N.Y. Public Health Law § 2899-k: Form of written request and witness attestation

§ 2899-k. Form of written request and witness attestation. 1. A

request for medication under this article shall be in substantially the

following form:

REQUEST FOR MEDICATION TO END MY LIFE

I, _________________________________, am an adult who has

decision-making capacity, which means I understand and appreciate the

nature and consequences of health care decisions, including the benefits

and risks of and alternatives to any proposed health care, and to reach

an informed decision and to communicate health care decisions to a

physician.

I have been diagnosed with (insert diagnosis), which my attending

physician has determined is a terminal illness or condition, which has

been medically confirmed by a consulting physician and mental health

professional and will, in the judgment of the physicians and mental

health professional, produce death within six months whether or not

treatment is provided.

I have been fully informed of my diagnosis and prognosis, the nature

of the medication to be prescribed and potential associated risks, the

expected result, and the feasible alternatives and treatment options

including but not limited to palliative care and hospice care.

I request that my attending physician prescribe medication that will

end my life if I choose to take it, and I authorize my attending

physician to contact another physician or any pharmacist about my

request.

INITIAL ONE:

( ) I have informed or intend to inform one or more members of my

family of my decision.

( ) I have decided not to inform any member of 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 or decline

to use the medication at any time.

I understand the importance of this request, and I expect to die if 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 physician has counseled me about this possibility.

I make this request voluntarily, of my own volition and without being

coerced, and I accept full responsibility for my actions.

Signed: __________________________

Dated: ___________________________

DECLARATION OF WITNESSES

I declare that the person signing this "Request for Medication to End

My Life":

(a) is personally known to me or has provided proof of identity;

(b) voluntarily signed the "Request for Medication to End My Life" in

my presence or acknowledged to me that the person signed it; and

(c) to the best of my knowledge and belief, has decision-making

capacity and is making the "Request for Medication to End My Life"

voluntarily, of the person's own volition and is not being coerced to

sign the "Request for Medication to End My Life".

I am not the attending physician or consulting physician of the person

signing the "Request for Medication to End My Life" or the mental health

professional who provides a decision-making capacity determination of

the person signing the "Request for Medication to End My Life" at the

time the "Request for Medication to End My Life" was signed.

I further declare under penalty of perjury that the statements made

herein are true and correct and false statements made herein are

punishable.

I further declare that I am not (i) related to the above-named patient

by blood, marriage or adoption; (ii) entitled at the time the patient

signed the "Request for Medication to End My Life" to any portion of the

estate of the patient upon such patient's death under any will or by

operation of law, or otherwise in a position to benefit financially from

the patient's death; (iii) an owner, operator, employee or independent

contractor of a health care facility where the patient is receiving

treatment or is a resident; (iv) a domestic partner of the patient, as

defined in subdivision seven of section twenty-nine hundred

ninety-four-a of the public health law; (v) an agent, as defined in

subdivision five of section twenty-nine hundred eighty of the public

health law, under the patient's health care proxy; or (vi) an agent, as

defined in section 5-1501 of the general obligations law, acting under a

power of attorney for the patient.

Witness 1, Date:

(Printed name)

(Address)

(Telephone number)

Witness 2, Date:

(Printed name)

(Address)

(Telephone number)

2. (a) The "Request for Medication to End My Life" shall be written in

the same language as any conversations, consultations, or interpreted

conversations or consultations between a patient and at least one of the

patient's attending or consulting physicians.

(b) Notwithstanding paragraph (a) of this subdivision, the written

"Request for Medication to End My Life" may be prepared in English even

when the conversations or consultations or interpreted conversations or

consultations were conducted in a language other than English or with

auxiliary aids or hearing, speech or visual aids, if the English

language form includes an attached declaration by the interpreter of the

conversation or consultation, which shall be in substantially the

following form:

INTERPRETER'S DECLARATION

I, (insert name of interpreter), (mark as applicable):

( ) for a patient whose conversations or consultations or interpreted

conversations or consultations were conducted in a language other than

English and the "Request for Medication to End My Life" is in English: I

declare that I am fluent in English and (insert target language). I have

the requisite language and interpreter skills to be able to interpret

effectively, accurately and impartially information shared and

communications between the attending or consulting physician and (name

of patient).

