HB 3497

                                 SECOND REGULAR SESSION
                    HOUSE BILL NO. 3497
                           103RD GENERAL ASSEMBLY
                            INTRODUCED BY REPRESENTATIVE CATON.
 7513H.02I  JOSEPH ENGLER, Chief Clerk
                                            AN ACT
 To amend chapters 191 and 565, RSMo, by adding thereto twenty-seven new sections relating
       to patient-directed care at the end of life.
 Be it enacted by the General Assembly of the state of Missouri, as follows:
        Section A. Chapters 191 and 565, RSMo, are amended by adding thereto twenty-
2 seven new sections, to be known as sections 191.2400, 191.2405, 191.2410, 191.2415,
3 191.2420, 191.2425, 191.2430, 191.2435, 191.2440, 191.2445, 191.2450, 191.2455,
4 191.2460, 191.2465, 191.2470, 191.2475, 191.2480, 191.2485, 191.2490, 191.2495,
5 191.2496, 191.2500, 191.2505, 191.2510, 191.2515, 191.2520, and 565.017, to read as
6 follows:
        191.2400. Sections 191.2400 to 191.2520 shall be known and may be cited as the
2 "Death with Dignity Act".
        191.2405. As used in sections 191.2400 to 191.2520, unless the context otherwise
2 indicates, the following terms mean:
3(1) "Adult", a person who is eighteen years of age or older;
4(2) "Attending physician", the physician who has primary responsibility for the
5 care of a patient and the treatment of that patient's terminal disease;
6(3) "Competent", in the opinion of a court or in the opinion of the patient's
7 attending physician or consulting physician, psychiatrist, or psychologist, a patient has
8 the ability to make and communicate an informed decision to health care providers,
9 including communication through persons familiar with the patient's manner of
10 communicating if those persons are available;
 EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
 intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language.
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11(4) "Consulting physician", a physician who is qualified by specialty or
12 experience to make a professional diagnosis and prognosis regarding a patient's disease;
13(5) "Counseling", one or more consultations between a state-licensed
14 psychiatrist, state-licensed psychologist, state-licensed clinical social worker, or state-
15 licensed clinical professional counselor and a patient for the purpose of determining that
16 the patient is competent and not suffering from a psychiatric or psychological disorder
17 or depression that so impairs judgment as to prevent the patient's informed decision;
18(6) "Health care provider", the same meaning given to the term in section
19 376.1350 and includes any person licensed, certified, or otherwise permitted by law to
20 dispense medication in the ordinary course of business or practice of a profession;
21(7) "Informed decision", a decision by a qualified patient to request and obtain a
22 prescription for medication that the qualified patient may self-administer to end the
23 qualified patient's life in a humane and dignified manner that is based on an
24 appreciation of the relevant facts and that is made after being fully informed by the
25 attending physician of:
26(a) The qualified patient's medical diagnosis;
27(b) The qualified patient's prognosis;
28(c) The potential risks associated with taking the medication to be prescribed;
29(d) The probable result of taking the medication to be prescribed; and
30(e) The feasible alternatives to taking the medication to be prescribed, including
31 palliative care and comfort care, hospice care, pain control, and disease-directed
32 treatment options;
33(8) "Medically confirmed", the medical opinion of an attending physician has
34 been confirmed by a consulting physician who has examined the patient and the
35 patient's relevant medical records;
36(9) "Patient", an adult who is under the care of a physician;
37(10) "Physician", a doctor of medicine or osteopathy licensed to practice
38 medicine in this state;
39(11) "Qualified patient", a competent adult who is a resident of this state and
40 who has satisfied the requirements of sections 191.2400 to 191.2520 in order to obtain a
41 prescription for medication that the qualified patient may self-administer to end the
42 qualified patient's life in a humane and dignified manner;
43(12) "Self-administer", for a qualified patient, to voluntarily and consciously
44 perform the physical act of ingesting or otherwise administering to himself or herself the
45 medication to end the qualified patient's own life;
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46(13) "Terminal disease", an incurable and irreversible disease that has been
47 medically confirmed and will, within reasonable medical judgment, produce death
48 within six months.
