REPORT TITLE:
Terminal Sedation


DESCRIPTION:
Allows physicians to prescribe terminal sedation to adults
suffering from a terminal carcinomatous condition.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        
THE SENATE                              S.B. NO.           981
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO DEATH WITH COMPASSION.



BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 1      SECTION 1.  The legislature finds that all competent persons
 
 2 have the fundamental right to control the decisions relating to
 
 3 their own medical care, including the decision to have medical or
 
 4 surgical means or procedures calculated to prolong their lives
 
 5 provided, continued, withheld, or withdrawn.  The legislature
 
 6 further finds that the artificial prolongation of life for
 
 7 persons with a terminal condition may secure only a precarious
 
 8 and burdensome existence, while providing nothing medically
 
 9 necessary or beneficial to the person.
 
10      In order that the rights of a patient may be respected when
 
11 a medical prognosis of the patient's carcinomatous condition
 
12 confirms that the patient is not expected to recover from the
 
13 carcinomatous condition and has less than six months to live, the
 
14 legislature hereby declares that the laws of the State recognize
 
15 the right of a capable adult patient suffering from a terminal
 
16 carcinomatous condition with less than six months to live to
 
17 authorize an attending physician to prescribe terminal sedation.
 
18      SECTION 2.  The Hawaii Revised Statutes is amended by adding
 
19 a new chapter to be appropriately designated and to read as
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1 follows:
 
 2                             "CHAPTER
 
 3               DEATH WITH COMPASSION AND DIGNITY ACT
 
 4      §   -1 Definitions.  Whenever used in this chapter, unless
 
 5 the context otherwise requires:
 
 6      "Adult" means an individual who is eighteen years of age or
 
 7 older.
 
 8      "Attending physician" means the physician who has primary
 
 9 responsibility for the care of the patient and treatment of the
 
10 patient's terminal disease.
 
11      "Consulting physician" means a physician who is qualified by
 
12 specialty or experience to make a professional diagnosis and
 
13 prognosis regarding the patient's disease.
 
14      "Counseling" means a consultation between a state licensed
 
15 psychiatrist or psychologist and a patient for the purpose of
 
16 determining whether the patient is suffering from a psychiatric
 
17 or psychological disorder, or depression causing impaired
 
18 judgment.
 
19      "Health care provider" means a person licensed, certified,
 
20 or otherwise authorized or permitted by the law of this State to
 
21 administer health care in the ordinary course of business or
 
22 practice of a profession, and includes a health care facility.
 
23      "Incapable" means that in the opinion of a court or in the
 

 
Page 3                                                     
                                     S.B. NO.           981
                                                        
                                                        

 
 1 opinion of the patient's attending physician or consulting
 
 2 physician, the patient lacks the ability to make and communicate
 
 3 health care decisions to health care providers, including
 
 4 communication through persons familiar with the patient's manner
 
 5 of communicating if those persons are available.  Capable means
 
 6 not incapable.
 
 7      "Informed decision" means a decision by a qualified patient,
 
 8 to request and obtain a prescription to end the patient's life,
 
 9 that is based on an appreciation of the relevant facts and after
 
10 being fully informed by the attending physician of:
 
11      (1)  The patient's medical diagnosis;
 
12      (2)  The patient's prognosis;
 
13      (3)  The potential risks associated with taking the
 
14           medication to be prescribed;
 
15      (4)  The probable result of taking the medication to be
 
16           prescribed; and
 
17      (5)  The feasible alternatives, including, but not limited
 
18           to, comfort care, hospice care, and pain control.
 
19      "Medically confirmed" means the medical opinion of the
 
20 attending physician has been confirmed by a consulting physician
 
21 who has examined the patient and the patient's relevant medical
 
22 records.
 
23      "Palliative treatment" or "palliative care" means therapy
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1 designed to relieve or reduce the intensity of uncomfortable
 
 2 symptoms but which does not produce a cure to a terminal
 
 3 carcinomatous condition.  The terms "palliative treatment" or
 
 4 "palliative care" include but are not limited to comfort care,
 
 5 hospice care, and pain management techniques and protocols.
 
