Fillable Oregon Death with Dignity Act Attending Physician Follow-up (Death With Dignity)

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Oregon Death with Dignity Act Attending Physician Follow-up (Death With Dignity)

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For OHA use only:
Case ID: ______ - __________
Page 1 of 5 Rev. 2/19
Forms available at: http://www.healthoregon.org/dwd
Oregon Death with Dignity Act
Attending Physician Follow-up Form
Dear Physician:
The Death with Dignity Act requires physicians who write a prescription for a lethal dose of
medication to complete this follow-up form within 10 calendar days of a patient's death, whether
from ingestion of the lethal dose of medications obtained under the Act or from any other cause.
For OHA to accept this form, it must be signed by the Attending (Prescribing) Physician,
whether or not he or she was present at the patient’s time of death.
Mail completed form to:
All information is kept strictly confidential. If you have any questions, call 971-673-1150.
Did the patient die from i
ngesting the lethal dose of medication, from their underlying illness, or
from another cause such as terminal sedation or ceasing to eat or drink? If unknown, please
contact the family or patient’s representative.
1. Death with Dignity (lethal medication) Please sign below and go to page 2.
Attending (Prescribing) Physician Signature:
2. Underlying illness Please sign below and
stop. There is no need to complete
the rest of the form. Submit page 1 only.
Attending (Prescribing) Physician Signature:
3. Other Please specify the circumstances of the patient’s death, sign below, and
stop. There is no need to complete the rest of the form. Submit page 1 only.
Please specify:
Attending (Prescribing) Physician Signature:
Date: __________________
Patient’s Name: _____
Attending (Prescribing) Physician:
Oregon Center for Health Statistics
P.O. Box 14050
Portland, OR 97293-0050
Patient:
Page 2 of 5
Rev. 2/19
Check the appropriate box below and follow the instructions for completing
PART A and PART B of this form.
PART A covers the circumstances of the patient’s ingestion and death.
PART B covers the patient’s status and possible reasons for utilizing the DWDA.
1. The Attending (Prescribing) Physician was present at the time
of death.
The Attending (Prescribing) Physician must complete and sign Part A and Part B.
2. The Attending (Prescribing) Physician was not present at the
time of death, but another licensed health care provider or
volunteer was present.
The licensed provider or volunteer may complete and sign Part A of this form. The
Attending (Prescribing) Physician must complete and sign Part B of the form.
Licensed provider or volunteer contact information:
Name:
Phone:
Affiliation:
3. Neither the Attending (Prescribing) Physician nor another
licensed health care provider or volunteer was present at the
time of death.
Part A may be left blank.
The Attending (Prescribing) Physician must complete and sign Part B of the form.
PART A and PART B should only be completed if the patient died from ingesting the
lethal dose of medication.
PART A: Completed and signed by the health care provider
or volunteer who was present at death.
Patient:
Page 3 of 5
Rev. 2/19
1. Was the attending physician at the patient's bedside when the patient took the lethal dose of
medication?
1. Yes
2. No
1a. If no: Was another physician, licensed health care provider, or volunteer
present when the patient took the lethal dose of medication?
1. Yes, another physician
2. Yes, another
licensed health care provider
3. Yes, a volunteer
4. No
9. Unknown
2. Was the attending physician at the patient's bedside at the time of death?
1. Yes
2. No
2a. If no: Was another physician, licensed health care provider, or volunteer
present at the patient’s time of death?
1. Yes, another physician
2. Yes, another licensed health care provider
3. Yes, a volunteer
4. No
9. Unknown
3. On what date did the patient consume the lethal dose of medication?
_____ / _____ / _______ (month/day/year) Unknown
4. On what date did the patient die after consuming the lethal dose of medication?
_____ / _____ / _______ (month/day/year) Unknown
5. Where did the patient ingest the lethal dose of medication?
1. Private home
2. Assisted-living residence (including foster care)
3. Nursing home
4. Acute care hospital in-patient
5. In-patient hospice resident
6. Other – specify:
9. Unknown
6. What was the time between lethal medication ingestion and unconsciousness?
Minutes: ______ or Hours: ______ Unknown
PART A: Completed and signed by the health care provider
or volunteer who was present at death.
Patient:
Page 4 of 5
Rev. 2/19
7. What was the time between lethal medication ingestion and death?
Minutes: ______ or Hours: ______ Unknown
7a. If longer than six hours: Are there any observations on why the patient lived
for more than six hours after ingesting the lethal dose of mediation?
8. Were there any complications that occurred after the patient took the lethal dose of
medication?
1. Yes, vomiting
2. Yes, seizures
3. Yes, regained consciousness
4. No complications
5. Other – describe:
9. Unknown
9. Was the Emergency Medical System activated for any reason after ingesting the lethal dose
of medication?
1. Yes – describe:
2. No
9. Unknown
10. At the time of ingesting the lethal dose of medication, was the patient receiving hospice
care?
1. Yes
2. No, refused care
3. No, never offered care
4. No, other – describe:
9. Unknown
11. Please provide any other comments, feedback, or insights you would like to share with us.
Person completing PART A of this form:
Signature: Date:
Check
one:
Patient’s Attending (Prescribing) Physician
A physician (other than the patient’s Attending Physician)
Another licensed health care provider
Volunteer
PART B: Completed and signed by the Attending
(Prescribing) Physician.
Patient:
Page 5 of 5 Rev. 2/19
12. Date attending physician begin caring for patient: _____ / _____ / _____ (month/day/year)
13. Date DWDA prescription written: _____ / _____ / _____ (month/day/year)
14. When the patient initially requested a prescription for a lethal dose of medication, was the
patient receiving hospice care?
1. Yes
2. No, refused care
3. No, never offered care
4. No, other – describe:
9. Unknown
15. Several possible concerns contributing to the patient’s decision to request a prescription for
lethal medication are shown below. Please check yes, no, or unknown to indicate whether
you believe each concern contributed to the patient’s request.
A concern about…
Yes
No
Unk
...the financial cost of treating or prolonging his or her terminal condition?
Y
N
U
...the physical or emotional burden on family, friends, or caregivers?
Y
N
U
...his or her terminal condition representing a steady loss of autonomy?
Y
N
U
...the decreasing ability to participate in activities that made life enjoyable?
Y
N
U
...the loss of control of bodily functions, such as incontinence and vomiting?
Y
N
U
...inadequate pain control at the end of life?
Y
N
U
...a loss of dignity?
Y
N
U
16. What type(s) of health-care coverage did the patient have for their underlying illness?
Check all that apply:
6. Private insurance (e.g., Kaiser, Blue Cross)
7. No insurance
8. Had insurance, don't know type
9. Unknown
1. Medicare
2. Oregon Health Plan/Medicaid
3. Military/CHAMPUS
4. V.A.
5. Indian Health Service
17. Please provide any other comments, feedback, or insights you would like to share with us.
Signature of Attending (Prescribing) Physician:
Signature: Date:
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Oregon Death with Dignity Act Attending Physician Follow-up (Death With Dignity)

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Completed 11 March 2021

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