Medications Used in Medical Assistance in Dying (MAID)
Standard Three-Drug Protocol
The MAID procedure uses a sequential three-drug protocol: midazolam for initial sedation, propofol for coma induction, and rocuronium as a neuromuscular blocker to complete the procedure. 1
Sequential Administration
- Midazolam is administered first to provide sedation, allowing the patient to have final moments with loved ones before losing consciousness 1
- Propofol follows as the primary coma-inducing agent, typically administered in high doses to ensure complete loss of consciousness 1, 2
- Rocuronium is administered last as a neuromuscular blocker to complete the procedure and ensure respiratory arrest 1, 2
Alternative Coma-Inducing Agents
While propofol is the standard in Canada, thiopental (a barbiturate) is used as the coma-inducing agent in the Netherlands and Belgium instead of propofol, followed by rocuronium 2
Oral MAID Protocols (Self-Administration)
For patients choosing self-administered oral MAID rather than intravenous administration:
- Barbiturates (particularly secobarbital) are the most common and efficacious oral agents, based on extensive experience from the Netherlands 3, 4
- Antiemetic prophylaxis should be administered prior to oral barbiturate ingestion to prevent vomiting 3, 4
- Some protocols combine barbiturates with opioid medications for oral administration 4
Death Confirmation Protocol
- Death is confirmed after 5 minutes of continuous monitoring for cardiac and respiratory cessation using ECG and assessment of apnea 1, 2
- If any return of cardiac or respiratory activity occurs during the observation period, a new 5-minute observation period must be initiated 5
Special Considerations for Organ Donation
When MAID is combined with organ donation (ODE/ODEH):
- The same three-drug protocol is used (midazolam, propofol, rocuronium), but with additional invasive blood pressure monitoring in some jurisdictions 2
- Cardioplegic agents may be added to shorten the time to circulatory arrest by 1-2 minutes, improving organ viability 2
- No organ preservation medications (such as heparin) should be administered until death has been formally certified 5
Common Pitfalls
- Venous access problems are among the rare complications that can occur, occasionally requiring a second dose 2
- Timing of medication administration is critical—drugs must be given at appropriate intervals to ensure the patient experiences optimal anxiolytic and sedative effects at the intended time 6
- For oral protocols, difficulty swallowing the oral agents can be a complication 4