 6      "Patient" means a person who is under the care of a
 
 7 physician.
 
 8      "Physician" means a doctor of medicine or osteopathy
 
 9 licensed to practice medicine in this State.
 
10      "Qualified patient" means a capable adult who has satisfied
 
11 the requirements of this chapter in order to obtain a
 
12 prescription for medication to end that adult's life.
 
13      "Terminal carcinomatous condition" means an incurable and
 
14 irreversible disease that is a result of a malignant epithelial
 
15 neoplasm invading surrounding tissue that may or may not
 
16 metastasize in other regions of the body and which results in a
 
17 condition that has been medically confirmed and, within
 
18 reasonable medical judgment, will produce death within six
 
19 months.
 
20      §   -2 Who may initiate a written request for medication.
 
21 An adult who is capable and has been determined by the attending
 
22 physician and consulting physician to be suffering from a
 
23 terminal carcinomatous condition and who:
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1      (1)  Is not undergoing medical treatment to cure the
 
 2           terminal carcinomatous condition;
 
 3      (2)  Is only receiving palliative care to abate the terminal
 
 4           carcinomatous condition; and
 
 5      (3)  Who has voluntarily expressed the wish to die;
 
 6 may make a written request for medication for the purpose of
 
 7 ending the person's life in accordance with this chapter.
 
 8      §   -3 Form of the written request.(a)  A valid request
 
 9 for medication under this chapter shall be in substantially the
 
10 form described in section    -19, signed and dated by the
 
11 qualified patient and witnessed by at least two individuals who
 
12 are not related to the patient by blood, marriage, or adoption,
 
13 and who, in the presence of the patient, attest to the best of
 
14 their knowledge and belief that the patient is capable, acting
 
15 voluntarily, and is not being coerced to sign the request.
 
16      (b)  The witnesses shall not be:
 
17      (1)  A person who at the time the request is signed would be
 
18           entitled to any portion of the estate of the qualified
 
19           patient upon death under any will or by operation of
 
20           law; or
 
21      (2)  An owner, operator, or employee of a health care
 
22           facility where the qualified patient is receiving
 
23           medical treatment or is a resident.
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1      (c)  The qualified patient's attending physician at the time
 
 2 the request is signed shall not be a witness.
 
 3      §   -4 Attending physician responsibilities.  The attending
 
 4 physician shall:
 
 5      (1)  Make the initial determination of whether:
 
 6           (A)  A patient has a terminal carcinomatous condition;
 
 7           (B)  Is capable;
 
 8           (C)  Is no longer receiving medical treatment to cure
 
 9                the carcinomatous condition;
 
10           (D)  Is only receiving palliative care to abate the
 
11                terminal carcinomatous condition; and
 
12           (E)  The patient has made the request for terminal
 
13                sedation voluntarily;
 
14      (2)  Inform the patient of:
 
15           (A)  The patient's medical diagnosis;
 
16           (B)  The patient's prognosis;
 
17           (C)  The potential risks associated with taking the
 
18                medication to be prescribed;
 
19           (D)  The probable result of taking the medication to be
 
20                prescribed; and
 
21           (E)  The feasible alternatives, including, but not
 
22                limited to the extension of comfort care, hospice
 
23                care, and pain management techniques and
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1                protocols;
 
 2      (3)  Refer the patient to a consulting physician for medical
 
 3           confirmation of the diagnosis, and for a determination
 
 4           that the patient is capable and acting voluntarily;
 
 5      (4)  Refer the patient for counseling if appropriate,
 
 6           pursuant to section    -6;
 
 7      (5)  Request that the patient notify next of kin;
 
 8      (6)  Inform the patient that the patient has an opportunity
 
 9           to rescind the request at any time and in any manner,
 
10           and offer the patient an opportunity to rescind the
 
11           request at the end of the fifteen-day waiting period
 
12           required under section    -9;
 
13      (7)  Verify, immediately prior to writing the prescription
 
14           for medication under this chapter, that the patient is
 
15           making an informed decision;
 
16      (8)  Fulfill the medical record documentation requirements
 
17           of section    -12; and
 
18      (9)  Ensure that all appropriate steps are carried out in
 
19           accordance with this chapter prior to writing a
 
20           prescription for medication to enable a qualified
 
21           patient to end the patient's life.
 