       191.2410. A patient has a right to information regarding all treatment options
 2 reasonably available for the care of the patient, including, but not limited to,
 3 information in response to specific questions about the foreseeable risks and benefits of
 4 medication, without a physician withholding requested information regardless of the
 5 purpose of the questions or the nature of the information.
       191.2415. An adult who is competent, is a resident of this state, has been
 2 determined by an attending physician and a consulting physician to be suffering from a
 3 terminal disease, and has voluntarily expressed the wish to die may make a written
 4 request for medication that the adult may self-administer in accordance with sections
 5 191.2400 to 191.2520. An adult does not qualify under sections 191.2400 to 191.2520
 6 solely because of age or disability.
       191.2420. 1. A valid request for medication under sections 191.2400 to 191.2520
 2 shall be substantially in the form described in section 191.2515, signed and dated by the
 3 patient, and witnessed by at least two individuals who, in the presence of the patient,
 4 attest that to the best of their knowledge and belief the patient is competent, is acting
 5 voluntarily, and is not being coerced to sign the request.
62. (1) The language of a written request for medication under sections 191.2400
 7 to 191.2520 shall be the language in which any conversations or consultations or
 8 interpreted conversations or consultations between a patient and the patient's attending
 9 physician or consulting physician are held.
10(2) Notwithstanding subdivision (1) of this subsection, the language of a written
11 request for medication under sections 191.2400 to 191.2520 may be English when the
12 conversations or consultations or interpreted conversations or consultations between a
13 patient and the patient's attending physician or consulting physician were conducted in
14 a language other than English if the form described in section 191.2515 contains the
15 attachment described in section 191.2520.
163. At least one of the two or more witnesses required under this section and any
17 interpreter required under this section shall be a person who is not:
18(1) A relative of the patient by blood, marriage, or adoption;
19(2) A person who at the time the request is signed would be entitled to any
20 portion of the estate of the qualified patient upon death, under any will, trust, transfer
21 on death election, beneficiary designation, or otherwise by operation of any law; or
22(3) An owner, operator, or employee of a health care facility where the qualified
23 patient is receiving medical treatment or is a resident.
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244. The patient's attending physician at the time the written request is signed
25 shall not be a witness.
265. If the patient is a patient in a long-term care facility at the time the patient
27 makes the written request, one of the witnesses shall be an individual designated by the
28 facility who has the qualifications specified by the department of health and senior
29 services by rule.
         191.2425. The attending physician shall:
2(1) Make the initial determination of whether a patient has a terminal disease, is
3 competent, and has made the written request under section 191.2415 voluntarily;
4(2) Request that the patient demonstrate state residency as required by section
5 191.2470;
6(3) To ensure that the patient is making an informed decision, inform the patient
7 of:
8(a) The patient's medical diagnosis;
9(b) The patient's prognosis;
10(c) The potential risks associated with taking the medication to be prescribed;
11(d) The probable result of taking the medication to be prescribed; and
12(e) The feasible alternatives to taking the medication to be prescribed, including
13 palliative care and comfort care, hospice care, pain control, and disease-directed
14 treatment options;
15(4) Refer the patient to a consulting physician for medical confirmation of the
16 diagnosis and for a determination that the patient is competent and acting voluntarily;
17(5) Confirm that the patient's request does not arise from coercion or undue
18 influence by another individual by discussing with the patient, outside the presence of
19 any other individual, except for an interpreter, whether the patient is feeling coerced or
20 unduly influenced;
21(6) Refer the patient for counseling, if appropriate, as described in section
22 191.2435;
23(7) Recommend that the patient notify the patient's next of kin;
24(8) Counsel the patient about the importance of having another person present
25 when the patient takes the medication prescribed under sections 191.2400 to 191.2520
26 and counsel the patient about not taking the medication prescribed under sections
27 191.2400 to 191.2520 in a public place;
28(9) Inform the patient that the patient has an opportunity to rescind the request
29 at any time and in any manner and offer the patient an opportunity to rescind the
30 request at the end of the fifteen-day waiting period in accordance with section 191.2450;
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31(10) Verify, immediately before writing the prescription for medication under
32 sections 191.2400 to 191.2520, that the patient is making an informed decision;
33(11) Fulfill the medical record documentation requirements of section 191.2465;
34(12) Ensure that all appropriate steps are carried out in accordance with sections
35 191.2400 to 191.2520 before writing a prescription for medication to enable a qualified
36 patient to end the qualified patient's life in a humane and dignified manner; and
37(13) Dispense medications directly, including ancillary medications intended to
38 minimize the patient's discomfort, if the attending physician is authorized under state
39 law or rule to dispense medications and has a current Drug Enforcement
40 Administration certificate or, with the patient's written consent:
41(a) Contact a pharmacist and inform the pharmacist of the prescription; and
42(b) Deliver the written prescription personally, by mail, or electronically to the
43 pharmacist, who may dispense the medications in person to the patient, the attending
44 physician, or an expressly identified agent of the patient.
