§ 25-48-112 — Form of written request

(1) A request for medical aid-in-dying
medication authorized by this article 48 must be in substantially the following form:

Request for medication to end my life

in a peaceful manner

I, am an adult of sound mind. I am suffering from , which my
attending provider has determined is a terminal illness and which has been
medically confirmed. I have been fully informed of my diagnosis and prognosis of
six months or less, the nature of the medical aid-in-dying medication to be
prescribed and potential associated risks, the expected result, and the feasible
alternatives or additional treatment opportunities, including comfort care, palliative
care, hospice care, and pain control.

I request that my attending provider prescribe medical aid-in-dying medication that
will end my life in a peaceful manner if I choose to take it, and I authorize my
attending provider to contact any pharmacist about my request.

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

I further understand that although most deaths occur within three hours, my death
may take longer, and my attending provider has counseled me about this possibility.
I make this request voluntarily, without reservation, and without being coerced, and
I accept full responsibility for my actions.

Signed:

Dated:

Declaration of witnesses

We declare that the individual signing this request:

Is personally known to us or has provided proof of identity;

Signed this request in our presence;

Appears to be of sound mind and not under duress, coercion, or undue influence;
and

I am not the attending provider for the individual.

witness 1/date

witness 2/date

Note: Of the two witnesses to the written request, at least one must not:

Be a relative (by blood, marriage, civil union, or adoption) of the individual signing
this request; be entitled to any portion of the individual's estate upon death; or own,
operate, or be employed at a health-care facility where the individual is a patient or
resident.

And neither the individual's attending or consulting provider nor a person
authorized as the individual's qualified power of attorney or durable medical power
of attorney shall serve as a witness to the written request.

Legislative History

Source: Initiated 2016: Entire article added, Proposition 106, L. 2017, p. 2809, � 1, effective upon proclamation of the Governor, December 16, 2016. L. 2024: Entire section amended, (SB 24-068), ch. 406, p. 2795, � 11, effective August 7.