22      §   -5 Consulting physician confirmation.  Before a patient
 
23 is qualified under this chapter, a consulting physician shall
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1 examine the patient and the patient's relevant medical records
 
 2 and confirm, in writing:
 
 3      (1)  The attending physician's diagnosis that the patient is
 
 4           suffering from a terminal carcinomatous condition;
 
 5      (2)  That the patient is no longer receiving medical
 
 6           treatment to cure the carcinomatous condition;
 
 7      (3)  That the patient is only receiving palliative care to
 
 8           abate the terminal carcinomatous condition; and
 
 9      (4)  That the patient is capable, acting voluntarily, and
 
10           has made an informed decision.
 
11      §   -6 Counseling referral.  If it is the opinion of the
 
12 attending or the consulting physician that a patient's judgment
 
13 may be impaired as a consequence of the patient's terminal
 
14 carcinomatous condition, resulting in depression or a psychiatric
 
15 or psychological disorder, either physician shall refer the
 
16 patient for counseling.  No medication to end a patient's life
 
17 shall be prescribed until the person performing the counseling
 
18 determines that the patient is not suffering from a psychiatric
 
19 or psychological disorder, or depression causing impaired
 
20 judgment.
 
21      §   -7 Informed decision.  No patient shall receive a
 
22 prescription for medication to end the patient's life unless the
 
23 patient has made an informed decision as defined in section   -1.
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1 Immediately prior to writing a prescription for medication under
 
 2 this chapter, the attending physician shall verify that the
 
 3 patient is making an informed decision.
 
 4      §   -8 Family notification.  The attending physician shall
 
 5 ask the patient to notify next of kin of the patient's request
 
 6 for medication pursuant to this chapter.  A patient who declines
 
 7 or is unable to notify next of kin shall not have the patient's
 
 8 request denied for that reason.
 
 9      §   -9 Written and oral requests.(a)  In order to receive
 
10 a prescription for medication to end the patient's life, a
 
11 qualified patient shall make an initial oral request accompanied
 
12 by a written request executed in accordance with sections    -3
 
13 and    -19 and reiterate the oral request to the patient's
 
14 attending physician no less than fifteen days after the initial
 
15 oral request.  At the time the qualified patient makes the
 
16 patient's second oral request, the attending physician shall
 
17 offer the patient an opportunity to rescind the request.
 
18      (b)  Both the initial and secondary oral requests required
 
19 under this section shall be witnessed by at least two witnesses
 
20 who meet the qualifications set forth in section    -3 and
 
21 documented by using either:
 
22      (1)  An audio tape or a video tape of the discussions during
 
23           which the witnesses acknowledge their presence; or
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1      (2)  A written summary of the discussion that the patient
 
 2           reads and signs and that the witnesses attest in
 
 3           writing to be accurate.
 
 4      (c)  If a qualified patient suffers from a condition that
 
 5 impairs the patient's vocal capacity to the extent that the
 
 6 condition renders the patient's speech unintelligible, then a
 
 7 written request containing separate sections that confirm each of
 
 8 the following:
 
 9      (1)  The qualified patient's debilitated vocal condition;
 
10      (2)  The qualified patient's initial request to obtain
 
11           medication to end the patient's life; and
 
12      (3)  The qualified patient's second request to obtain
 
13           medication to end the patient's life;
 
14 shall suffice as a substitution for the oral request requirements
 
15 of subsection (a).  Each section of the written request required
 
16 under this subsection shall be affirmatively signed by the
 
17 attending physician, the patient, and a consulting physician, and
 
18 attested by the witnesses; provided that the patient's second
 
19 request for medication to end the patient's life required under
 
20 paragraph (3) shall not be signed and attested to prior to the
 
21 lapsing of the required fifteen day waiting period.
 
22      §   -10  Right to rescind request.  A qualified patient may
 
23 rescind the patient's request orally or in writing at any time
 

 
Page 11                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 and in any manner without regard to the patient's mental state.
 
