Find an Aid-in-Dying Attendant | Academy of Aid-in-Dying Medicine

Find a Bedside Aid-in-Dying Attendant

Patients who have a knowledgeable attendant, such as a nurse, doctor, doula, or volunteer, have more peaceful deaths, and their loved ones have less complicated grief.

The preparations and procedures for aid in dying can be complex and more easily managed by a knowledgeable clinician than a stressed-out but well-intentioned loved one. Well-supported loved ones who don’t have to manage medications or make clinical decisions can focus more on each other during these tender moments.

If you are planning an oral self-administration, and your hospice staff or other providers cannot attend to your aid-in-dying day, or if you feel you need further bedside support — please fill out the form below so we can connect you to an aid-in-dying skilled attendant who can be with you and your loved ones on that day.

If you need a referral to an attending/prescriber (physician or, in some states, nurse practitioner or physician assistant), please click here

Patient-to-Attendant Intake Form

Patient Name*
First Last
Patient's address*
Street Address City State / Province / Region ZIP / Postal Code
Best Phone # to reach patient*
Best email to reach patient*
Person filling out this form (if not the patient)
First Last
your relationship to the patient
your email
your phone number
Other Contact (just in case)*
First Last
Other Contact's Phone Number*
Other Contact's email*
age of the patient*
terminal diagnosis*
Name of attending/prescribing provider for medical aid in dying*
Is this patient enrolled in hospice care*
- Yes
- No
Name of the hospice?
What US state, and city (or area) are your planning ingestion?
What steps have you taken so far for becoming eligible and/or planning for medical aid in dying? (Given a first verbal request? Still in the waiting period? Are the medications prescribed and waiting in the pharmacy? Are the medication in the home?)*
Urgency of Aid in Dying Consideration? Days, weeks, or months away? (If you are filling out this form for the patient and do not know the answer to this, please talk with the patient about it.)*
Does the patient have any special communication needs?
How did you learn about this form and referral system?
Please review the following statements carefully as you are being asked to release certain claims against The Academy of Aid-in-Dying Medicine (The Academy) in order to access this service.*
I have read and agree to the Academy’s Referral Policy
By selecting “I have read and agree to the Academy’s Referral Policy”, you acknowledge, understand, and agree to the following:
1) The Academy is not engaged in the practice of any health care profession through this referral system;
2) The Academy operates this referral system as a public service and its role in facilitating this referral system is limited to connecting patients with potential end-of-life doulas or bedside attendants;
3) The Academy has not and does not perform any quality checks and does not otherwise vet the end-of-life doulas or bedside attendants who participate in this referral system;
4) The Academy is not responsible for the care that the end-of-life doulas or bedside attendants in the referral program provide and does not attest to the quality of care these end-of-life doulas or bedside attendants may provide;
5) The Academy expressly disclaims any and all warranties in connection with the operation of this referral system; and
6) I HEREBY RELEASE THE ACADEMY, ITS REFERRAL SYSTEM, AND ANY OF THEIR OFFICERS, EMPLOYEES, AND COMMITTEE MEMBERS FROM ANY LIABILITY, LOSSES, DAMAGES, CLAIMS, CAUSES OF ACTION, INTEREST, EXPENSES, COSTS, AND ATTORNEYS’ FEES ARISING OUT OF OR RELATED TO THE REFERRAL.
7) If you do not agree to these terms, you may not access the referral system.

Teaching and supporting best practices for the care of patients considering or completing medical aid in dying.

Donate to the Academy