| | | (a)__A person who, without authorization of the patient, | | willfully alters or forges a request for medication or conceals | | or destroys a revocation of that request with the intent or | | effect of causing the patient's death commits a Class A crime. |
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| | | (b)__A person who coerces or exerts undue influence on a | | patient to request medication for the purpose of ending the | | patient's life or to destroy a revocation of such a request | | commits a Class A crime. |
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| | | (c)__This Act does not limit liability for civil damages | | resulting from negligent conduct or intentional misconduct by any | | person or entity. |
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| | | (d)__The penalties in this Act do not preclude criminal | | penalties applicable under other law for conduct that is | | inconsistent with the provisions of this Act. |
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| | | A request for medication as authorized by this Act must be | | substantially in the following form. |
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| | | TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER |
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| | | I,........................., am an adult of sound mind. |
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| | | I am suffering from............................., which my | | attending physician has determined is a terminal disease and | | which has been medically confirmed by a consulting physician. |
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| | | I have been fully informed of my diagnosis and prognosis, the | | nature of the medication to be prescribed and its potential | | associated risks, the expected result of taking the medication | | and the feasible alternatives to ending my life in a humane and | | dignified manner, including comfort care, hospice care and pain | | control. |
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| | | I request that my attending physician prescribe medication | | that will end my life in a humane and dignified manner. |
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| | | I have informed my family or next of kin of my decision and | | have taken their opinions into consideration. |
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| | | I have decided not to inform my family or next of kin of my | | decision. |
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