I understand that I have the right to revoke this request at any time.__I understand the full importance of this request, and I expect to die when I take the medication to be prescribed.

I make this request voluntarily and without reservation.

Signed:...............................

Dated:................................

DECLARATION OF WITNESSES

We declare that the person signing this request:

(A)__Is personally known to us or has provided proof of identity;

(B)__Signed this request in our presence;

(C)__Appears to be of sound mind and not to be under duress or fraudulent or undue influence; and

(D)__Is not a patient for whom either of us is the attending physician.

......................................Witness 1.........Date

......................................Witness 2.........Date

Note:__Neither witness may be a relative by blood, marriage or adoption of the person signing this request, may be entitled to any portion of the person's estate upon death or may own, operate or be employed at a health care facility where the person is a patient or resident.__If the patient is an inpatient at a health care facility, one of the witnesses must be an individual designated by the facility.

SUMMARY

This initiated bill creates the Maine Death with Dignity Act. It allows a mentally competent adult who is suffering from a terminal illness to request and obtain medication from a physician to end that patient's own life in a humane and dignified manner, with safeguards to ensure that the patient's request is voluntary and based on an informed decision.