 2 No prescription for medication under this chapter shall be
 
 3 provided to the qualified patient without the attending physician
 
 4 first offering the patient an opportunity to rescind the request.
 
 5      §   -11  Waiting periods.  In no case shall a prescription
 
 6 under this chapter be provided to a qualified patient less than
 
 7 fifteen days after the patient's initial oral request under
 
 8 section    -9(a) or initial written request under section
 
 9    -9(c).
 
10      §   -12  Medical record documentation requirements.  The
 
11 following shall be documented or filed in the qualified patient's
 
12 medical record:
 
13      (1)  All oral requests by a qualified patient for medication
 
14           to end the patient's life;
 
15      (2)  All audio and video tapes documenting the qualified
 
16           patient's discussions of obtaining medication to end
 
17           the patient's life;
 
18      (3)  All written requests by a qualified patient for
 
19           medication to end the patient's life;
 
20      (4)  The attending physician's diagnosis and prognosis,
 
21           determination that the qualified patient is capable,
 
22           acting voluntarily, has made an informed decision, and
 
23           any other information required under section    -4;
 

 
Page 12                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1      (5)  The consulting physician's diagnosis and prognosis,
 
 2           verification that the qualified patient is capable,
 
 3           acting voluntarily, has made an informed decision, and
 
 4           any other information required under section    -5;
 
 5      (6)  A report of the outcome and determinations made during
 
 6           counseling, if performed;
 
 7      (7)  The attending physician's offer to the qualified
 
 8           patient to rescind the patient's request at the time of
 
 9           the patient's second oral request pursuant to
 
10           section    -9; and
 
11      (8)  A note by the attending physician indicating that all
 
12           requirements under this chapter have been met and
 
13           indicating the steps taken to carry out the request,
 
14           including a notation of the medication prescribed.
 
15      §   -13  Reporting requirements.(a)  The department of
 
16 health shall annually review a sample of records maintained
 
17 pursuant to this chapter.
 
18      (b)  The department of health shall adopt rules in
 
19 accordance with chapter 91 to facilitate the collection of
 
20 information regarding compliance with this chapter.  The
 
21 information collected shall not be a public record and shall not
 
22 be made available for inspection by the public.
 
23      (c)  The department of health shall generate and make
 

 
Page 13                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 available to the public an annual statistical report of
 
 2 information collected under subsection (b); provided that the
 
 3 information contained in the report shall be reported in a manner
 
 4 that maintains the anonymity of the patients who have expired
 
 5 subject to this chapter.
 
 6      §   -14  Effect on construction of wills, contracts, and
 
 7 statutes.  No provision in a contract, will, or other agreement,
 
 8 whether written or oral, to the extent the provision would affect
 
 9 whether a person may make or rescind a request for medication to
 
10 end that person's life, shall be valid.
 
11      §   -15  Insurance or annuity policies.  No sale,
 
12 procurement, or issuance of any life, health, or accident
 
13 insurance or annuity policy or the rate charged for any policy
 
14 shall be conditioned upon or affected by the making, rescinding,
 
15 or executing of a request, by a person, for medication to end
 
16 that person's life.  A qualified patient's act of taking
 
17 medication to end the patient's life shall have no effect upon a
 
18 life, health, or accident insurance or annuity policy.
 
19      §   -16  Construction of chapter.  Nothing in this chapter
 
20 shall be construed to authorize a physician or any other person
 
21 to end a patient's life by lethal injection, mercy killing, or
 
22 active euthanasia.  Actions taken in accordance with this chapter
 
23 shall not, for any purpose, constitute suicide, assisted suicide,
 

 
Page 14                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 mercy killing, or homicide, under the law.
 
 2      §   -17  Immunities.  Except as provided in section     -18:
 
 3      (1)  No person shall be subject to civil or criminal
 
 4           liability or professional disciplinary action for
 
 5           participating in good faith compliance with this
 
 6           chapter.  This includes being present when a qualified
 
 7           patient takes the prescribed medication to end the
 
 8           patient's life.
 
