"REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND PEACEFUL MANNER
"I, _____________, am an adult of sound mind.
"I am suffering from ____________, which my attending physician has determined is a terminal disease and which has been medically confirmed by a consulting physician.
"I have been fully informed of my diagnosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including comfort care, hospice care, and pain control.
"I request that my attending physician prescribe medication that will end my life in a humane and peaceful manner.
"INITIAL ONE:
"[ ] I have informed my family of my decision and taken their opinion 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 as 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 3 hours of taking the medication to be prescribed, my death may take longer, and my physician 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:
"Date:
"Witness 1:
"Address:
"Witness 1 signature:
"Date:
"Witness 2:
"Address:
"Witness 2 signature:
"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 the health care facility where the person is a patient or resident. If the patient is a patient at a long-term care facility, one of the witnesses shall be an individual designated by the facility.".
D.C. Code § 7-661.02
Applicability
Section 7018 of D.C. Law 22-33 repealed § 18 of D.C. Law 21-182. Therefore the creation of this section by D.C. Law 21-182 has been implemented.
A certification dated June 6, 2017, that the fiscal effect of the Death with Dignity Act of 2016, D.C. Law 21-182, has been included in an approved budget and financial plan was published in the D.C. Register on June 16, 2017 (64 DCR 5670). Therefore the creation of this section by that amendment has been implemented.
Applicability of D.C. Law 21-182: § 18 of D.C. Law 21-182 provided that the creation of this section by § 3 of D.C. Law 21-182 is subject to the inclusion of the law's fiscal effect in an approved budget and financial plan. Therefore that amendment has not been implemented.