I certify that on (insert date), at approximately (insert time), I

interpreted the communications and information conveyed between the

physician and (name of patient) as accurately and completely to the best

of my knowledge and ability and read the "Request for Medication to End

My Life" to (name of patient) in (insert target language).

(Name of patient) affirmed to me such patient's desire to sign the

"Request for Medication to End My Life" voluntarily, of (name of

patient)'s own volition and without coercion.

() for a patient with a speech, hearing or vision disability: I

declare that I have the requisite language, reading and/or interpreter

skills to communicate with the patient and to be able to read and/or

interpret effectively, accurately and impartially information shared and

communications that occurred on (insert date) between the attending or

consulting physician and (name of patient).

I certify that on (insert date), at approximately (insert time), I

read and/or interpreted the communications and information conveyed

between the physician and (name of patient) impartially and as

accurately and completely to the best of my knowledge and ability and,

where needed for effective communication, read or interpreted the

"Request for Medication to End my Life" to (name of patient).

(Name of patient) affirmed to me such patient's desire to sign the

"Request for Medication to End My Life" voluntarily, of (name of

patient)'s own volition and without coercion.

I further declare under penalty of perjury that (i) the foregoing is

true and correct; (ii) I am not (A) related to (name of patient) by

blood, marriage or adoption; (B) entitled at the time (name of patient)

signed the "Request for Medication to End My Life" to any portion of the

estate of (name of patient) upon such patient's death under any will or

by operation of law, or otherwise in a position to benefit financially

from the patient's death; (C) an owner, operator, employee or

independent contractor of a health care facility where (name of patient)

is receiving treatment or is a resident, except that if I am an employee

or independent contractor at such health care facility, providing

interpreter services is part of my job description at such health care

facility or I have been trained to provide interpreter services and

(name of patient) requested that I provide interpreter services to such

patient for the purposes stated in this Declaration; (D) a domestic

partner of the patient, as defined in subdivision seven of section

twenty-nine hundred ninety-four-a of the public health law; (E) an

agent, as defined in subdivision five of section twenty-nine hundred

eighty of the public health law, under the patient's health care proxy;

or (F) an agent, as defined in section 5-1501 of the general obligations

law, acting under a power of attorney for the patient; and (iii) false

statements made herein are punishable.

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

month) of (insert month), (insert year).

(Signature of Interpreter)

(Printed name of Interpreter)

(ID # or Agency Name)

(Address of Interpreter)

(Language Spoken by Interpreter)

(c) An interpreter whose services are provided under paragraph (b) of

this subdivision shall not (i) be related to the patient who signs the

"Request for Medication to End My Life" by blood, marriage or adoption;

(ii) be entitled at the time the "Request for Medication to End My Life"

is signed by the patient to any portion of the estate of the patient

upon death under any will or by operation of law, or otherwise in a

position to benefit financially from the patient's death; (iii) be an

owner, operator, employee or independent contractor of a health care

facility where the patient is receiving treatment or is a resident;

provided that an employee or independent contractor whose job

description at the health care facility includes interpreter services or

who is trained to provide interpreter services and who has been

requested by the patient to serve as an interpreter under this article

shall not be prohibited from serving as an interpreter under this

article; (iv) be a domestic partner of the patient, as defined in

subdivision seven of section twenty-nine hundred ninety-four-a of this

chapter; (v) be an agent, as defined in subdivision five of section

twenty-nine hundred eighty of this chapter, under the patient's health

care proxy; or (vi) be an agent, as defined in section 5-1501 of the

general obligations law, acting under a power of attorney for the

patient.