 9      (2)  No professional organization or association, or health
 
10           care provider, may subject a person to censure,
 
11           discipline, suspension, loss of license, loss of
 
12           privileges, loss of membership, or other penalty for
 
13           participating or refusing to participate in good faith
 
14           compliance with this chapter.
 
15      (3)  No request by a patient for or provision by an
 
16           attending physician of medication in good faith
 
17           compliance with this chapter shall constitute neglect
 
18           for any purpose of law or by itself provide a basis for
 
19           the appointment of a guardian or conservator; and
 
20      (4)  No health care provider shall be under any duty,
 
21           whether by contract, by statute, or by any other legal
 
22           requirement to participate in the provision to a
 
23           qualified patient of medication to end the patient's
 

 
Page 15                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1           life.  If a health care provider is unable or unwilling
 
 2           to carry out a patient's request under this chapter,
 
 3           and if the patient transfers the patient's care to a
 
 4           new health care provider, the prior health care
 
 5           provider shall transfer, upon request, a copy of the
 
 6           patient's relevant medical records to the new health
 
 7           care provider.
 
 8      §   -18  Penalties.(a)  A person who wilfully alters or
 
 9 forges a request for medication or conceals or destroys a
 
10 rescission of that request with the intent or effect of causing
 
11 the patient's death without authorization of the patient shall be
 
12 guilty of a class A felony.
 
13      (b)  A person who coerces or exerts undue influence on a
 
14 patient to request medication for the purpose of ending the
 
15 patient's life, or to destroy a rescission of such a request,
 
16 shall be guilty of a class A felony.
 
17      (c)  Nothing in this chapter limits further liability for
 
18 civil damages resulting from other negligent conduct or
 
19 intentional misconduct by any person.
 
20      (d)  The penalties in this chapter do not preclude criminal
 
21 penalties applicable under any other law for conduct which is
 
22 inconsistent with this chapter.
 
23      §   -19  Form of the request.  A request for a medication as
 

 
Page 16                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 authorized by this chapter shall be in substantially the
 
 2 following form:
 
 3                            DECLARATION
 
 4                       REQUESTING MEDICATION
 
 5                          TO END MY LIFE
 
 6 A.  Statement of Declarant
 
 7      Declaration made this day of               (month, year).
 
 8 I,                     , being an adult of sound mind and
 
 9 understanding that I have the right to request that my life be
 
10 prolonged to the greatest extent possible, wilfully and
 
11 voluntarily make known my desire that my dying shall not be
 
12 artificially prolonged under the circumstances set forth below,
 
13 and do hereby declare:
 
14      I am suffering from                   , which my attending
 
15 physician has determined is a terminal carcinomatous disease and
 
16 which has been medically confirmed by a consulting physician.
 
17      I am only receiving palliative care to abate the
 
18 uncomfortable symptoms associated with the terminal carcinomatous
 
19 condition and am not receiving medical treatment to cure the
 
20 terminal carcinomatous condition itself.
 
21      I have been fully informed of my diagnosis, prognosis, the
 
22 nature of medication to be prescribed and potential associated
 
23 risks, the expected results, and the feasible alternatives,
 

 
Page 17                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 including the extension of comfort care, hospice care, and pain
 
 2 management techniques and protocols.
 
 3      I request that my attending physician prescribe medication
 
 4 that will end my life.
 
 5      INITIAL ONE:
 
 6           , I have informed my family of my decision and taken
 
 7 their opinions into consideration.
 
 8           , I have decided not to inform my family of my
 
 9 decision.
 
10           , I have no family to inform of my decision.
 
11      I understand that I have the right to rescind this request
 
12 at any time.
 
13      I understand the full import of this request and I expect to
 
14 die when I take the medication to be prescribed.
 
15      I make this request voluntarily and without reservation, and
 
16 I accept full moral responsibility for my actions.
 
17                                   Signed:                       
 
18                                   Address:                      
 
19 B.   Statement of Witnesses
 
20      I am at least 18 years of age and
 
21           -not related to the declarant by blood, marriage, or
 
22           adoption; and
 
23           -not currently the attending physician, an employee of
 

 
Page 18                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1           the attending physician, or an employee of the health
 
 2           care facility in which the declarant is a patient.
 
