[§327L-23]  Form of the request.  A request for a prescription as authorized by this chapter shall be in substantially the following form:

"REQUEST FOR MEDICATION TO END MY LIFE

     I, ______________________, am an adult of sound mind.

     I am suffering from ___________, which my attending provider has determined is a terminal disease and that has been medically confirmed by a consulting provider.

     I have received counseling to determine that I am capable and not suffering from undertreatment or nontreatment of depression or other conditions which may interfere with my ability to make an informed decision.

     I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, the possibility that I may choose not to obtain or not to use the medication, and the feasible alternatives or additional treatments, including comfort care, hospice care, and pain control.

     I request that my attending provider prescribe medication that I may self-administer to end my life.

     INITIAL ONE:

     _______   I have informed my family of my decision and taken their opinions into consideration.

     _______   I have decided not to inform my family of my decision.

     _______   I have no family to inform of my decision.

     I understand that I have the right to rescind this request at any time.

     I understand the full import of this request and I expect to die when I take the medication to be prescribed.  I further understand that although most deaths occur within three hours, my death may take longer and my attending provider has counseled me about this possibility.

     I make this request voluntarily and without reservation, and I accept full moral responsibility for my actions.

     Signed:  ____________________

     Dated:   ____________________

DECLARATION OF WITNESSES

     We declare that the person signing this request:

    (a)   Is personally known to us or has provided proof of identity;

    (b)   Signed this request in our presence;

    (c)   Appears to be of sound mind and not under duress or to have been induced by fraud, or subjected to undue influence when signing the request; and

    (d)   Is not a patient for whom either of us is the attending provider.

     ____________________Witness        Date__________

     ____________________Witness        Date__________

     NOTE:  One witness shall not be a relative (by blood, marriage, or adoption) of the person signing this request, shall not be entitled to any portion of the person's estate upon death and shall not own, operate, or be employed at a health care facility where the person is a patient or resident."

[L 2018, c 2, pt of §3]