How to make a Patient Request for Medical Assistance in Dying (MAiD) on Vancouver Island, BC
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1 How to make a Patient Request for Medical Assistance in Dying (MAiD) on Vancouver Island, BC
2 The process: 1. Get the form 2. Complete the top parts of the form: PATIENT INFORMATION PATIENT REQUEST 3. Find independent witnesses 4. Sign the form in front of witnesses 5. Find an assessor
3 1. Get the Patient Request form. The BC MAiD Patient Request Record (form) is HLTH 1632 (dated 2016/12/15) Get a copy from: Island Health MAiD coordinator: (Greater Victoria) Toll-free: maid@viha.ca continued
4 Or get a copy of the form online: Island Health: BC Ministry of Health: ms/1632fil.pdf OR Ask your doctor, nurse practitioner or any health care professional.
5
6 The form: HLTH 1632
7 2. Complete the form. Fill in Patient Information: This section may be completed by you or someone else. You don t have to personally fill it out. Please print clearly, in pen.
8 Print full name in pen and ink.
9 Add BC Personal Health Number
10 Add your birthdate.
11 Select gender.
12 Write in your home address, the address where you live.
13 Write in Main Medical Diagnosis that is relevant for an assisted death.
14 Check the box where you are making the request (location).
15 If you are not at home, indicate where you are. If you are in a facility, write which one.
16 Fill in the Patient Request section: You, the patient, must complete this section by initialing each line to show you understand what each statement means and that you agree.
17 If you cannot initial, a proxy is needed. If you are unable to initial, then a proxy may read each statement and if you agree, the proxy may initial each statement. If this is done, the 2 witnesses must be present when the proxy reads the statements to you and then initials each one to show you understand and agree.
18 Read each statement and initial that you understand and agree.
19 Once the statements in the Patient Request have all been initialed, STOP at that point. Do not sign in the space marked Patient Signature until you are asked to sign when the 2 witnesses are present.
20 3. Find 2 independent witnesses. The law requires two (2) independent witnesses watch you sign the MAiD Patient Request. They must witness you (or a proxy) sign page 1 and also witness each other sign.
21 Who can be an independent witness or proxy? At least 18 years old Does not know or believe they will benefit from the death of the patient e.g., not a beneficiary in the Will Not the owner or operator of the healthcare facility where the patient is treated or where they live Not involved in providing health or personal care services to the patient
22 How to Find Witnesses (or Proxy): Can be friends or neighbors. Ask your doctor or Nurse Practitioner. In the Victoria area, contact (volunteer Independent Witnesses and Proxy). Or contact Island Health MAiD Coordinator: (Greater Victoria) Toll-free:
23 Witnesses fill in Witness section. Page 2 of the Patient Request Form is the Confirmation of Independent Witnesses section.
24
25 Print the patient s name in the space provided at the top of page 2.
26 NOTE: The second statement requires the witnesses either know the patient or if not, they need to identify the patient with an ID. Photo ID is preferred, e.g. BC Care Card or drivers licence.
27 When the witnesses are present and ready, the patient signs on Page 1 and completes the rest of that line: Full name and the date.
28 If you cannot physically sign, a proxy is needed. Requirement for a proxy is the same as for witnesses. The proxy cannot also be a witness. i.e., must be a different person. The proxy must sign in the presence of the 2 witnesses who then sign.
29 Have Witness 1 read, initial each line then fill in and sign the section below.
30 Have Witness 2 read, initial each line then fill in and sign the section below.
31 Optional Complete the section: NEAREST RELATIVE
32 The Patient Request form is now COMPLETE. Keep the form for the 1 st assessor (see following slides) do not give it to the witnesses.
33 4. Find an assessor Contact your GP or Nurse Practitioner if you have one, and, if you are comfortable speaking with them about assisted dying Or contact a MAiD provider directly refer to the list at Or if need assistance at any time, please contact Island Health MAiD Coordinator: (Greater Victoria) Toll-free: maid@viha.ca
34 That completes the presentation. Acknowledgement: Special thanks to Jeffrey Brooks for the concept and production, and Ellen Agger for editing. Disclaimer: This presentation and content is for information purposes only. THIS IS NOT LEGAL ADVICE. This presentation was prepared at the express request of a MAiD Provider MD. The purpose of the presentation is to provide useful information about the steps involved and where to find the information needed by a person who may wish to apply for a medically assisted death. It helps navigate through the process leading to completing a patient request for themselves or for a loved one. The opinions expressed are those of the producer. It is not intended to encourage a person to have a Medically Assisted Death. Only a capable patient can make this choice and they must do so as their own free choice, without undue outside influence. Jeffrey Brooks identified in the examples of completed forms is the creator of these documents. All other phone numbers, addresses, dates of birth, MSP numbers, and names are fictional.
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