Forms for Implementation of the California End of Life Option Act

The following forms are part of Assembly Bill 15, California End of Life Option Act. Each form can be printed from this page or downloaded as a fillable pdf using the link at the end of each section.

Written Request for Medications

The End of Life Option Act requires the patient to submit a written request to the attending physician. It is recommended that the written request form be completed and signed only after seeing both the attending and consulting physicians and after both physicians have completed their respective paperwork confirming the patient meets the requirements of the law. We also recommend the patient keep a copy of the written request for their records.

The written request must be witnessed by two individuals, at least one of whom is not related to the patient, or entitled to any portion of his or her estate, or the physician, or an employee of a health care facility caring for the patient.

The written request can be rescinded at any time.

* * * Form begins here * * *

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 facility where the person is a patient or resident.

* * * Form ends here * * *

Interpreter’s Declaration

Under the End of Life Option Act, 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 his or her attending or consulting physicians. 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:

* * * Form begins here * * *

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 ………………………………………………. (insert name of patient/qualified individual) affirmed to me that he/she understood the content of this form and affirmed his/her desire to sign this form under his/her 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

* * * Form ends here * * *

Final Attestation Form

The attending physician must provide the patient the following form which the patient has to complete within 48 hours prior to taking the medications.

* * * Form begins here * * *

FINAL ATTESTATION 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 have received the aid-in-dying drug and am fully aware that this aid-in-dying drug will end my life in a humane and dignified manner.

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.

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 decision to ingest the aid-in-dying drug to end my life in a humane and dignified manner. I understand I still may choose not to ingest the drug and by signing this form I am under no obligation to ingest the drug. I understand I may rescind this request at any time.

Signed: ………………………………………………
Dated: ………………………………………………
Time: ………………………………………………

* * * Form ends here * * *