(a) A request for an aid-in-dying drug as authorized by this part shall be in the following form:

REQUEST FOR AN AID-IN-DYING DRUG TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER I, ………………………………………………, am an adult of sound mind and a resident of the State of California.
I am suffering from ……………., which my attending physician has determined is in its terminal phase and which has been medically confirmed.
I have been fully informed of my diagnosis and prognosis, the nature of the aid-in-dying drug to be prescribed and potential associated risks, the expected result, and the feasible alternatives or additional treatment options, including comfort care, hospice care, palliative care, and pain control.
I request that my attending physician prescribe an aid-in-dying drug that will end my life in a humane and dignified manner if I choose to take it, and I authorize my attending physician to contact any pharmacist about my request.
INITIAL ONE:
………… I have informed one or more members of 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 withdraw or rescind this request at any time.
I understand the full import of this request and I expect to die if I take the aid-in-dying drug to be prescribed. My attending physician has counseled me about the possibility that my death may not be immediately upon the consumption of the drug.
I make this request voluntarily, without reservation, and without being coerced.
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) voluntarily signed this request in our presence;
(c) is an individual whom we believe to be of sound mind and not under duress, fraud, or undue influence; and
(d) is not an individual for whom either of us is the attending physician, consulting physician, or mental health specialist.
……………………….Witness 1/Date
……………………….Witness 2/Date
NOTE: Only one of the two witnesses may be a relative (by blood, marriage, registered domestic partnership, or adoption) of the person signing this request or be entitled to a portion of the person’s estate upon death. Only one of the two witnesses may own, operate, or be employed at a health care entity where the person is a patient or resident.

(b) (1) The written language of the request shall be written in the same translated language as any conversations, consultations, or interpreted conversations or consultations between a patient and their attending or consulting physicians.

Terms Used In California Health and Safety Code 443.11

  • Adult: means an individual 18 years of age or older. See California Health and Safety Code 443.1
  • Affirmed: In the practice of the appellate courts, the decree or order is declared valid and will stand as rendered in the lower court.
  • Aid-in-dying drug: means a drug determined and prescribed by a physician for a qualified individual, which the qualified individual may choose to self-administer to bring about their death due to a terminal disease. See California Health and Safety Code 443.1
  • Attending physician: means the physician who has primary responsibility for the health care of an individual and treatment of the individual's terminal disease. See California Health and Safety Code 443.1
  • Consulting physician: means a physician who is independent from the attending physician and who is qualified by specialty or experience to make a professional diagnosis and prognosis regarding an individual's terminal disease. See California Health and Safety Code 443.1
  • County: includes city and county. See California Health and Safety Code 14
  • Department: means the State Department of Public Health. See California Health and Safety Code 443.1
  • Fraud: Intentional deception resulting in injury to another.
  • Health care entity: means any clinic, health dispensary, or health facility licensed pursuant to Division 2 (commencing with Section 1200), including a general hospital, medical clinic, nursing home or hospice facility. See California Health and Safety Code 443.1
  • Medically confirmed: means the medical diagnosis and prognosis of the attending physician has been confirmed by a consulting physician who has examined the individual and the individual's relevant medical records. See California Health and Safety Code 443.1
  • Mental health specialist: means a psychiatrist or a licensed psychologist. See California Health and Safety Code 443.1
  • Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
  • Person: means any person, firm, association, organization, partnership, business trust, corporation, limited liability company, or company. See California Health and Safety Code 19
  • Physician: means a doctor of medicine or osteopathy currently licensed to practice medicine in this state. See California Health and Safety Code 443.1
  • Qualified individual: means an adult who has the capacity to make medical decisions, is a resident of California, and has satisfied the requirements of this part in order to obtain a prescription for a drug to end their life. See California Health and Safety Code 443.1
  • State: means the State of California, unless applied to the different parts of the United States. See California Health and Safety Code 23

(2) Notwithstanding paragraph (1), the written request may be prepared in English even when the conversations or consultations or interpreted conversations or consultations were conducted in a language other than English if the English language form includes an attached interpreter’s declaration that is signed under penalty of perjury. The interpreter’s declaration shall state words to the effect that:

I, (INSERT NAME OF INTERPRETER), am fluent in English and (INSERT TARGET LANGUAGE).

On (insert date) at approximately (insert time), I read the “Request for an Aid-In-Dying Drug to End My Life” to (insert name of individual/patient) in (insert target language).

Mr./Ms./Mx. (insert name of patient/qualified individual) affirmed to me that they understood the content of this form and affirmed their desire to sign this form under their own power and volition and that the request to sign the form followed consultations with an attending and consulting physician.

I declare that I am fluent in English and (insert target language) and further declare under penalty of perjury that the foregoing is true and correct.

Executed at (insert city, county, and state) on this (insert day of month) of (insert month), (insert year).

X______Interpreter signature

X______Interpreter printed name

X______Interpreter address

(3) An interpreter whose services are provided pursuant to paragraph (2) shall not be related to the qualified individual by blood, marriage, registered domestic partnership, or adoption or be entitled to a portion of the person’s estate upon death. An interpreter whose services are provided pursuant to paragraph (2) shall meet the standards promulgated by the California Healthcare Interpreting Association or the National Council on Interpreting in Health Care or other standards deemed acceptable by the department for health care providers in California.

(Amended by Stats. 2021, Ch. 542, Sec. 5. (SB 380) Effective January 1, 2022. Repealed as of January 1, 2031, pursuant to Section 443.215.)

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