        191.2430. Before a patient is determined to be a qualified patient under sections
2 191.2400 to 191.2520, a consulting physician shall examine the patient and the patient's
3 relevant medical records and confirm, in writing, the attending physician's diagnosis
4 that the patient is suffering from a terminal disease and verify that the patient is
5 competent, is acting voluntarily, and has made an informed decision.
        191.2435. If, in the opinion of the attending physician or the consulting
2 physician, a patient may be suffering from a psychiatric or psychological disorder or
3 depression causing impaired judgment, the physician shall refer the patient for
4 counseling. Medication for the patient to self-administer to end the patient's own life in
5 a humane and dignified manner shall not be prescribed until the person performing the
6 counseling determines that the patient is not suffering from a psychiatric or
7 psychological disorder or depression that so impairs judgment as to prevent the
8 patient's informed decision.
        191.2440. A qualified patient shall not receive a prescription for medication
2 under sections 191.2400 to 191.2520 unless the qualified patient has made an informed
3 decision. Immediately before writing a prescription for medication under sections
4 191.2400 to 191.2520, the attending physician shall verify that the qualified patient is
5 making an informed decision.
        191.2445. A patient who declines or is unable to notify the patient's next of kin
2 shall not have the patient's request for medication denied for that reason.
        191.2450. To receive a prescription for medication that the qualified patient may
2 self-administer under sections 191.2400 to 191.2520, a qualified patient shall make an
3 oral request and a written request and reiterate the oral request to the qualified
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4 patient's attending physician at least fifteen days after making the initial oral request.
5 At the time the qualified patient makes the qualified patient's second oral request, the
6 attending physician shall offer the qualified patient an opportunity to rescind the
7 request.
         191.2455. A patient may rescind the patient's request at any time and in any
2 manner without regard to the patient's mental state. A prescription for medication shall
3 not be written under sections 191.2400 to 191.2520 without the attending physician
4 offering the qualified patient an opportunity to rescind the request.
         191.2460. At least fifteen days are required to elapse between the patient's initial
2 oral request and the date the patient signs the written request under section 191.2450.
3 At least forty-eight hours are required to elapse between the date the patient signs the
4 written request and the writing of a prescription under sections 191.2400 to 191.2520.
         191.2465. The following shall be documented or filed in a patient's medical
2 record:
3(1) All oral requests by the patient for medication to end that patient's life in a
4 humane and dignified manner;
5(2) All written requests by the patient for medication to end that patient's life in
6 a humane and dignified manner;
7(3) The attending physician's diagnosis and prognosis and the attending
8 physician's determination that the patient is competent, is acting voluntarily, and has
9 made an informed decision;
10(4) The consulting physician's diagnosis and prognosis and the consulting
11 physician's verification that the patient is competent, is acting voluntarily, and has made
12 an informed decision;
13(5) A report of the outcome and determinations made during counseling, if
14 counseling is provided as described in section 191.2435;
15(6) The attending physician's offer to the patient to rescind the patient's request
16 at the time of the patient's second oral request under section 191.2450; and
17(7) A note by the attending physician indicating that all requirements under
18 sections 191.2400 to 191.2520 have been met, including the requirements of section
19 191.2425, and indicating the steps taken to carry out the patient's request, including a
20 notation of the medication prescribed.
