Hawaii Revised Statutes Division 1. Government § 327L-24

“FINAL ATTESTATION FOR A REQUEST FOR MEDICATION TO END MY LIFE

I, _______________, am an adult of sound mind.

I am suffering from __________, which my attending provider has determined is a terminal disease and that has been medically confirmed by a consulting provider.

I have received counseling to determine that I am capable and not suffering from undertreatment or nontreatment of depression or other conditions which may interfere with my ability to make an informed decision.

I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, the possibility that I may choose not to obtain or not to use the medication, and the feasible alternatives or additional treatment options, including comfort care, hospice care, and pain control.

I understand that I am requesting that my attending provider prescribe medication that I may self-administer to end my life.

INITIAL ONE:

I understand that I have the right to rescind this request at any time.

I understand that I still may choose not to use the medication prescribed and by signing this form I am under no obligation to use the medication prescribed.

I am fully aware that the prescribed medication will end my life and while I expect to die when I take the medication prescribed, I also understand that my death may not be immediate and my attending provider has counseled me about this possibility.

I make this request voluntarily and without reservation.

Signed: _______________

Dated: _______________”