Maine's Death with Dignity Act requires a second physician's opinion before a prescription. The attending physician refers the patient to a consulting physician, who uses this one-page form to record the date and time of their examination, confirm they reviewed the relevant medical records, name the terminal diagnosis, and confirm that the patient is competent, acting voluntarily and making an informed decision.
The consulting physician completes Sections A to D, including their name and license number in Section D, and signs. Section B identifies the referring or attending physician, who files the form.
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Consulting Physician End-of-Life Care
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The consulting physician confirms the attending physician's diagnosis that the patient has a terminal disease, writing in the specific diagnosis, and verifies that the patient is competent, is making an informed decision and is acting voluntarily. The form also records when the patient was examined and that the relevant medical records were reviewed.
The consulting physician returns it to the attending physician. The attending physician keeps the original in the patient's medical record and provides a copy to the State Registrar at Maine CDC's Office of Data, Research, and Vital Statistics, which collects all Death with Dignity reporting forms.