         191.2470. For purposes of sections 191.2400 to 191.2520, only requests made by
2 residents of this state shall be granted. The residence of a person is that place where the
3 person has established a fixed and principal home to which the person, whenever
4 temporarily absent, intends to return. The following factors may be offered in
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5 determining a person's residence under sections 191.2400 to 191.2520 and need not all
6 be present in order to determine a person's residence:
7(1) Possession of a valid driver's license issued by the department of revenue;
8(2) Registration to vote in this state;
9(3) Evidence that the person owns or leases property in this state;
10(4) The location of any dwelling currently occupied by the person;
11(5) The place where any motor vehicle owned by the person is registered;
12(6) The residence address, not a post office box, shown on a current income tax
13 return;
14(7) The residence address, not a post office box, at which the person's mail is
15 received;
16(8) The residence address, not a post office box, shown on any current resident
17 hunting or fishing licenses held by the person;
18(9) The residence address, not a post office box, shown on any driver's license
19 held by the person;
20(10) The receipt of any public benefit conditioned upon residency, defined
21 substantially as provided in this section; or
22(11) Any other objective facts tending to indicate a person's place of residence.
         191.2475. A person who has custody of or control over any unused medications
2 prescribed in accordance with sections 191.2400 to 191.2520 after the death of the
3 qualified patient shall personally deliver the unused medications to the nearest facility
4 qualified to dispose of controlled substances or, if such delivery is impracticable,
5 personally dispose of the unused medications by any lawful means, in accordance with
6 any guidelines adopted by the department of health and senior services.
         191.2480. 1. The department of health and senior services shall annually review
2 all records maintained under sections 191.2400 to 191.2520.
32. (1) The department of health and senior services shall require any health care
4 provider upon writing a prescription or dispensing medication under sections 191.2400
5 to 191.2520 to file a copy of the prescription or dispensing record, and other
6 documentation required under section 191.2465 associated with writing the prescription
7 or dispensing the medication, with the department.
8(2) Documentation required to be filed under this subsection shall be mailed or
9 otherwise transmitted as allowed by rules of the department no later than thirty
10 calendar days after the writing of the prescription or the dispensing of medication under
11 sections 191.2400 to 191.2520, except that all documents required to be filed with the
12 department by the prescribing physician after the death of the qualified patient shall be
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13 submitted no later than thirty calendar days after the date of the death of the qualified
14 patient.
15(3) In the event that a person required under sections 191.2400 to 191.2520 to
16 report information to the department provides an inadequate or incomplete report, the
17 department shall contact the person to request an adequate or complete report.
183. The department of health and senior services shall promulgate rules to
19 facilitate the collection of information regarding compliance with sections 191.2400 to
20 191.2520. Except as otherwise provided by law, the information collected is confidential,
21 is not a public record, and shall not be made available for inspection by the public.
224. The department of health and senior services shall generate and make
23 available to the public an annual statistical report of information collected under this
24 section and submit a copy of the report to the standing committees of the house of
25 representatives and the senate having jurisdiction over health matters annually by
26 March first.
275. In addition to the rules required to be promulgated under this section, the
28 department of health and senior services shall promulgate all necessary rules for the
29 administration of sections 191.2400 to 191.2520. Any rule or portion of a rule, as that
30 term is defined in section 536.010, that is created under the authority delegated in this
31 section shall become effective only if it complies with and is subject to all of the
32 provisions of chapter 536 and, if applicable, section 536.028. This section and chapter
33 536 are nonseverable and if any of the powers vested with the general assembly
34 pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul
35 a rule are subsequently held unconstitutional, then the grant of rulemaking authority
36 and any rule proposed or adopted after August 28, 2026, shall be invalid and void.
         191.2485. Any provision in a contract, will, or other agreement, whether written
2 or oral, to the extent the provision would affect whether a person may make or rescind a
3 request for medication to end the person's life in a humane and dignified manner, is not
4 valid. Any obligation owing under any currently existing contract shall not be
5 conditioned upon or affected by the making or rescinding of a request by a person for
6 medication to end the person's life in a humane and dignified manner.
