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- ATTENDING PHYSICIAN CHECKLIST & COMPLIANCE FORM (Death With Dignity)

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  • 34 check-boxes
  • 31 other fields

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ATTENDING PHYSICIAN CHECKLIST &
COMPLIANCE FORM
A
PATIENT INFORMATION
PATIENT’S NAME (LAST, FIRST, M.I)
DATE OF BIRTH
PATIENT RESIDENTIAL ADDRESS (STREET, CITY, ZIP CODE)
B
ATTENDING PHYSICIAN INFORMATION
PHYSICIAN’S NAME (LAST, FIRST, M.I)
TELEPHONE NUMBER
( )
-
MAILING ADDRESS (STREET, CITY, ZIP CODE)
PHYSICIAN’S LICENSE NUMBER
C
CONSULTING PHYSICIAN INFORMATION
PHYSICIAN’S NAME (LAST, FIRST, M.I)
TELEPHONE NUMBER
( )
-
MAILING ADDRESS (STREET, CITY, ZIP CODE)
PHYSICIAN’S LICENSE NUMBER
D
ELIGIBILITY DETERMINATION
TERMINAL DISEASE
CHECK BOXES FOR COMPLIANCE:
☐ 1. Determination that the patient has a terminal disease.
☐ 2. Determination that patient is a resident of California.
☐ 3. Determination that patient has the capacity to make medical decisions**
☐ 4. Determination that patient is acting voluntarily.
☐ 5. Determination of capacity by mental health specialist, if necessary.
☐ 6. Determination that patient has made his/her decision after being fully informed of:
☐ a) His or her medical diagnosis; and
☐ b) His or her prognosis; and
☐ c) The potential risks associated with ingesting the requested aid-in-dying drug;
☐ d) The probable result of ingesting the aid-in-dying drug;
☐ e) The possibility that he or she may choose to obtain the aid-in-dying drug but not take it
ATTENDING PHYSICIAN CHECKLIST &
COMPLIANCE FORM
E
ADDITIONAL COMPLIANCE REQUIREMENTS
☐ 1. Counseled patient about the importance of all of the following:
☐ a) Maintaining the aid-in-dying drug in a safe and secure location until the time the qualified individual will
ingest it;
☐ b) Having another person present when he or she ingests the aid-in-dying drug;
☐ c) Not ingesting the aid-in-dying drug in a public place;
☐ d) Notifying the next of kin of his or her request for an aid-in-dying drug. (an individual who declines or is
unable to notify next of kin shall not have his or her request denied for that reason); and
☐ e) Participating in a hospice program or palliative care program.
☐ 2. Informed patient of right to rescind request (1
st
time)
☐ 3. Discussed the feasible alternatives, including, but not limited to, comfort care, hospice care, palliative care
and pain control.
☐ 4. Met with patient one-on-one, except in the presence of an interpreter, to confirm the request is not coming
from coercion
☐ 5. First oral request for aid-in-dying: ___/___/_____ Attending physician initials:_______________
☐6. Second oral request for aid-in-dying: ___/___/_____ Attending physician initials: _______________
☐ 7. Written request submitted: ___/___/_____ Attending physician initials: _______________
☐ 8. Offered patient right to rescind (2
nd
time)
F
PATIENT’S MENTAL STATUS
Check one of the following (required):
☐ I have determined that the individual has the capacity to make medical decisions and is not suffering from
impaired judgment due to a mental disorder.
☐ I have referred the patient to the mental health specialist
****listed below for one or more consultations to
determine that the individual has the capacity to make medical decisions and is not suffering from
impaired judgment due to a mental disorder.
☐ If a referral was made to a mental health specialist, the mental health specialist has determined that the patient
is not suffering from impaired judgment due to a mental disorder
Mental health specialist’s information, if applicable:
MENTAL HEALTH SPECIALIST NAME
MENTAL HEALTH SPECIALIST TITLE & LICENSE NUMBER
MENTAL HEALTH SPECIALIST ADDRESS (STREET, CITY, ZIP CODE)
ATTENDING PHYSICIAN CHECKLIST &
COMPLIANCE FORM
G
MEDICATION PERSCRIBED
PHARMACIST NAME
TELEPHONE NUMBER
( )
-
1. Aid-in-dying medication prescribed:
☐ a. Name:
☐ b. Dosage:
2. Antiemetic medication prescribed:
☐ a. Name:
☐ b. Dosage:
3. Method prescription was delivered:
☐ a. In person
☐ b. By mail
☐ c. Electronically
4.
Date medication was prescribed: ___/___/_____
PHYSICIAN’S SIGNATURE
DATE
NAME (PLEASE PRINT)
** "Capacity to make medical decisions" means that, in the opinion of an individual’s attending physician, consulting physician,
psychiatrist, or psychologist, pursuant to Section 4609 of the Probate Code, the individual has the ability to understand the nature and
consequences of a health care decision, the ability to understand its significant benefits, risks, and alternatives, and the ability to make
****"Mental Health Specialist" means a psychiatrist or a licensed psychologist.
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- ATTENDING PHYSICIAN CHECKLIST & COMPLIANCE FORM (Death With Dignity)

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Completed 11 March 2021

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