26:16-20 Form for request of medication.
20. A written request for a medication as authorized by P.L.2019, c.59 (C.26:16-1 et al.) shall be in substantially the following form:
REQUEST FOR MEDICATION TO END MY LIFE IN A
HUMANE AND DIGNIFIED MANNER
I, . . . . . . . . . . . . . . . , am an adult of sound mind and a resident of New Jersey.
I am suffering from . . . . . . . . . . . . . . . , which my attending physician has determined is a terminal illness, disease, or condition and which has been medically confirmed by a consulting physician.
I have been fully informed of my diagnosis, prognosis, the nature of medication to be prescribed and potential associated risks, the expected result, and the feasible alternatives, including concurrent or additional treatment opportunities, palliative care, comfort care, hospice care, and pain control.
I request that my attending physician prescribe medication that I may self-administer to end my life in a humane and dignified manner and to contact any pharmacist as necessary to fill the prescription.
INITIAL ONE:
. . . . I have informed my family of my decision and taken their opinions into consideration.
. . . . . I have decided not to inform my family of my decision.
. . . . . I have no family to inform of my decision.
INITIAL ALL THAT APPLY:
. . . . .My attending physician has recommended that I participate in a consultation concerning concurrent or additional treatment opportunities, palliative care, comfort care, hospice care, and pain control options, and provided me with a referral to a health care professional qualified to discuss these options with me.
. . . . .I have participated in a consultation concerning concurrent or additional treatment opportunities, palliative care, comfort care, hospice care, and pain control options.
. . . I am currently receiving palliative care, comfort care, or hospice care.
I understand that I have the right to rescind this request at any time.
I understand the full import of this request, and I expect to die if and when I take the medication to be prescribed. I further understand that, although most deaths occur within three hours, my death may take longer and my physician has counseled me about this possibility.
I make this request voluntarily and without reservation, and I accept full responsibility for my decision.
Signed:. . . . . . . . . . . . . . .
Dated:. . . . . . . . . . . . . . .
DECLARATION OF WITNESSES
By initialing and signing below on or after the date the person named above signs, we declare that the person making and signing the above request:
Witness 1 Witness 2
Initials Initials
. . . . . . . . . . . . . . . . . .
1. Is personally known to us or has provided proof of identity.
. . . . . . . . . . . . . . . . . .
2. Signed this request in our presence on the date of the person's signature.
. . . . . . . . . . . . . . . . . .
3. Appears to be of sound mind and not under duress, fraud, or undue influence.
. . . . . . . . . . . . . . . . . .
4. Is not a patient for whom either of us is the attending physician.
. . . . . . . . . . . . . . . . . .
Printed Name of Witness 1: . . . . . . . . . . . . .
Signature of Witness 1/Date: . . . . . . . . . . . .
Printed Name of Witness 2: . . . . . . . . . . . . .
Signature of Witness 2/Date: . . . . . . . . . . . .
NOTE: At least one witness shall not be a relative by blood, marriage, or adoption of the person signing this request, shall not be entitled to any portion of the person's estate upon death, and shall not own, operate, or be employed at a health care facility, other than a long term care facility, where the person is a patient or resident.
L.2019, c.59, s.20.