Fillable ATTENDING PHYSICIANS COMPLIANCE FORM PLEASE PRINT (Death With Dignity)

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ATTENDING PHYSICIANS COMPLIANCE FORM PLEASE PRINT (Death With Dignity)

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SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION
ATTENDING PHYSICIAN’S COMPLIANCE FORM
ORS 127.800 - ORS 127.897
MAIL FORM TO: Oregon State Public Health Division, Center for Health Statistics,
P.O. Box 14050, Portland, OR 97293-0050
PLEASE PRINT
A PATIENT INFORMATION
PATIENT’S NAME (LAST, FIRST, M.I.)
DATE OF BIRTH:
MEDICAL DIAGNOSIS
B PHYSICIAN INFORMATION
NAME (LAST, FIRST, M.I.)
TELEPHONE NUMBER
MAILING ADDRESS
CITY, STATE AND ZIP CODE
C ACTION TAKEN TO COMPLY WITH LAW
1. FIRST ORAL REQUEST
DATE
Comments:
Indicate compliance by checking the boxes. (Both the attending and consulting physicians must make these determinations.)
1. Determination that the patient has a terminal disease.
2. Determination the patient has six months or less to live.
3. Determination that patient is capable.**
4. Determination that patient is an Oregon resident.***
5. Determination that patient is acting voluntarily.
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 taking the medication to be prescribed; and
d) The potential result of taking the medication to be prescribed; and
e) The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control.
DATE:
2. Patient recommended to inform next of kin.
3. Patient counseled about the importance of having another person present
when the patient takes the medication(s).
4. Patient counseled about the importance of not taking the medication in a public place.
2. SECOND ORAL REQUEST (Must be made 15 days or more after the first oral request.)
DATE:
Comments:
Rev. 5/18
Page 1 of 2
SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION
ATTENDING PHYSICIAN’S COMPLIANCE FORM (continued)
PATIENT INFORMATION
PATIENT’S NAME (LAST, FIRST, M.I.)
DATE OF BIRTH
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. (No less than 48
hours shall elapse between the written request and writing the prescription.)
DATE
Comments:
D MEDICAL CONSULTATION (Attach consultant’s form.)
Medical consultation and second opinion requested from:
MEDICAL CONSULTANT’S NAME
TELEPHONE NUMBER
DATE
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
TELEPHONE NUMBER
DATE
F
MEDICATION PRESCRIBED AND INFORMATION PROVIDED TO PATIENT
(To be prescribed no sooner than 48 hours after patient’s written request has been signed.)
Lethal medication prescribed and dose
DATE PRESCRIBED
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)
(a) his or her medical diagnosis;
(b) his or her prognosis;
(c) the potential risks associated with taking the medication to be prescribed;
(d) the probable result of taking the medication to be prescribed;
(e) 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.
PHYSICIAN’S SIGNATURE
DATE
* If comments in any section exceed the space provided, please use an attached page. Supplemental comments should be identified
using the appropriate alpha-numeric notation (e.g., C3).
** “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.
*** 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. Only
the attending physician is required to affirm Oregon residency.
Note: Besides this form, 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 us
ing the most current version, please refer to: http://www.healthoregon.org/dwd
Rev. 5/18
Page 2 of 2
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ATTENDING PHYSICIANS COMPLIANCE FORM PLEASE PRINT (Death With Dignity)

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Completed 11 March 2021

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