ORS 127.897
§6.01. Form of the request

A request for a medication as authorized by ORS 127.800 (§1.01. Definitions) to 127.897 (§6.01. Form of the request) shall be in substantially the following form:
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, prognosis, 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 dignified manner.
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 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: _______________
We declare that the person signing this request:

(a)

Is personally known to us or has provided proof of identity;

(b)

Signed this request in our presence;

(c)

Appears to be of sound mind and not under duress, fraud or undue influence;

(d)

Is not a patient for whom either of us is attending physician.
______________ Witness 1/Date
______________ Witness 2/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. If the patient is an inpatient at a health care facility, one of the witnesses shall be an individual designated by the facility.
[1995 c.3 §6.01; 1999 c.423 §11]

Source: Section 127.897 — §6.01. Form of the request, https://www.­oregonlegislature.­gov/bills_laws/ors/ors127.­html.

127.002
Definitions for ORS 127.005 to 127.045 127.005
When power of attorney in effect 127.015
Revocation of power of attorney 127.025
Authority under power of attorney recognizable regardless of date of execution 127.035
Limitations on liability of person reasonably relying on power of attorney 127.045
Duty of agent under power of attorney 127.505
Definitions for ORS 127.505 to 127.660 127.507
Capable adults may make own health care decisions 127.510
Appointment of health care representative and alternate health care representative 127.515
Execution 127.520
Persons not eligible to serve as health care representative 127.525
Acceptance of appointment 127.527
Form for appointing health care representative 127.529
Form of advance directive 127.532
Appointment 127.533
Duties 127.535
Authority of health care representative 127.540
Limitations on authority of health care representative 127.545
Revocation of advance directive or health care decision 127.550
Petition for judicial review of advance directives 127.555
Designation of attending physician or health care provider 127.560
Provisions not exclusive 127.565
Independent medical judgment of provider 127.570
Mercy killing 127.575
Instrument presumed valid 127.580
Presumption of consent to artificially administered nutrition and hydration 127.625
Providers under no duty to participate in withdrawal or withholding of certain health care 127.635
Withdrawal of life-sustaining procedures 127.640
Physician to determine that conditions met before withdrawing or withholding certain health care 127.642
Principal to be provided with certain care to insure comfort and cleanliness 127.646
Definitions for ORS 127.646 to 127.654 127.649
Health care organizations required to have written policies and procedures on providing information on patient’s right to make health care decisions 127.652
Time of providing information 127.654
Scope of requirement 127.658
Effect of ORS 127.505 to 127.660 on previously executed advance directives 127.660
Short title 127.663
Definitions for ORS 127.663 to 127.684 127.666
Establishment of registry 127.669
Oregon Health Authority not required to perform certain acts 127.672
POLST not required 127.678
Confidentiality 127.681
Immunity from liability 127.684
Short title 127.700
Definitions for ORS 127.700 to 127.737 127.702
Persons who may make declaration for mental health treatment 127.703
Required policies regarding mental health treatment rights information 127.705
Designation of attorney-in-fact for decisions about mental health treatment 127.707
Execution of declaration 127.710
Operation of declaration 127.712
Scope of authority of attorney-in-fact 127.715
Prohibitions against requiring person to execute or refrain from executing declaration 127.717
Declaration to be made part of medical record 127.720
Circumstances in which physician or provider may disregard declaration 127.722
Revocation of declaration 127.725
Limitations on liability of physician or provider 127.727
Persons prohibited from serving as attorney-in-fact 127.730
Persons prohibited from serving as witnesses to declaration 127.732
Withdrawal of attorney-in-fact 127.736
Form of declaration 127.737
Certain other laws applicable to declaration 127.760
Consent to health care services by person appointed by hospital 127.765
Health care advocate 127.800
§1.01. Definitions 127.805
§2.01. Who may initiate a written request for medication 127.810
§2.02. Form of the written request 127.815
§3.01. Attending physician responsibilities 127.820
§3.02. Consulting physician confirmation 127.825
§3.03. Counseling referral 127.830
§3.04. Informed decision 127.835
§3.05. Family notification 127.840
§3.06. Written and oral requests 127.845
§3.07. Right to rescind request 127.850
§3.08. Waiting periods 127.855
§3.09. Medical record documentation requirements 127.860
§3.10. Residency requirement 127.865
§3.11. Reporting requirements 127.870
§3.12. Effect on construction of wills, contracts and statutes 127.875
§3.13. Insurance or annuity policies 127.880
§3.14. Construction of Act 127.885
§4.01. Immunities 127.890
§4.02. Liabilities 127.892
Claims by governmental entity for costs incurred 127.895
§5.01. Severability 127.897
§6.01. Form of the request 127.995
Penalties
Green check means up to date. Up to date

Current through early 2024

§ 127.897’s source at oregon​.gov