Understanding the Goal of MAID Pharmacology
Medical Assistance in Dying (MAID) is a medical procedure that involves the administration of medications to bring about a peaceful death for an eligible person [1.4.1]. The primary pharmacological goal is to provide a serene experience, free from pain and distress, by inducing unconsciousness before life ends [1.3.2, 1.8.1]. This is achieved through a carefully selected and sequenced series of drugs that act on the central nervous system and other vital bodily functions [1.3.4]. In Canada, MAID is most often delivered via intravenous (IV) medications, though an oral option also exists [1.3.6].
The Physiological Cascade: What Intravenous (IV) MAID Does to the Body
The most common method for MAID in Canada is intravenous administration due to its reliability and rapid onset [1.5.3]. The standard protocol involves a sequence of three main types of medication, each with a distinct role in the physiological process [1.3.3, 1.3.6]. A study of over 3,500 cases in Canada found the median time from the first injection to death was 9 minutes [1.2.3, 1.2.5].
Step 1: Sedation and Anxiety Relief (Anxiolysis)
The process begins with the administration of a sedative, most commonly Midazolam [1.2.3, 1.2.5]. Midazolam is a benzodiazepine that works quickly to reduce anxiety and induce a state of deep relaxation [1.3.3, 1.3.4]. This initial step is crucial for patient comfort, helping to create a calm environment and allowing the person to fall into a relaxed, sleepy state, often losing consciousness [1.3.6, 1.4.1]. Some protocols may also include the administration of lidocaine, a local anesthetic, to numb the vein and prevent any discomfort from the injections [1.3.4].
Step 2: Induction of a Deep Coma
Once the patient is deeply relaxed and sedated, the next medication administered is a powerful general anesthetic, almost always Propofol [1.2.3, 1.2.5]. Propofol is widely used in operating rooms for general anesthesia [1.3.3]. It acts rapidly to induce a deep coma [1.3.2]. The dose used in MAID is significantly higher than that used for surgery, ensuring the patient is completely unconscious and unable to perceive any sensation, pain, or distress [1.3.3, 1.8.1]. In some frail individuals, the high dose of propofol may be sufficient to stop breathing and cardiac function on its own [1.3.6].
Step 3: Cessation of Bodily Functions
The final medication in the standard IV sequence is a neuromuscular blocking agent, most commonly Rocuronium or sometimes Cisatracurium [1.3.1, 1.3.3]. This drug causes the paralysis of all muscles in the body, including the diaphragm and other respiratory muscles [1.3.3, 1.3.4]. If the patient's breathing has not already ceased from the deep coma induced by propofol, the neuromuscular blocker will stop it [1.3.3]. The cessation of breathing prevents oxygen from reaching the organs. This leads to brain death, followed by the stopping of the heart (cardiac arrest), which is the final cause of death [1.3.2, 1.3.6]. Because the patient is in a deep coma, they are not aware of this final stage [1.8.2].
Oral vs. Intravenous (IV) MAID Protocols
While IV administration is the standard in Canada, oral protocols are also an option, though they are rare [1.3.6, 1.3.7]. Oral MAID is more common in some US states where self-administration is the only legal method [1.4.2]. The choice between methods involves trade-offs in reliability, speed, and patient experience.
| Feature | Intravenous (IV) MAID | Oral MAID |
|---|---|---|
| Administration | Administered by a physician or nurse practitioner [1.3.7]. | Self-administered by the patient, who must be able to ingest the medication [1.4.2, 1.5.2]. |
| Common Drugs | A sequence of Midazolam (sedative), Propofol (anesthetic), and Rocuronium (neuromuscular blocker) [1.3.4]. | Often a high dose of barbiturates (e.g., Secobarbital, Pentobarbital) or a combination cocktail like DDMA (Diazepam, Digoxin, Morphine, Amitriptyline) [1.2.2, 1.5.5]. |
| Time to Death | Predictable and rapid; median time is approximately 9-15 minutes [1.2.3, 1.3.6]. | Less predictable and longer; can range from 30 minutes to several hours or, in rare cases, even longer [1.2.2, 1.6.1]. |
| Reliability | Considered the 'gold standard' for its high reliability and 100% bioavailability [1.3.4, 1.5.3]. | Less reliable. Issues like difficulty swallowing, vomiting, or poor drug absorption can lead to prolonged dying or failure [1.2.2]. |
| Complications | Low complication rate (around 1.2%), mostly related to IV access issues [1.2.3]. Pain on injection is rare [1.3.1]. | Higher potential for complications, including burning sensation, nausea, vomiting, and prolonged dying process [1.2.2]. |
The Patient's Experience and Physical Changes
The MAID process is designed to be peaceful, dignified, and painless [1.4.1, 1.8.1]. Patients do not experience sensations of suffocation or pain because they are in a deep coma before their breathing and heart stop [1.8.1]. Family members who have been present often describe the passing as serene and peaceful [1.8.3, 1.8.4].
Upon death, the body's muscles relax completely, which can release the physical tension the person had been carrying from their illness [1.3.6]. The jaw may slacken, and over the following hours, the body will cool, and blood may pool, causing discoloration in areas under pressure. Rigor mortis, or muscle stiffening, typically begins several hours after death [1.3.6].
Conclusion
So, what does MAID do to the body? It initiates a controlled, multi-stage pharmacological process designed to ensure a peaceful death. Through a carefully orchestrated sequence of medications, the body is first calmed and sedated, then placed into a deep, unaware state of coma, before vital functions like breathing and cardiac activity are brought to a stop. While different protocols exist, the universal principle is the prioritization of patient comfort and the prevention of any awareness or suffering during the final moments of life.
For more information on the MAID process and support resources, one authoritative source is Dying With Dignity Canada.
