- This form is completed by the patient and provided to the Attending Physician. Patients should keep a copy of the form in their home.
- The completed form must be submitted to the Attending Physician at least 48 hours before medication can be dispensed.
- FORM: Written request for medication to end my life in a human and dignified manner
Provider Reporting Forms and Instructions
The Oregon Administrative Rules list the following instructions for providers:
The Attending Physician should send the following completed documentation within 10 calendar days of a patient's ingestion of DWDA medication or death from any other cause, whichever comes first:
The dispensing health care provider should file a copy of the following form within 10 calendar days of dispensing medication pursuant to the DWDA:
- The Attending Physician should send the following completed, signed and dated documentation to the Center for Health Statistics within 7 calendar days of writing a prescription for medication to end the life of a qualified patient:
Forms may be sent by:
Secure email: DWDA.FORMS@oha.oregon.gov
Mail: Oregon Health Authority - Center for Health Statistics
PO Box 14050
Portland, OR 97293-0050
Attn: Craig New
Death Certificate Recommendations
The Oregon Health Authority, Center for Health Statistics recommends that physicians record the underlying terminal disease as the cause of death and mark the manner of death "natural" for patients who die under Oregon's Death with Dignity Act (DWDA). Note: DWDA statutory language in ORS 127.880 states, "Actions taken in accordance with ORS 127.800 to 127.897 shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law."
A death certificate is a legal document that has two primary purposes: (1) to certify the occurrence of death for legal matters (e.g., settling the estate), and (2) to document causes of death for public health statistics. To ensure that we have accurate and complete data on patients who have ingested the medications, the Oregon Health Authority regularly matches the names of persons for whom a DWDA prescription is written with death certificates. The Attending Physician is then required to complete a follow-up form with information about whether the death resulted from ingesting the medications, or from the underlying disease. The recommendations for completing the death certification are intended to balance the confidentiality of patients and their families, while ensuring that we have complete information for statistical purposes.
OHA Form (internal use only)