It is sickening to read the proposed bureaucratic forms that patients and their death doctors will fill out and send to the state when planning assisted suicides. Twenty years ago, people would have called me a total paranoid if I predicted this is what we would become. I wouldn’t have believed it myself. Nonetheless, this is where we are as a culture. From the Proposed Rule Making document filed by the now ironically misnamed Department of Health:
Even the name of the form is propaganda. The death culture, or a death cult?REQUEST FOR MEDICATION
TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
I, ______________________________________________________________________, am an adult of sound mind.
First Middle Last
I am suffering from _____________________________________, which my attending physician has determined is an incurable, irreversible terminal disease 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 feasible alternatives, including 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 dispense or to contact a pharmacist to dispense 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.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 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 moral responsibility for my actions.Signature: County of Residence: Date:
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