Medications Used in Medical Assistance in Dying (MAID)
Primary Drug Protocols
The most effective MAID protocols use barbiturates as the primary agent, administered either intravenously with a neuromuscular blocker or orally at high doses. 1, 2
Intravenous Administration
For IV MAID, use either pentobarbital or phenobarbital as the primary sedative, followed immediately by a neuromuscular blocking agent:
- Pentobarbital: 1-3 mg/kg IV bolus, followed by infusion of 0.5 mg/kg/h, with usual maintenance of 50-100 mg/h 1
- Phenobarbital: Alternative barbiturate with similar dosing parameters, offering rapid onset and anticonvulsant properties 1
- Propofol: Loading dose of 20 mg, followed by infusion of 50-70 mg/h, provides very rapid and titratable unconsciousness 1
The barbiturate induces deep unconsciousness, while the neuromuscular blocker (typically a curare derivative) ensures respiratory arrest 2, 3. This combination is highly reliable and produces predictable outcomes 2.
Oral Administration
For oral MAID, prescribe high-dose barbiturates (typically 9-10 grams), often combined with antiemetics:
- Barbiturates alone are most commonly used (37 of 50 oral protocols reviewed) 2
- Some protocols combine barbiturates with opioids (7 of 50 protocols) 2
- Always recommend a prokinetic agent prior to lethal drug ingestion to prevent vomiting and ensure adequate absorption 2
Critical caveat: Opioids alone are NOT reliable for MAID because they produce an unpredictable duration of the dying process, even at high doses 3. The same limitation applies to benzodiazepines used as sole agents 3.
Adjunctive Medications
Benzodiazepines
Midazolam is frequently used in combination protocols, particularly when additional sedation is needed:
- Starting dose: 0.5-1 mg/h continuous infusion 4, 1
- Usual effective dose: 1-20 mg/h 4
- Advantages: Rapid onset, can be co-administered with morphine or haloperidol, compatible with subcutaneous administration 4
Antipsychotics (for delirium management)
If the patient exhibits delirium or agitation during the process:
- Levomepromazine: 12.5-25 mg starting dose, up to 300 mg/day continuous infusion 4, 1
- Chlorpromazine: 12.5 mg IV/IM every 4-12 hours, or 25-100 mg rectally 4, 1
These agents provide antipsychotic effects and some analgesic properties 4.
Common Complications
The most frequent complication is prolonged duration of the dying process due to impaired drug uptake 2. Other complications include:
- Difficulty obtaining intravenous access 2
- Difficulty swallowing oral agents 2
- Vomiting of oral medications (mitigated by prokinetic agents) 2
These complications can cause significant distress for patients, families, and providers, emphasizing the importance of proper medication selection and dosing 2.
Clinical Context
The barbiturate protocols described above differ fundamentally from palliative sedation or withdrawal of life-sustaining measures. In those contexts, morphine is the initial opioid of choice for opioid-naïve patients (2 mg IV bolus, titrated to effect), with sedatives like benzodiazepines or propofol used as second-line agents 4. However, for MAID specifically, barbiturates remain the most reliable and predictable agents 2, 3.