SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION - PDF document

1 SEND A COPY OF THIS FORM TO THE OREGON S
SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION ATTEND I NG PHYSIC I AN’S COMPLIANCE FORM (cont i nued) PATIENT INFORMAT I ON PATIE N T ’S NAME DA T E O F BIR T H C ACTION TAKEN T O COMPLY WI T H THE LAW continued 3 . PATIENT’ S WRITTE N REQUEST Written request for medication to end life re c eived ( Plea s e attach request ) ( Must be at least 48 hours before writing the presc r iptio n unless patient is exempt 3 ) DA T E Comments: D MED I CAL CONSULTA T ION (Attach consultant’s form.) Medi c a l con s u l tatio n a nd sec o n d o p in i o n r eq ueste d from: MEDICA L CONSUL T AN T S NAME T ELEPHON E NUMBER DA T E E PSYCHIATRIC/PSYCHOLOGICAL EVALUATI O N Chec k o n e o f th e fol l o w in g ( 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 depre ssion causing impaired judgment, and attached the consultant’s form. PSYCHIA T RI C CONSUL T AN T S NAME T ELEPHON E NUMBER DA T E F MED I CAT I O N P RE SC RIBE D AN D INFO R MA T IO N P ROV I DE D T O P A TIENT ( To be p r e scribed no so on er than 48 ho urs after pat i ent s written requ e st h a s b een s i gn e d unless patient is exempt 3 ) Lethal med i cation pr e s cr ib ed an d d o se DA T E PRES C RIBED Pleas e ch e c k on e o f th e followi n g: Disps Date Contacted pharm a cis t an d deliv e r e d prescript i o n perso n a ll y o r b y mai l t o th e phar m a c i st Pharmac y Nam e : City : Phone # : Immediately prior to writing the prescription, the patient was fully informed of: (check boxes) 1. H i s or h e r medical d i a g nos i s 2. H is or her prognosis 3. T h e potentia l risk s a s sociate d wit h takin g th e medicatio n t o b e p r escribe d 4. T h e p r obabl e resul t o f takin g th e medicatio n t o b e prescribe d 5. T h e fea s ibl e alternative s, inclu d ing , b ut no t limite d to , comfor t care , hospic e car e an d pai n control T o th e b e s t o f m y knowl e d g e , al l o f th e requir emen t s u nder the Dea t h with Di g nity Act have be e n met. PHYSICIAN’ S SIGNA T URE DA T E 1. “Ca p ab l e mean s tha t i n t h e o p in i o n o f a court , o r i n t h e opi n io n o f th e pati e nt’ s atten d in g ph y sic i a n or consult i n g ph y si c ian , a p ati e n t ha s th e a bi l i t y t o mak e a nd c o mmunica t e h e alt h car e d ecis i on s t o h e alt h c ar e pro v iders , i ncl u di ng com m uni c atio n th r o u g h per s ons familia r w i t h t he pati e nt’ s ma n ne r o f comm u n icati n g , i f thos e person s a r e av ail a b l e. 2. Factors d e monstrati ng r e sid e n c y inc l u d e , bu t ar e no t l i mite d to : 1 ) p ossessi on o f a n Orego n d r iver ’s licen s e , 2 ) r egistratio n t o vote i n Oreg o n , 3 ) e vid e nc e tha t a pers on lea s es /o w n s p r oper t y in O r egon , o r 4 ) f ilin g o f a n O r eg on ta x re t ur n fo r th e mos t recen t ta x y e ar . 3. A p atient is exempt from any waiting period that e

2 xceeds his/her life expectancy . T he At
xceeds his/her life expectancy . T he 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 A TT E NDING PH YS I C I A R ES PON S IB I LITY t o sen d th e fo l l ow in g doc um en t s t o th e Publi c Heal t h Divi s io n: 1 ) Patien t s wri tte n request ; 2 ) Cons u ltin g p h ysicia n s re p ort ; an d 3 ) Psych i atri c eva l uati on referra l re p or t (i f performed). T h is form is r e vised periodi c all y . T o assur e tha t yo u ar e us i n g th e mos t c u rren t versi o n , plea s e refe r to http://www.healthoregon.org/dwd Rev. 1 / 20 Page 2 of 2 4 4 4 4 4 4 4 4 4 4 4 4 SEND A COPY OF THIS FORM TO THE OREGON STATE PUBLIC HEALTH DIVISION ATTEND IN G PH Y S IC I AN’S C OMPLIAN C E FO R M OR S 127.8 00 - OR S 127.8 97 M A I L FO R M TO : Ore gon Stat e P ub li c Healt h D i v i si on, C e nt e r f or Heal t h Statistics, P.O. Box 14050, Portland, OR 97293 - 0050 PLEASE P R INT A PATIENT INFORMAT I ON PATIE N T ’S NAME (LAST, F IRST, M . I.) DA T E O F BIR T H: MEDICA DIAGNOSIS B PHYS I CIA N INFO R MA T ION NAME (LAS T , FIR S T , M .I.) T ELEPHON E NUMBER MAILIN G ADDRESS CI T Y , S T AT E AN D ZI P CODE C ACTION T A KEN T O COMPLY WI T H LAW 1 . FIRS T ORA L REQUE S T FOR MEDICATION Indicate co m plia n ce b y c h ecking the bo x e s 1. Determi na tio n tha t th e patien t ha s a t e rmi n a l dise a s e D A T E 2 . Determi na tio n th e pati e n t ha s si x m o nth s o r l e s s t o live (If less than 15 days, check here: - see footnote 3.) 3 . Determi na tio n tha t patien t i s ca p able 1 4 . Determi na tio n tha t patien t i s a n Ore g o n r e sid e nt 2 5 . Determi na tio n tha t patien t i s actin g v o luntarily 6. Determination that patient has made his/her decision after being fully informed of: a) His o r h e r m e dical d i agn o s i s b) His o r h e r pr o gn o sis c) The potential risks a s s o cia t ed with tak i ng the medicat i on to be pr e s cri b ed d ) Th e potentia l resul t o f taki n g th e medicatio n t o b e pr e scri b ed e ) Th e fe a s ibl e alternativ e s, incl u d ing , bu t no t li m ite d to , comfor t care , hosp i c e car e an d pai n co n trol Indicate co m plia n ce b y c h ecking the bo x e s. 1. Patient inform e d of his or h e r r i gh t t o rescin d th e requ e s t a t an y time DA T E : 2 . Patient recommende d t o infor m nex t o f 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 Comments: 2 . SECON D ORA L REQUES T FOR MEDICATION Must be 15 days or m ore a f ter the first oral req u est unless patient is exempt 3 Indicate co m plia n ce b y c h the bo x e s. DA T E : 1 . Patient made secon d o ra l req u es t fo r medicatio n t o en d life 2 . Patien t inform e d o f th e righ t t o r e sc in d th e req u es t a t an y time Com m ents: Rev . 1 / 20 Page 1 of