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;

Terms Used In Hawaii Revised Statutes 327L-23

  • Adult: means an individual who is eighteen years of age or older. See Hawaii Revised Statutes 327L-1
  • Attending provider: means a physician licensed pursuant to chapter 453 or advanced practice registered nurse licensed pursuant to chapter 457 who has responsibility for the care of the patient and treatment of the patient's terminal disease. See Hawaii Revised Statutes 327L-1
  • Capable: means that in the opinion of the patient's attending provider or consulting provider, psychiatrist, psychologist, or clinical social worker, a patient has the ability to understand the patient's choices for care, including risks and benefits, and make and communicate health care decisions to health care providers. See Hawaii Revised Statutes 327L-1
  • Consulting provider: means a physician licensed pursuant to chapter 453 who is qualified by specialty or experience to make a professional diagnosis and prognosis regarding the patient's disease or advanced practice registered nurse licensed pursuant to chapter 457 who is qualified by specialty or experience to diagnose and prescribe medication. See Hawaii Revised Statutes 327L-1
  • Counseling: means one or more consultations, which may be provided through telehealth, as necessary between a psychiatrist licensed under chapter 453, psychologist licensed under chapter 465, clinical social worker licensed pursuant to chapter 467E, advanced practice registered nurse or clinical nurse specialist licensed under chapter 457 with psychiatric or mental health training, or marriage and family therapist licensed pursuant to chapter 451J, and a patient for the purpose of determining that the patient is capable, and that the patient does not appear to be suffering from undertreatment or nontreatment of depression or other conditions that may interfere with the patient's ability to make an informed decision pursuant to this chapter. See Hawaii Revised Statutes 327L-1
  • Fraud: Intentional deception resulting in injury to another.
  • Informed decision: means a decision by a qualified patient to request and obtain a prescription to end the qualified patient's life pursuant to this chapter. See Hawaii Revised Statutes 327L-1
  • Medically confirmed: means the medical opinion of the attending provider has been confirmed by a consulting provider who has examined the patient and the patient's relevant medical records. See Hawaii Revised Statutes 327L-1
  • Patient: means a person who is under the care of an attending provider. See Hawaii Revised Statutes 327L-1
  • Prescription: means prescription medication or medications that the qualified patient may self-administer to end the qualified patient's life pursuant to this chapter. See Hawaii Revised Statutes 327L-1
  • Self-administer: means an individual performing an affirmative, conscious, voluntary act to take into the individual's body prescription medication to end the individual's life pursuant to this chapter. See Hawaii Revised Statutes 327L-1
  • Terminal disease: means an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months. See Hawaii Revised Statutes 327L-1
(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.”

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