After a patient who received a Death with Dignity Act prescription dies, from the medication or any other cause, the prescribing physician reports the circumstances on this five-page form, Rev. 4/26. The Oregon Health Authority matches prescription recipients against death certificates and uses the form to learn whether death followed ingestion, any complications, end-of-life care and the concerns behind the patient's request.
The attending (prescribing) physician signs page 1 and completes Part B on the patient's status and reasons. Part A, on the ingestion and death, is completed by whoever was present: the attending physician, another licensed provider or a volunteer.
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Attending Physician Follow-up Form
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Within 10 calendar days of the patient's ingestion of the lethal medication or death from any other cause, whichever comes first. It goes to OHA by secure email, fax or mail, and OHA keeps the information strictly confidential.
Check underlying illness on page 1, sign, and stop; submit page 1 only. Parts A and B are completed only when the patient died from ingesting the lethal dose. OHA's guidance for death certificates is to list the underlying terminal disease as the cause and mark the manner of death natural.