Fillable ATTENDING PHYSICIAN FOLLOW-UP FORM The End of Life (Death With Dignity)

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ATTENDING PHYSICIAN FOLLOW-UP FORM The End of Life (Death With Dignity)

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The ATTENDING PHYSICIAN FOLLOW-UP FORM The End of Life (Death With Dignity) form is 4 pages long and contains:

  • 6 signatures
  • 45 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

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______________________________
: ___________________________________________________
cause such as terminal sedation or ceasing to eat or drink?
______________________________
ATTENDING PHYSICIAN FOLLOW-UP FORM
The End of Life Option Act requires physicians who write a prescription for an aid-in-dying drug to
complete his follow-up form within 30 calendar days of a patient’s death, whether from ingestion of the
aid-in-dying drug obtained under the Act or from any other cause.
For the State Department of Public Health to accept this form, it must be signed by the attending
physician, whether or not he or she was present at the patient's time of death.
This form should be mailed or sent electronically to the State Department of Public Health. All information
is kept strictly confidential.
Date:
____________________
Patient Name: ____________________________________
Attending physician name: ____________________________________
Did the patient die from ingesting the aid-in-dying drug, from their underlying illness, or from another
☐ Aid-in-dying drug (lethal dose)
☐
☐
Please sign below and go to page 2.
Attending physician signature:
Underlying illness There is no need to complete the rest of the form.
Attending physician signature:
Other
Ther
e is no need to complete the rest of the form. Please specify the circumstances
surrounding the patient's death and sign
Please specify:
_______________________________________________________________
_________________________________________________________
________
Attending physician signature
PART A and PART B should only be completed if the patient died from ingesting the lethal dose of
the aid-in-dying drug.
Please read carefully the following to determine which situation applies. Check the box that indicates the
scenario and complete the remainder of the form accordingly.
☐ The attending physician was present at the time of death.
T
he attending physician must complete this form in its entirety and sign Part A and Part B.
☐ The attending physician was not present at the time of death, but another licensed health care provider
was present.
The licensed health care provider must complete and sign Part A of this form. The attending
physician must complete and sign Part B of the form.
☐ Neither the attending physician nor another licensed health care provider was present at the time of
death.
Part A may be left blank. The attending physician must complete and sign Part B of the form.
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ATTENDING PHYSICIAN FOLLOW-UP FORM
PART A: To be completed and signed by the attending physician or another licensed health
care provider present at death:
1.
Was the attending physician at the patient's bedside when the patient took the aid-in-dying drug?
☐ Yes
☐ No
If no, was another physician or trained health care provider present when the patient ingested the aid-in-
dying drug?
☐ Yes, another physician
☐ Yes, a trained health-care provider/volunteer
☐ No
☐ Unknown
2. Was the attending physician at the patient's bedside at the time of death?
☐ Yes
☐ No
If no, was another physician or a licensed health care provider present at the patient'
☐ Yes, another physician or licensed health care provider
☐ No
☐ Unknown
3. On what day did the patient consume the lethal dose of the aid-in-dying?
___/___/_____ (month/day/year) ☐ Unknown
4. On what day did the patient die after consuming the lethal dose of the aid-in-dying drug?
___/___/_____ (month/day/year) ☐ Unknown
5. Where did the patient ingest the lethal dose of the aid-in-dying drug?
☐ Private home
☐ Assisted-living residence
☐ Nursing home
☐ Acute care hospital in-patient
☐ In-patient hospice resident
☐ Other (specify) ____________________________
☐ Unknown
6. What was the time between the ingestion of the lethal dose of aid-in-dying drug and
unconsciousness?
Minutes_________________ and/or Hours_______________ ☐Unknown
7. What was the time between lethal medication ingestion and death?
Minutes_________________ and/or Hours_______________ ☐Unknown
s
time of death?
ATTENDING PHYSICIAN FOLLOW-UP FORM
8. Were there any complications that occurred after the patient took the lethal dose of the aid-in-
dying drug?
☐
☐
☐
☐
☐
Yes- vomiting, emesis
Yes-regained consciousness
No Complications
Other- Please describe:_________________________________________________
Unknown
9. Was the Emergency Medical System activated for any reason after ingesting the lethal dose of
the aid-in-dying drug?
☐ Yes- Please describe:__________________________________________________
☐ No
☐ Unknown
10. At the time of ingesting the lethal dose of the aid-in-dying drug, was the patient receiving hospice
care?
☐ Yes
☐ No, refused care
☐ No, other (specify):__________________________________________________
Signature of attending physician present at time of death: ____________________________
Name of Licensed Health Care Provider present
At time of death if not attending physician: ________________________________________
Signature of Licensed Health Care Provider: ______________________________________
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___/___/_____
ATTENDING PHYSICIAN FOLLOW-UP FORM
PART B: To be completed and signed by the attending physician
12.
On what date was the prescription written for the aid-in-dying drug?
(month/day/year)
13. When the patient initially requested a prescription for the aid-in-dying drug, was the patient
receiving hospice care?
☐ Yes
☐
No, refused care
☐ No other (specify) _______________________________
14. What type of health-care coverage did the patient have for their underlying illness?(Check all that
apply.)
☐ Medicare
☐ Medi-Cal
☐ Covered California
☐ VA
☐ Private Insurance
☐ No insurance
☐ Had insurance, don't know type
15. Possible concerns that may have contributed to the patient's decision to request a prescription for
aid-in-dying drug Please check "yes," "no,” or "Don't know," depending on whether or not you believe that
concern contributed to their request (Please check as many boxes as you think may apply)
A concern about. . .
o His or her terminal condition representing a steady loss of autonomy
☐ Yes
☐ No
☐ Don't Know
o The decreasing ability to participate in activities that made life enjoyable
☐ Yes
☐ No
☐ Don't Know
o The loss of control of bodily functions
☐ Yes
☐ No
☐ Don't Know
o Persistent and uncontrollable pain and suffering
☐ Yes
☐ No
☐ Don't Know
o A loss of Dignity
☐ Yes
☐ No
☐ Don't Know
o Other concerns (specify): ____________________________________________
Signature of attending physician: _________________________________________________
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ATTENDING PHYSICIAN FOLLOW-UP FORM The End of Life (Death With Dignity)

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Completed 11 March 2021

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