Oregon's Death with Dignity Act, ORS 127.800 to 127.897, requires the attending physician to document every step before and when writing a prescription for medication to end life. This two-page form, Rev. 04/24, records the patient's diagnosis, both oral requests, the written request, the medical consultation, the mental health determination and the medication prescribed, and goes to the Oregon Health Authority.
The attending physician completes Sections A to F and signs, stating that all requirements of the Act have been met. The consulting physician and any psychiatric or psychological consultant complete their own forms, which are attached.
Download the current version from the source each time; forms change without notice.
Attending Physician's Compliance Form
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Within 7 calendar days of writing the prescription. The attending physician sends it to the OHA Center for Health Statistics by secure email, fax or mail, together with the patient's written request, the consulting physician's compliance form and, if an evaluation was done, the psychiatric or psychological consultant's form.
The form records that the patient was informed of the diagnosis, prognosis, potential risks, probable result and feasible alternatives such as comfort care, hospice and pain control, and of the right to rescind. It also records advice to tell next of kin, to have someone present and not to take the medication in public.