(c) The patient's attending physician at the time the request is signed shall not be a witness.
(d) If a person uses an interpreter, the interpreter shall not be a witness.
(e) The written request for medication under this Act shall be substantially as follows:
"Request for Medication to End My Life in a Peaceful Manner
I, ............... (NAME OF PATIENT), am an adult of sound mind, and a resident of Illinois. I have been diagnosed with ............... (NAME OF CONDITION) and given a terminal disease prognosis of 6 months or less to live by my attending physician.
I affirm that my terminal disease diagnosis was given or confirmed during at least one in-person visit to a health care professional.
I have been fully informed of the feasible alternatives and concurrent or additional treatment opportunities for my terminal disease, including, but not limited to, comfort care, palliative care, hospice care, or pain control, as well as the potential risks and benefits of each. I have been offered, have received, or have been offered and received resources or referrals to pursue these alternatives and concurrent or additional treatment opportunities for my terminal disease.
I have been fully informed of the nature of the medication to be prescribed, including the risks and benefits, and I understand that the likely outcome of self-administering the medication is death.
I understand that I can rescind this request at any time, that I am under no obligation to fill the prescription once written, and that I have no duty to self-administer the medication if I obtain it.
I request that my attending physician furnish a prescription for medication that will end my life if I choose to self-administer it, and I authorize my attending physician to transmit the prescription to a pharmacist to dispense the medication at a time of my choosing.
I make this request voluntarily, free from coercion or undue influence.
Dated: ................
Signed........................................................(patient)Dated: ................
Signed........................................................(witness #1)Dated: ................
Signed........................................................(witness #2)"
(f) The interpreter attachment for a written request for medication under this Act shall be substantially as follows:
"Request for Medication to End My Life in a Peaceful MannerInterpreter Attachment
I, ............... (NAME OF INTERPRETER), am fluent in English and ............... (LANGUAGE OF PATIENT, INCLUDING SIGN LANGUAGE).
On ....... (DATE) at approximately ....... (TIME), I read the "Request for Medication to End My Life in a Peaceful Manner" form to ............... (NAME OF PATIENT) in ............... (LANGUAGE OF PATIENT, INCLUDING SIGN LANGUAGE).
............... (NAME OF PATIENT) affirmed to me that they understand the content of this form, that they desire to sign this form under their own power and volition, and that they requested to sign the form after consultations with an attending physician.
Under penalty of perjury, I declare that I am fluent in English and ............... (LANGUAGE OF PATIENT, INCLUDING SIGN LANGUAGE) and that the contents of this form, to the best of my knowledge, are true and correct. Executed at .................................. (NAME OF CITY, COUNTY, AND STATE) on ....... (DATE).
Interpreter's signature: .....................................
Interpreter's printed name: ..................................
Interpreter's address: ......................................".
(Source: P.A. 104-441, eff. 9-12-26.) |