         191.2490. The sale, procurement, or issuance of any life, health, or accident
2 insurance or annuity policy or the rate charged for any life, health, or accident
3 insurance or annuity policy shall not be conditioned upon or affected by the making or
4 rescinding of a request by a qualified patient for medication that the patient may self-
5 administer to end the patient's life in accordance with sections 191.2400 to 191.2520. A
6 qualified patient whose life is insured under a life insurance policy issued by insurers
7 organized under chapter 376 and the beneficiaries of the policy shall not be denied
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8 benefits on the basis of self-administration of medication by the qualified patient in
9 accordance with sections 191.2400 to 191.2520. The rating, sale, procurement, or
10 issuance of any medical professional liability insurance policy delivered or issued for
11 delivery in this state shall be in accordance with the insurance laws of this state.
         191.2495. Sections 191.2400 to 191.2520 do not authorize a physician or any
2 other person to end a patient's life by lethal injection, mercy killing, or active
3 euthanasia. Actions taken in accordance with sections 191.2400 to 191.2520 do not, for
4 any purpose, constitute suicide, assisted suicide, mercy killing, or homicide under the
5 law. State reports shall not refer to acts committed under sections 191.2400 to 191.2520
6 as "suicide" or "assisted suicide". Consistent with the provisions of sections 191.2400 to
7 191.2520, state reports shall refer to acts committed under sections 191.2400 to 191.2520
8 as obtaining and self-administering life-ending medication. Nothing contained in
9 sections 191.2400 to 191.2520 shall be interpreted to lower the applicable standard of
10 care for the attending physician, the consulting physician, a psychiatrist, a psychologist,
11 or other health care provider providing services under sections 191.2400 to 191.2520.
         191.2496. 1. As used in this section, the term "covered individual" means a
2 health care provider, physician, psychiatrist, psychologist, clinical social worker,
3 professional counselor, pharmacist, pharmacist's assistant, patient, witness, or family
4 member or friend of a patient.
52. Any covered individual who is present during, has knowledge of, performs, or
6 engages in any of the activities described in sections 191.2400 to 191.2520 shall not, on
7 account of such activities, be subject to any civil or criminal liability, professional
8 discipline, or other penalty of any nature so long as such covered individual is acting in
9 good faith and is not guilty of willful misconduct or gross negligence.
         191.2500. Nothing in sections 191.2400 to 191.2520 requires a health care
2 provider to provide medication to a qualified patient to end the qualified patient's life.
3 If a health care provider is unable or unwilling to carry out the qualified patient's
4 request under sections 191.2400 to 191.2520, the health care provider shall transfer any
5 relevant medical records for the patient to a new health care provider upon request by
6 the patient.
         191.2505. 1. As used in this section, unless the context otherwise indicates, the
2 following terms mean:
3(1) "Notice", a separate statement in writing advising of the prohibiting health
4 care provider's policy with respect to participating in activities under sections 191.2400
5 to 191.2520;
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6(2) "Participating, or entering into an agreement to participate, in activities
7 under sections 191.2400 to 191.2520", doing or entering into an agreement to do any one
8 or more of the following:
9(a) Performing the duties of an attending physician as specified in sections
10 191.2400 to 191.2520;
11(b) Performing the duties of a consulting physician as specified in sections
12 191.2400 to 191.2520;
13(c) Performing the duties of a state-licensed psychiatrist, state-licensed
14 psychologist, state-licensed clinical social worker, or state-licensed clinical professional
15 counselor, in the circumstance that a referral to one is made under section 191.2435;
16(d) Delivering the prescription for, dispensing, or delivering the dispensed
17 medication in accordance with sections 191.2400 to 191.2520; or
18(e) Being present when the qualified patient takes the medication prescribed in
19 accordance with sections 191.2400 to 191.2520.
