Evaluation for Medical Assistance in Dying (MAID) Template

Name: Elizabeth Marie Thompson
DOB: 1949-06-15
Medicare: 1234-567-890
PPRN: 87654321
Family Practitioner: Dr. Caroline Peters, MD, CCFP
Assessor: Dr. James Donovan, MD, Palliative Care Specialist
Second Assessor: Dr. Anjali Patel, MD, Oncology
Diagnosis: Metastatic pancreatic adenocarcinoma
Date of Diagnosis: 2023-04-10
MAID request date: 2025-06-10
CRITERIA
[✔] eligible to receive health services funded by the Government of Canada
[✔] over 18 years of age
[✔] capacity to make decisions with respect to their own health
[✔] voluntary request for MAID that is not the result of external pressure
[✔] grievous and irremediable medical condition: a serious and incurable illness, disease, or disability
[✔] advanced state of irreversible decline in capability
[✔] enduring physical or psychological suffering, caused by either the illness, disease, or disability, or by the advanced state of decline in capability, that is intolerable to the patient and cannot be relieved under conditions that they consider acceptable
[✔] informed that they can withdraw their request for MAID at any time, in any manner
[✔] I have informed of the risks associated with taking the medication to be prescribed; and the result of taking or being administered the medication prescribed
TRACK
1, Reasonably Foreseeable Death
OPTIONS
Medication route: IV
Location of administration: Patient’s home, 45 Greenview Crescent, Halifax
Organ donation: Patient expressed interest but did not complete final documentation
Waiver of final consent: Completed and signed June 18, 2025
Patient History and Status
Elizabeth Thompson is a 76-year-old woman with metastatic pancreatic cancer involving the liver, peritoneum, and retroperitoneal lymph nodes. She was diagnosed after progressive fatigue, severe epigastric pain radiating to the back, and unintended weight loss of approximately 40 pounds over 6 months. She has undergone palliative chemotherapy with gemcitabine and nab-paclitaxel, but experienced severe nausea, protracted vomiting, and chemotherapy-induced peripheral neuropathy. Despite maximal supportive care, she continues to suffer from debilitating pain, anorexia, profound fatigue, and existential distress.
At today’s assessment, she was sitting in a recliner, frail in appearance, oriented to person, place, and time. Her speech was deliberate but clear. She demonstrated understanding of her diagnosis, prognosis, and all available palliative options.
She stated:
'I have fought this cancer with everything I had, but I can’t go on like this. I am exhausted in every way.'
'The pain is unrelenting, and nothing touches it anymore except sedation that makes me feel like I am not myself.'
She also reported:
'I am not afraid of dying. I am afraid of losing the last bit of dignity I have left.'
Elizabeth has consistently reiterated her wish for MAID since first raising it in May 2025. She has had multiple conversations with her family, her oncologist, her palliative care team, and her spiritual advisor. She has signed a written request witnessed appropriately, has been offered hospice and expanded home palliative services, and has declined further interventions except comfort measures until her preferred date of assisted death.
She has explicitly confirmed that no family members, care providers, or others have pressured her in any way to request MAID. She expressed deep relief that this option exists:
'Knowing this is available gives me peace. I feel like I have some control left.'
Past Medical History
Metastatic pancreatic adenocarcinoma (diagnosed 2023-04-10)
Chemotherapy-induced peripheral neuropathy (diagnosed 2024-02)
Hypertension (diagnosed 2005)
Osteoarthritis, bilateral knees (diagnosed 2012)
Cholecystectomy (1998)
Depression, situational, managed with psychotherapy (2023)
Medications
Hydromorphone 4 mg PO q4h and q1h PRN for breakthrough pain
Olanzapine 2.5 mg PO at bedtime for nausea
Metoclopramide 10 mg PO three times daily before meals
Bisacodyl 10 mg per rectum every 3 days as needed for constipation
Ramipril 5 mg PO daily
Acetaminophen 650 mg PO every 6 hours scheduled
Allergies
Codeine – severe nausea/vomiting