 3      The declarant is personally known to me and I believe the
 
 4 declarant to be of sound mind.
 
 5      Witness:                    
 
 6      Address:                    
 
 7      Witness:                    
 
 8      Address:                    
 
 9 C.   Notarization
 
10      Subscribed, sworn to and acknowledged before me by
 
11 ____________________, the declarant, and subscribed and sworn to
 
12 before me by _____________________ and ____________________,
 
13 witnesses, this __________ day of____________________, 19_____.
 
14 (SEAL)                    Signed:                               
 
15                           Name of Notary:                       
 
16                                   (Official capacity of officer)
 
17                            DECLARATION
 
18                        OF VOCAL INCAPACITY
 
19 D.  Statement of Declarant
 
20      Declaration made this day of               (month, year).
 
21 I,                     , being an adult of sound mind, do hereby
 
22 declare that I am suffering from                   , which my
 
23 attending physician has determined is a condition that has
 

 
Page 19                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 rendered me unable to speak in an intelligible manner and which
 
 2 has been medically confirmed by a consulting physician.
 
 3                                   Signed:                       
 
 4                                   Address:                      
 
 5 E.   Statement of Attending Physician
 
 6      I,                     , being a physician duly licensed to
 
 7 practice medicine in the State of Hawaii, do hereby declare that
 
 8 the patient described above is under my care and is suffering
 
 9 from                       (name of condition), which renders the
 
10 patient unable to speak in an intelligible manner.  I also
 
11 declare that in my medical opinion, the vocally incapacitating
 
12 condition stated above does not render the patient incapable of
 
13 exercising sound judgment on the patient's behalf.
 
14                                    Signed:                       
 
15                                    Address:                      
 
16 F.   Statement of Consulting Physician
 
17      I,                     , being a physician duly licensed to
 
18 practice medicine in the State of Hawaii, do hereby declare that,
 
19 having examined the patient described above and reviewing the
 
20 patient's pertinent medical records, that the patient is
 
21 suffering from                       (name of condition), which
 
22 renders the patient unable to speak in an intelligible manner.  I
 
23 also declare that in my medical opinion, the vocally
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1 incapacitating condition stated above does not render the patient
 
 2 incapable of exercising sound judgment on the patient's behalf.
 
 3                                    Signed:                       
 
 4                                    Address:                      
 
 5 G.   Statement of Witnesses
 
 6      I am at least 18 years of age and
 
 7           -not related to the declarant by blood, marriage, or
 
 8           adoption; and
 
 9           -not currently the attending physician, an employee of
 
10           the attending physician, or an employee of the health
 
11           care facility in which the declarant is a patient.
 
12      The declarant is personally known to me and I believe the
 
13 declarant to be of sound mind.
 
14      Witness:                    
 
15      Address:                    
 
16      Witness:                    
 
17      Address:                    
 
18 H.   Notarization
 
19      Subscribed, sworn to and acknowledged before me by
 
20 ____________________, the declarant, and subscribed and sworn to
 
21 before me by _____________________ and ____________________,
 
22 witnesses, this __________ day of____________________, 19_____.
 
23 (SEAL)                    Signed:                               
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1                           Name of Notary:                       
 
 2                                   (Official capacity of officer)
 
 3        WRITTEN DECLARATION IN LIEU OF INITIAL ORAL REQUEST
 
 4                       TO REQUEST MEDICATION
 
 5                          TO END MY LIFE
 
 6 I.  Statement of Declarant
 
 7      Declaration made this day of               (month, year).
 
 8 I,                     , being an adult of sound mind and
 
 9 understanding that I have the right to request that my life be
 
10 prolonged to the greatest extent possible, wilfully and
 
11 voluntarily make known my desire that my dying shall not be
 
12 artificially prolonged under the circumstances set forth below,
 
13 and do hereby declare:
 
14      I am suffering from                   , which my attending
 
15 physician has determined is a terminal carcinomatous disease and
 
16 which has been medically confirmed by a consulting physician.
 
17      I am also suffering from a medically confirmed condition
 
18 that renders me vocally incapacitated and understand that this
 
19 written declaration to request medication to end my life is being
 
20 executed in lieu of the required initial oral request to end my
 
21 life.
 
