______________________________________________________________________________
REQUEST FOR MEDICATION
TO END MY LIFE IN A HUMANE
AND DIGNIFIED MANNER
I, ______________________, am an adult of sound mind.
I am suffering from _________, which my attending physician has determined is a terminal disease and which has been medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including comfort care, hospice care and pain control.
I request that my attending physician prescribe medication that will end my life in a humane and dignified manner.
INITIAL ONE:
______ I have informed my family of my decision and taken their opinions into consideration.
______ I have decided not to inform my family of my decision.
______ I have no family to inform of my decision.
I understand that I have the right to rescind this request at any time.
I understand the full import of this request and I expect to die when I take the medication to be prescribed. I further understand that although most deaths occur within three hours, my death may take longer and my physician has counseled me about this possibility.
I make this request voluntarily and without reservation, and I accept full moral responsibility for my actions.
Signed: _______________
Dated: _______________
DECLARATION OF WITNESSES
We declare that the person signing this request:
(a) Is personally known to us or has provided proof of identity;
(b) Signed this request in our presence;
(c) Appears to be of sound mind and not under duress, fraud or undue influence;
(d) Is not a patient for whom either of us is attending physician.
______________ Witness 1/Date
______________ Witness 2/Date
NOTE: One witness shall not be a relative (by blood, marriage or adoption) of the person signing this request, shall not be entitled to any portion of the person’s estate upon death and shall not own, operate or be employed at a health care facility where the person is a patient or resident. If the patient is an inpatient at a health care facility, one of the witnesses shall be an individual designated by the facility.
______________________________________________________________________________ [1995 c.3 §6.01; 1999 c.423 §11]
Structure 2021 Oregon Revised Statutes
Volume : 03 - Landlord-Tenant, Domestic Relations, Probate
Section 127.002 - Definitions for ORS 127.005 to 127.045.
Section 127.005 - When power of attorney in effect; accounting to conservator.
Section 127.505 - Definitions for ORS 127.505 to 127.660.
Section 127.515 - Execution; witnesses; out-of-state execution.
Section 127.525 - Acceptance of appointment; withdrawal.
Section 127.527 - Form for appointing health care representative.
Section 127.529 - Form of advance directive.
Section 127.532 - Appointment; term of office; rules.
Section 127.533 - Duties; advance directive elements; reports.
Section 127.535 - Authority of health care representative; duties; objection by principal.
Section 127.540 - Limitations on authority of health care representative.
Section 127.570 - Mercy killing; suicide.
Section 127.642 - Principal to be provided with certain care to insure comfort and cleanliness.
Section 127.646 - Definitions for ORS 127.646 to 127.654.
Section 127.652 - Time of providing information.
Section 127.654 - Scope of requirement; limitation on liability for failure to comply.
Section 127.658 - Effect of ORS 127.505 to 127.660 on previously executed advance directives.
Section 127.660 - Short title.
Section 127.663 - Definitions for ORS 127.663 to 127.684.
Section 127.666 - Establishment of registry; rules.
Section 127.669 - Oregon Health Authority not required to perform certain acts.
Section 127.700 - Definitions for ORS 127.700 to 127.737.
Section 127.702 - Persons who may make declaration for mental health treatment; period of validity.
Section 127.720 - Circumstances in which physician or provider may disregard declaration.
Section 127.722 - Revocation of declaration.
Section 127.727 - Persons prohibited from serving as attorney-in-fact.
Section 127.730 - Persons prohibited from serving as witnesses to declaration.
Section 127.732 - Withdrawal of attorney-in-fact; rescission of withdrawal.
Section 127.736 - Form of declaration.
Section 127.737 - Certain other laws applicable to declaration.
Section 127.760 - Consent to health care services by person appointed by hospital; exceptions.
Section 127.800 - sect;1.01. Definitions.
Section 127.805 - sect;2.01. Who may initiate a written request for medication.
Section 127.810 - sect;2.02. Form of the written request.
Section 127.815 - sect;3.01. Attending physician responsibilities.
Section 127.840 - sect;3.06. Written and oral requests.
Section 127.850 - sect;3.08. Waiting periods.
Section 127.855 - sect;3.09. Medical record documentation requirements.
Section 127.860 - sect;3.10. Residency requirement.
Section 127.865 - sect;3.11. Reporting requirements.
Section 127.870 - sect;3.12. Effect on construction of wills, contracts and statutes.
Section 127.890 - sect;4.02. Liabilities.