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Medications and dosages used in medical assistance in dying: a cross-sectional study

Igor Stukalin, Oluwatobi R. Olaiya, Viren Naik, Ellen Wiebe, Mike Kekewich, Michaela Kelly, Laura Wilding, Roxanne Halko and Simon Oczkowski
January 18, 2022 10 (1) E19-E26; DOI: https://doi.org/10.9778/cmajo.20200268
Igor Stukalin
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Oluwatobi R. Olaiya
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Viren Naik
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Ellen Wiebe
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Mike Kekewich
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Michaela Kelly
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Laura Wilding
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Roxanne Halko
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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Simon Oczkowski
Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
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    Figure 1:

    Flow diagram showing hierarchal structure of data sources. Note: OCC = Office of the Chief Coroner.

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    Figure 2:

    Kaplan–Meier survival curve comparing low-, standard- and high-dose propofol. Note: MAiD = medical assistance in dying.

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    Table 1:

    Characteristics of intravenous provision of medical assistance in dying in Ontario between 2016 and 2018 (n = 2895), and in 3 Canadian academic hospitals (in Hamilton and Ottawa, Ontario, and Vancouver, British Columbia) between 2019 and 2020 (n = 662)

    CharacteristicNo. (%) of patients*
    n = 3557
    Patient age, mean ± SD, yr74 ± 13.0
    Patient sex
     Male1786 (50.2)
     Female1770 (49.8)
     Missing1 (0.03)
    Location of MAiD provision (n = 3113)†
     Hospital1382 (44.4)
     Hospice or palliative care facility187 (6.0)
     Community/other (e.g., private residence, long-term care)1537 (49.4)
     Missing7 (0.2)
    Patient diagnosis
     Cancer2519 (70.8)
     Neurologic disorder23 (0.6)
     Cardiovascular/respiratory disorder840 (23.6)
     Other126 (3.5)
     Missing49 (1.4)
    Provider profession
     Physician3304 (92.9)
     Nurse practitioner240 (6.7)
     Missing13 (0.4)
    Physician specialty (n = 3113)†
     Anesthesia473 (15.2)
     Critical care95 (3.0)
     Emergency medicine96 (3.1)
     Family medicine1391 (44.7)
     Internal medicine290 (9.3)
     Neurology12 (0.4)
     Oncology1 (0.03)
     Palliative care382 (12.3)
     Radiation oncology31 (1.0)
     Surgery47 (1.5)
     Other10 (0.3)
     Missing285 (9.2)
    • Note: MAiD = medical assistance in dying, SD = standard deviation.

    • ↵* Except where noted otherwise.

    • ↵† For Ontario patients only.

    • View popup
    Table 2:

    Medications and dosages used

    Medication, unitNo. (%) of patientsMedian dosage (Q1, Q3, max)Dosage range; no. (%) of patients
    n = 3557
    HighStandardLowMissingNone
    Sedative3255 (91.5)
    Midazolam, milligrams3251 (91.4)10 (10, 20, 70)> 19
    816 (22.9)
    10–19
    2247 (63.2)
    1–9
    188 (5.3)
    –
    0 (0.0)
    0
    306 (8.6)
    Metoclopramide, 10 mg4 (0.1)–––––
    Analgesic2928 (82.3)
    Lidocaine, milligrams2906 (81.7)40 (40, 60, 1000)> 60
    341 (9.6)
    40–60
    2477 (69.6)
    1–39
    88 (2.5)
    –
    0 (0.0)
    0
    651 (18.3)
    Magnesium sulfate, milligrams1 (0.0)5000––––
    Opioids (various)21 (0.6)––––
    Anesthetic3527 (99.2)
    Propofol, milligrams3523 (99.0)1000 (1000, 1000, 3000)> 1000
    96 (2.7)
    1000
    2999 (84.3)
    1–999
    409 (11.5)
    –
    19 (0.5)
    0
    34 (1.0)
    Phenobarbital, milligrams4 (0.1)3000 (3000, 3000, 3000)––––
    Paralytic3486 (98.0)
    Rocuronium, milligrams3295 (92.6)200 (200, 200, 400)> 200
    23 (0.6)
    150–200
    2832 (79.6)
    1–149
    373 (10.5)
    –
    67 (1.9)
    0
    262 (7.4)
    Cisatracurium, milligrams325 (9.1)40 (30, 40, 80)> 40
    4 (0.1)
    30–40
    252 (7.1)
    1–29
    2 (0.1)
    –
    67 (1.9)
    0
    3232 (90.9)
    Cardiotoxic medication863 (24.3)
    Bupivacaine, milligrams722 (20.3)400 (400, 400, 2000)> 400
    18 (0.5)
    400
    582 (16.4)
    1–399
    122 (3.4)
    –
    0 (0.0)
    0
    2835 (79.7)
    Potassium chloride, milliequivalents141 (4.0)80 (80, 80, 1000)> 80
    7 (0.2)
    80
    129 (3.6)
    1–79
    5 (0.1)
    –
    0 (0.0)
    0
    3416 (96.0)
    • Note: max = maximum, Q = quartile.

    • View popup
    Table 3:

    Multivariable adjusted hazard ratios for time to death

    Medication/categoryMedian time until death (Q1, Q3), min*HR (95% CI)
    Lidocaine (Ref = none)8 (6, 10)
     Low-dose6 (7, 12)0.8 (0.6–1.0)
     Standard-dose9 (6, 12)0.6 (0.6–0.7)
     High-dose8 (6, 10)0.8 (0.7–0.9)
    Propofol (Ref = low-dose)8 (5, 11)
     None7 (6, 15)1.4 (0.5–1.0)
     Standard-dose9 (6, 12)0.9 (0.8–1.0)
     High-dose12 (8, 16)0.4 (0.3–0.5)
    Paralytic (Ref = standard-dose rocuronium)9 (6, 12)
     Rocuronium
      Low-dose9 (6, 11)0.9 (0.8–1.0)
      High-dose14 (8, 22)0.4 (0.3–0.7)
     Cisatracurium
      Standard-dose9 (12, 13)1.0 (0.9–1.0)
      Low-dose14†0.8 (0.1–5.6)
      High-dose17 (14, 43)0.4 (0.1–1.3)
    Bupivacaine (Ref = none)9 (6, 12)
     Low-dose8 (5, 12)1.0 (0.8–1.3)
     Standard-dose8 (5, 12)1.2 (1.0–1.3)
     High-dose8 (6, 20)0.7 (0.4–1.2)
    Potassium chloride (Ref = none)9 (6, 12)
     Low-dose10 (8, 13)1.3 (0.5–3.5)
     Standard-dose7 (5, 9)1.2 (0.9–1.4)
     High-dose14 (11, 15)0.7 (0.3–1.6)
    • Note: CI = confidence interval, HR = hazard ratio, Ref = reference category.

    • ↵* Unadjusted for covariates.

    • ↵† One patient.

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Medications and dosages used in medical assistance in dying: a cross-sectional study
Igor Stukalin, Oluwatobi R. Olaiya, Viren Naik, Ellen Wiebe, Mike Kekewich, Michaela Kelly, Laura Wilding, Roxanne Halko, Simon Oczkowski
Jan 2022, 10 (1) E19-E26; DOI: 10.9778/cmajo.20200268

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Medications and dosages used in medical assistance in dying: a cross-sectional study
Igor Stukalin, Oluwatobi R. Olaiya, Viren Naik, Ellen Wiebe, Mike Kekewich, Michaela Kelly, Laura Wilding, Roxanne Halko, Simon Oczkowski
Jan 2022, 10 (1) E19-E26; DOI: 10.9778/cmajo.20200268
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