 4
• Research shows that only 59.5% of MAID requestors had any palliative care involvement prior to their request, and only 27.4% had a community palliative care physician 4
• Document whether an Edmonton Symptom Assessment Scale has been completed (only 23.8% of MAID requestors had this basic symptom assessment tool completed) 4

Ensuring Informed Decision-Making About Palliative Options

• Explicitly discuss and document that the patient understands the benefits of palliative care in managing their symptoms 4
• Physical suffering is reported by 77.4% of MAID requestors, yet many have not received adequate symptom management 4
• Other common reasons for MAID requests include loss of autonomy (36.9%) and poor quality of life (27.4%), which may be addressable through interdisciplinary palliative approaches 4
• Offer referral to palliative care if not already involved, as this is a critical step in ensuring the patient has explored all options 5, 4

Specific Geriatric Syndrome Screening

Fall Risk and Functional Status

• Assess fall history and risk factors, as elderly patients with diabetes, stroke, or COPD are at increased risk for injurious falls 1
• Document functional abilities using standardized tools like the Barthel Index to establish baseline independence 1
• Determine the level of assistance required for activities of daily living (independent, standby assist, hands-on assistance, or dependent) 6

Medication Review

• Conduct a comprehensive medication reconciliation to identify drugs that may contribute to depression, cognitive impairment, or other symptoms 1
• Polypharmacy is common in elderly patients with multiple comorbidities and can significantly impact quality of life 1
• Review for drug-drug and drug-disease interactions that may be exacerbating suffering 1

Pain Assessment

• Systematically evaluate for undertreated pain, particularly neuropathic pain in patients with diabetes or stroke 1
• Document pain severity, location, and current management strategies 1

Neuroimaging Considerations

• Obtain structural brain imaging (preferably MRI) if cognitive impairment is present to detect vascular lesions, subdural hematomas, hydrocephalus, or other potentially treatable structural abnormalities 1, 2
• This is particularly important in patients with stroke history or rapidly progressive cognitive decline 1

Critical Process Considerations

Capacity Assessment

• Cognitive impairment identified during screening raises serious questions about the patient's capacity to provide informed consent for MAID 1, 2
• Patients with significant cognitive deficits may require formal capacity evaluation by psychiatry or neurology before proceeding 2

Timeline and Validation

• Many MAID requestors report that the assessment process itself provides validation of their illness and suffering, even if they don't immediately proceed 7
• The 90-day assessment period allows time to address reversible causes and ensure the request is stable 7, 8
• Be aware that 47% of MAID requests do not proceed to completion, often due to death before assessment completion, ineligibility, or loss of capacity 4, 8

Interdisciplinary Approach

• Involve interdisciplinary care early in the process, including social work, pharmacy, nursing, and spiritual care 5, 8
• Document the patient's circle of support and ensure family/caregivers are appropriately involved in discussions 5

Common Pitfalls to Avoid

• Do not proceed with MAID assessment without first screening for depression and cognitive impairment 1, 2
• Do not assume the patient has received adequate palliative care without explicit documentation 4
• Do not overlook reversible medical causes of suffering such as thyroid dysfunction, vitamin deficiencies, or medication side effects 1, 2
• Do not fail to document the patient's understanding of palliative care alternatives 4