20
21 "Participating, or entering into an agreement to participate, in activities under sections
22 191.2400 to 191.2520" does not include doing, or entering into an agreement to do, any
23 of the following: diagnosing whether a patient has a terminal disease; informing the
24 patient of the medical prognosis or determining whether a patient has the capacity to
25 make decisions; providing information to a patient about sections 191.2400 to 191.2520;
26 or providing a patient, upon the patient's request, with a referral to another health care
27 provider for the purposes of participating in the activities authorized by sections
28 191.2400 to 191.2520.
292. The provisions of this section govern the basis for prohibiting persons or
30 entities from participating in activities under sections 191.2400 to 191.2520, notification,
31 penalties, and permissible actions.
323. Subject to compliance with subsection 4 of this section and notwithstanding
33 any other law, a health care provider may prohibit its employees, independent
34 contractors, or other persons or entities, including other health care providers, from
35 participating in activities under sections 191.2400 to 191.2520 while on premises owned
36 or under the management or direct control of that prohibiting health care provider or
37 while acting within the course and scope of any employment by, or contract with, the
38 prohibiting health care provider.
394. A health care provider that elects to prohibit its employees, independent
40 contractors, or other persons or entities, including other health care providers, from
41 participating in activities under sections 191.2400 to 191.2520, as described in subsection
42 3 of this section, shall first give notice of the policy prohibiting participation under
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43 sections 191.2400 to 191.2520 to those employees, independent contractors, or other
44 persons or entities, including other health care providers. A health care provider that
45 fails to provide notice to those employees, independent contractors, or other persons or
46 entities, including other health care providers, in compliance with this subsection shall
47 not enforce such a policy against those employees, independent contractors, or other
48 persons or entities, including other health care providers.
495. Subject to compliance with subsection 4 of this section, the prohibiting health
50 care provider may take action, including, but not limited to, the following, as applicable,
51 against an employee, independent contractor, or other person or entity, including
52 another health care provider, that violates the health care provider's policy prohibiting
53 participation in activities under sections 191.2400 to 191.2520:
54(1) Loss of privileges, loss of membership, or other action authorized by the
55 bylaws or rules and regulations of the medical staff;
56(2) Suspension, loss of employment, or other action authorized by the policies
57 and practices of the prohibiting health care provider;
58(3) Termination of any lease or other contract between the prohibiting health
59 care provider and the employee, independent contractor, or other person or entity,
60 including another health care provider, that violates the policy; or
61(4) Imposition of any other nonmonetary remedy provided for in any lease or
62 contract between the prohibiting health care provider and the employee, independent
63 contractor, or other person or entity, including another health care provider, in violation
64 of the policy.
656. Nothing in this section shall be construed to prevent, or to allow a prohibiting
66 health care provider to prohibit, an employee, independent contractor, or other person
67 or entity, including another health care provider, from any of the following:
68(1) Participating, or entering into an agreement to participate, in activities under
69 sections 191.2400 to 191.2520 while on premises that are not owned or under the
70 management or direct control of the prohibiting health care provider or while acting
71 outside the course and scope of the participant's duties as an employee of, or an
72 independent contractor for, the prohibiting health care provider; or
73(2) Participating, or entering into an agreement to participate, in activities under
74 sections 191.2400 to 191.2520 as an attending physician or consulting physician while on
75 premises that are not owned or under the management or direct control of the
76 prohibiting health care provider.
777. In taking actions under subsection 5 of this section, a health care provider
78 shall comply with all procedures required by law, its own policies or procedures, and
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79 any contract with the employee, independent contractor, or other person or entity,
80 including another health care provider, in violation of the policy, as applicable.
818. Any action taken by a prohibiting health care provider under this section is
82 not reportable to the appropriate licensing board including, but not limited to, the state
83 board of registration for the healing arts and the state board of pharmacy. The fact that
84 a health care provider participates in activities under sections 191.2400 to 191.2520 shall
85 not be the sole basis for a complaint or report by another health care provider to the
86 appropriate licensing board including, but not limited to, the state board of registration
87 for the healing arts and the state board of pharmacy.
        191.2510. Any governmental entity that incurs costs resulting from a person
2 ending the person's life under sections 191.2400 to 191.2520 in a public place has a claim
3 against the estate of the person to recover the costs and reasonable attorney's fees
4 related to enforcing the claim.
