SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION
ATTENDING PHYSICIAN’S COMPLIANCE FORM (continued)
C ACTION TAKEN TO COMPLY WITH THE LAW – continued
3. PATIENT’S WRITTEN REQUEST
Written request for medication to end life received (Please attach request)
(Must be at least 48 hours before writing the prescription unless patient is exempt
3
)
D MEDICAL CONSULTATION (Attach consultant’s form.)
Medical consultation and second opinion requested from:
MEDICAL CONSULTANT’S NAME
E
PSYCHIATRIC/PSYCHOLOGICAL EVALUATION
Check one of the following (REQUIRED):
I have determined that the patient is not suffering from a psychiatric or psychological disorder, or depression,
causing impaired judgment, in conformance with ORS 127.825.
I have referred the patient to the provider listed below for evaluation and consulting for a possible psychiatric or
psychological disorder, or depression causing impaired judgment, and attached the consultant’s form.
PSYCHIATRIC CONSULTANT’S NAME
MEDICATION PRESCRIBED AND INFORMATION PROVIDED TO PATIENT
(To be prescribed no sooner than 48 hours after patient’s written request has been signed unless patient is exempt
3
)
Lethal medication prescribed and dose
Please check one of the following:
Dispensed medication directly → Date
Contacted pharmacist and delivered prescription personally or by mail to the pharmacist
Pharmacy Name: City: Phone #:
Immediately prior to writing the prescription, the patient was fully informed of: (check boxes)
1. His or her medical diagnosis
2. His or her prognosis
3. The potential risks associated with taking the medication to be prescribed
4. The probable result of taking the medication to be prescribed
5. The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control
To the best of my knowledge, all of the requirements under the Death with Dignity Act have been met.
1. “Capable” means that in the opinion of a court, or in the opinion of the patient’s attending physician or consulting physician, a patient
has the ability to make and communicate health care decisions to health care providers, including communication through persons
familiar with the patient’s manner of communicating, if those persons are available.
2. Factors demonstrating residency include, but are not limited to: 1) possession of an Oregon driver’s license, 2) registration to vote in
Oregon, 3) evidence that a person leases/owns property in Oregon, or 4) filing of an Oregon tax return for the most recent tax year.
3. A patient is exempt from any waiting period that exceeds his/her life expectancy. The Attending Physician must have a medically
confirmed certification of the imminence of the patient’s death in the patient’s medical record if any waiting periods are not completed.
IT IS THE ATTENDING PHYSICIAN’S RESPONSIBILITY to send the following documents to the Public Health Division:
1) Patient’s written request; 2) Consulting physician’s report; and 3) Psychiatric evaluation referral report (if performed).
This form is revised periodically. To assure that you are using the most current version, please refer to http://www.healthoregon.org/dwd
Rev. 1/20 Page 2 of 2