22      I understand that I have the right to rescind this request
 
23 at any time.
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1      I understand the full import of this request and I expect to
 
 2 die when I take the medication to be prescribed.
 
 3      I make this request voluntarily and without reservation, and
 
 4 I accept full moral responsibility for my actions.
 
 5                                   Signed:                       
 
 6                                   Address:                      
 
 7 J.   Statement of Witnesses
 
 8      I am at least 18 years of age and
 
 9           -not related to the declarant by blood, marriage, or
 
10           adoption; and
 
11           -not currently the attending physician, an employee of
 
12           the attending physician, or an employee of the health
 
13           care facility in which the declarant is a patient.
 
14      The declarant is personally known to me and I believe the
 
15 declarant to be of sound mind.
 
16      Witness:                    
 
17      Address:                    
 
18      Witness:                    
 
19      Address:                    
 
20 K.   Notarization
 
21      Subscribed, sworn to and acknowledged before me by
 
22 ____________________, the declarant, and subscribed and sworn to
 
23 before me by _____________________ and ____________________,
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1 witnesses, this __________ day of____________________, 19_____.
 
 2 (SEAL)                    Signed:                               
 
 3                           Name of Notary:                       
 
 4                                   (Official capacity of officer)
 
 5        WRITTEN DECLARATION IN LIEU OF SECOND ORAL REQUEST
 
 6                       TO REQUEST MEDICATION
 
 7                          TO END MY LIFE
 
 8 L.  Statement of Declarant
 
 9      Declaration made this day of               (month, year).
 
10 I,                     , being an adult of sound mind and
 
11 understanding that I have the right to request that my life be
 
12 prolonged to the greatest extent possible, wilfully and
 
13 voluntarily make known my desire that my dying shall not be
 
14 artificially prolonged under the circumstances set forth below,
 
15 and do hereby declare:
 
16      I am suffering from                   , which my attending
 
17 physician has determined is a terminal carcinomatous disease and
 
18 which has been medically confirmed by a consulting physician.
 
19      I am also suffering from a medically confirmed condition
 
20 that renders me vocally incapacitated and understand that this
 
21 written declaration to request medication to end my life is being
 
22 executed in lieu of the required second oral request to end my
 
23 life.
 

 
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                                     S.B. NO.           981
                                                        
                                                        

 
 1      I understand that I have the right to rescind this request
 
 2 at any time.
 
 3      I understand the full import of this request and I expect to
 
 4 die when I take the medication to be prescribed.
 
 5      I make this request voluntarily and without reservation, and
 
 6 I accept full moral responsibility for my actions.
 
 7                                   Signed:                       
 
 8                                   Address:                      
 
 9 M.   Statement of Witnesses
 
10      I am at least 18 years of age and
 
11           -not related to the declarant by blood, marriage, or
 
12           adoption; and
 
13           -not currently the attending physician, an employee of
 
14           the attending physician, or an employee of the health
 
15           care facility in which the declarant is a patient.
 
16      The declarant is personally known to me and I believe the
 
17 declarant to be of sound mind.
 
18      Witness:                    
 
19      Address:                    
 
20      Witness:                    
 
21      Address:                    
 
22 N.   Notarization
 
23      Subscribed, sworn to and acknowledged before me by
 

 
Page 25                                                    
                                     S.B. NO.           981
                                                        
                                                        

 
 1 ____________________, the declarant, and subscribed and sworn to
 
 2 before me by _____________________ and ____________________,
 
 3 witnesses, this __________ day of____________________, 19_____.
 
 4 (SEAL)                    Signed:                               
 
 5                           Name of Notary:                       
 
 6                                   (Official capacity of officer)
 
 7      SECTION 3.  If any section of this chapter is held invalid
 
 8 as to any person or circumstance then the invalidity of that
 
 9 section shall not affect the application of any other section of
 
10 this chapter which can be given full effect without the invalid
 
11 section or application."
 
12      SECTION 4.  This Act shall take effect upon its approval.
 
13 
 
14                           INTRODUCED BY:  _______________________