/ APPLICATION FOR PRIVILEGES FOR MEDICAL ASSISTANCE IN DYING (MAID)
Pleasesubmit your completed applicationand completed BCMQI Dictionary
to or by fax to 1-888-865-2941

NAME:

Community ofCare:

Please checkoneofthefollowingasyourprimarycommunity of care

CoastalRichmondVancouver-AcuteVancouver-Community

Pleasecheckthefollowingto indicate the communities of care in which you would be prepared to serve as an Assessor orPrescriber(Cross Appointment is an additional step, following initial confirmation of the non-core privilege for MAID)

CoastalRichmondVancouver-AcuteVancouver-Community

Obtainingprivileges

Torequest the non-core privilege to be a Prescriber for medicalassistance indying in a VCH program or facility,please

  • reviewand complete the requirements on this application, including review of the accompanying materialsand those indicated in this document and found on theVCHMedicalStaffwebsite( partner websites;
  • completeand sign thisform and the accompanyingBCMQI Application of the non-core privilege for Medical Assistance in Dying (MAID); and
  • submitboth to fax to 1-888-865- 2941.

The Assisted Dying Program will work with Medical Affairs (for Physicians) and Professional Practice (Nurse Practitioners) toschedule adiscussion with theappropriateleaders toconcerningyour application.

PrivilegingRequirements

Physiciansor Nurse Practitioners applyingforprivilegesformedicalassistanceindyingare requiredtosubmit thefollowingsupportiveinformationtodemonstratethe requisiteknowledge,educationandskillstoprovidetheservice.

Pleaseconfirmviacheckmarkthatyouhavereviewed and understandthefollowing documents:

Physicians: TheProfessionalStandardoftheCollegeofPhysiciansand SurgeonsofBCforMedicalAssistanceinDying:

Nurse Practitioners: TheScope of Practice for Nurse Practitioners, Medical Assistance in Dying (CollegeofRegistered NursesofBC):

VancouverCoastalHealthMedicalAssistance inDying,PolicyStatement,ProcedureandForms:

Role of the Care Coordination Service of the Assisted Dying Program (accompanying)

Medical Assistance in Dying: British Columbia Pharmacy Protocols (accompanying; please do not disseminate further). Note: The Pre-Printed Order in use at VCH will be provided once your privileges have been confirmed.

Review questions for Applicants to be an Assessor/Prescriber, a non-core privilege(accompanying)

BCMQIdictionaryforMedicalAssistanceinDyingprivileges(accompanying, for completion and submission)

PleaseindicatewhichofthefollowingCMErequirementsyouhavecompleted(indicateatleast one):

CanadianMedicalAssociationCMEonlinemoduleonmedicalassistanceindying

CanadianMedicalAssociationCMEface-to-facecourseonend-of-lifecareandmedicalassistanceindying September15-17,2016

VCH / PHSA Seminar: Collaboration and Compassion: a team approach to medical assistance in dying,September 28th, 2016 In person,byvideolink,oronline)

Pleaseindicate which of thefollowingrecommendedadditional education you have completed:

Observation with experienced Assessor & Assessor / Prescriber(Required for Nurse Practitioners; Recommended for Physicians)

Observation of Assessment (1), Date:______, with Assessor: ______

Observation of Assessment (2), Date:______, with Assessor: ______

Observation of Provision (1), Date: ______, with Assessor / Prescriber: ______

Observation of Provision (2), Date:______, with Assessor / Prescriber: ______

Other (please describe):

RelevantClinicalSkills

Pleasedescribe yourrelevant clinical skills that wouldsupport yourability toprovide medical assistance indyingina VancouverCoastalHealthfacility or program.

Signature: ______Date: ______

Phone: ______Email: ______

If you haveanyquestions related to medical assistance in dying,please contact theVCH Assisted Dying call 1-844-550-5556.