        191.2515. A request for medication as authorized by sections 191.2400 to
2 191.2520 shall be in substantially the following form:
3REQUEST FOR MEDICATION TO END MY LIFE IN A
4HUMANE AND DIGNIFIED MANNER
5I, ______ , am an adult of sound mind. I am suffering from _____
6_ , which my attending physician has determined is a terminal
7disease and which has been medically confirmed by a consulting
8physician.
9I have been fully informed of my diagnosis and prognosis, the
10nature of medication to be prescribed and potential associated
11risks, the expected result, and feasible alternatives, including
12palliative care and comfort care, hospice care, pain control, and
13disease-directed treatment options.
14I request that my attending physician prescribe medication that I
15may self-administer to end my life in a humane and dignified
16manner and contact any pharmacist to fill the prescription.
17INITIAL ONE:
18______ I have informed my family of my decision and taken their
19opinions into consideration.
20______ I have decided not to inform my family of my decision.
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21      ______ I have no family to inform of my decision.
22      I understand that I have the right to rescind this request at any
23      time.
24      I understand the full import of this request, and I expect to die
25      when I take the medication to be prescribed. I further
26      understand that, although most deaths occur within three hours,
27      my death may take longer, and my physician has counseled me
28      about this possibility.
29      I make this request voluntarily and without reservation, and I
30      accept full moral responsibility for my actions.
31      Signed: __________________
32      Dated: __________________
33      DECLARATION OF WITNESSES
34      By initialing and signing below on or after the date the person
35      named above signs, we declare that the person making and
36      signing the above request:
37      Initials of Witness 1:
38      ______ 1. Is personally known to us or has provided proof of
39      identity;
40      ______ 2. Signed this request in our presence on the date of the
41      person's signature;
42      ______ 3. Appears to be of sound mind and not under duress,
43      fraud, or undue influence; and
44      ______ 4. Is not a patient for whom either of us is the attending
45      physician.
46      Printed Name of Witness 1: __________________
47      Signature of Witness 1/Date: __________________
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48Initials of Witness 2:
49______ 1. Is personally known to us or has provided proof of
50identity;
51______ 2. Signed this request in our presence on the date of the
52person's signature;
53______ 3. Appears to be of sound mind and not under duress,
54fraud, or undue influence; and
55______ 4. Is not a patient for whom either of us is the attending
56physician.
57Printed Name of Witness 2: __________________
58Signature of Witness 2/Date: __________________
59NOTE: One witness must be a person who is not a relative by
60blood, marriage, or adoption of the person signing this request, is
61not entitled to any portion of the person's estate upon death, and
62does not own or operate or is not employed at a health care
63facility where the person is a patient or resident. The person's
64attending physician at the time the request is signed may not be a
65witness. If the person is an inpatient at a long-term care facility,
66one of the witnesses must be an individual designated by the
67facility.
      191.2520. The form of an attachment for purposes of providing interpretive
 2 services as described in subsection 2 of section 191.2420 shall be in substantially the
 3 following form:
4I, ______ , am fluent in English and (language of patient).
5On (date) at approximately (time) I read the "REQUEST FOR
6MEDICATION TO END MY LIFE IN A HUMANE AND
7DIGNIFIED MANNER" to (name of patient) in (language of
8patient).
9Mr./Ms. (name of patient) affirmed to me that he/she understands
10the content of this form, that he/she desires to sign this form
HB 3497  15
11under his/her own power and volition and that he/she requested
12to sign the form after consultations with an attending physician
13and a consulting physician.
14Under penalty of perjury, I declare that I am fluent in English
15and (language of patient) and that the contents of this form, to the
16best of my knowledge, are true and correct.
17Executed at (name of city, county, and state) on (date).
18Interpreter's signature: __________________
19Interpreter's printed name: __________________
20Interpreter's address: __________________
      565.017. It shall be an affirmative defense to prosecutions under sections
 2 565.020, 565.021, and 565.023 that the person's conduct was expressly authorized by
 3 sections 191.2400 to 191.2520.
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