N.Y. Pub. Health Law § 2899-k

* § 2899-k. Form of written request and witness attestation. 1. A\nrequest for medication under this article shall be in substantially the\nfollowing form:\n REQUEST FOR MEDICATION TO END MY LIFE\n I, _________________________________, am an adult who has\ndecision-making capacity, which means I understand and appreciate the\nnature and consequences of health care decisions, including the benefits\nand risks of and alternatives to any proposed health care, and to reach\nan informed decision and to communicate health care decisions to a\nphysician.\n I have been diagnosed with (insert diagnosis), which my attending\nphysician has determined is a terminal illness or condition, which has\nbeen medically confirmed by a consulting physician and mental health\nprofessional and will, in the judgment of the physicians and mental\nhealth professional, produce death within six months whether or not\ntreatment is provided.\n I have been fully informed of my diagnosis and prognosis, the nature\nof the medication to be prescribed and potential associated risks, the\nexpected result, and the feasible alternatives and treatment options\nincluding but not limited to palliative care and hospice care.\n I request that my attending physician prescribe medication that will\nend my life if I choose to take it, and I authorize my attending\nphysician to contact another physician or any pharmacist about my\nrequest.\n INITIAL ONE:\n ( ) I have informed or intend to inform one or more members of my\nfamily of my decision.\n ( ) I have decided not to inform any member of my family of my\ndecision.\n ( ) I have no family to inform of my decision.\n I understand that I have the right to rescind this request or decline\nto use the medication at any time.\n I understand the importance of this request, and I expect to die if I\ntake the medication to be prescribed. I further understand that although\nmost deaths occur within three hours, my death may take longer, and my\nattending physician has counseled me about this possibility.\n I make this request voluntarily, of my own volition and without being\ncoerced, and I accept full responsibility for my actions.\nSigned: __________________________\nDated: ___________________________\n DECLARATION OF WITNESSES\n I declare that the person signing this "Request for Medication to End\nMy Life":\n (a) is personally known to me or has provided proof of identity;\n (b) voluntarily signed the "Request for Medication to End My Life" in\nmy presence or acknowledged to me that the person signed it; and\n (c) to the best of my knowledge and belief, has decision-making\ncapacity and is making the "Request for Medication to End My Life"\nvoluntarily, of the person's own volition and is not being coerced to\nsign the "Request for Medication to End My Life".\n I am not the attending physician or consulting physician of the person\nsigning the "Request for Medication to End My Life" or the mental health\nprofessional who provides a decision-making capacity determination of\nthe person signing the "Request for Medication to End My Life" at the\ntime the "Request for Medication to End My Life" was signed.\n I further declare under penalty of perjury that the statements made\nherein are true and correct and false statements made herein are\npunishable.\n I further declare that I am not (i) related to the above-named patient\nby blood, marriage or adoption; (ii) entitled at the time the patient\nsigned the "Request for Medication to End My Life" to any portion of the\nestate of the patient upon such patient's death under any will or by\noperation of law, or otherwise in a position to benefit financially from\nthe patient's death; (iii) an owner, operator, employee or independent\ncontractor of a health care facility where the patient is receiving\ntreatment or is a resident; (iv) a domestic partner of the patient, as\ndefined in subdivision seven of section twenty-nine hundred\nninety-four-a of the public health law; (v) an agent, as defined in\nsubdivision five of section twenty-nine hundred eighty of the public\nhealth law, under the patient's health care proxy; or (vi) an agent, as\ndefined in section 5-1501 of the general obligations law, acting under a\npower of attorney for the patient.\nWitness 1, Date:\n(Printed name)\n(Address)\n(Telephone number)\nWitness 2, Date:\n(Printed name)\n(Address)\n(Telephone number)\n 2. (a) The "Request for Medication to End My Life" shall be written in\nthe same language as any conversations, consultations, or interpreted\nconversations or consultations between a patient and at least one of the\npatient's attending or consulting physicians.\n (b) Notwithstanding paragraph (a) of this subdivision, the written\n"Request for Medication to End My Life" may be prepared in English even\nwhen the conversations or consultations or interpreted conversations or\nconsultations were conducted in a language other than English or with\nauxiliary aids or hearing, speech or visual aids, if the English\nlanguage form includes an attached declaration by the interpreter of the\nconversation or consultation, which shall be in substantially the\nfollowing form:\n INTERPRETER'S DECLARATION\n I, (insert name of interpreter), (mark as applicable):\n ( ) for a patient whose conversations or consultations or interpreted\nconversations or consultations were conducted in a language other than\nEnglish and the "Request for Medication to End My Life" is in English: I\ndeclare that I am fluent in English and (insert target language). I have\nthe requisite language and interpreter skills to be able to interpret\neffectively, accurately and impartially information shared and\ncommunications between the attending or consulting physician and (name\nof patient).\n I certify that on (insert date), at approximately (insert time), I\ninterpreted the communications and information conveyed between the\nphysician and (name of patient) as accurately and completely to the best\nof my knowledge and ability and read the "Request for Medication to End\nMy Life" to (name of patient) in (insert target language).\n (Name of patient) affirmed to me such patient's desire to sign the\n"Request for Medication to End My Life" voluntarily, of (name of\npatient)'s own volition and without coercion.\n () for a patient with a speech, hearing or vision disability: I\ndeclare that I have the requisite language, reading and/or interpreter\nskills to communicate with the patient and to be able to read and/or\ninterpret effectively, accurately and impartially information shared and\ncommunications that occurred on (insert date) between the attending or\nconsulting physician and (name of patient).\n I certify that on (insert date), at approximately (insert time), I\nread and/or interpreted the communications and information conveyed\nbetween the physician and (name of patient) impartially and as\naccurately and completely to the best of my knowledge and ability and,\nwhere needed for effective communication, read or interpreted the\n"Request for Medication to End my Life" to (name of patient).\n (Name of patient) affirmed to me such patient's desire to sign the\n"Request for Medication to End My Life" voluntarily, of (name of\npatient)'s own volition and without coercion.\n I further declare under penalty of perjury that (i) the foregoing is\ntrue and correct; (ii) I am not (A) related to (name of patient) by\nblood, marriage or adoption; (B) entitled at the time (name of patient)\nsigned the "Request for Medication to End My Life" to any portion of the\nestate of (name of patient) upon such patient's death under any will or\nby operation of law, or otherwise in a position to benefit financially\nfrom the patient's death; (C) an owner, operator, employee or\nindependent contractor of a health care facility where (name of patient)\nis receiving treatment or is a resident, except that if I am an employee\nor independent contractor at such health care facility, providing\ninterpreter services is part of my job description at such health care\nfacility or I have been trained to provide interpreter services and\n(name of patient) requested that I provide interpreter services to such\npatient for the purposes stated in this Declaration; (D) a domestic\npartner of the patient, as defined in subdivision seven of section\ntwenty-nine hundred ninety-four-a of the public health law; (E) an\nagent, as defined in subdivision five of section twenty-nine hundred\neighty of the public health law, under the patient's health care proxy;\nor (F) an agent, as defined in section 5-1501 of the general obligations\nlaw, acting under a power of attorney for the patient; and (iii) false\nstatements made herein are punishable.\nExecuted at (insert city, county and state) on this (insert day of\nmonth) of (insert month), (insert year).\n(Signature of Interpreter)\n(Printed name of Interpreter)\n(ID # or Agency Name)\n(Address of Interpreter)\n(Language Spoken by Interpreter)\n (c) An interpreter whose services are provided under paragraph (b) of\nthis subdivision shall not (i) be related to the patient who signs the\n"Request for Medication to End My Life" by blood, marriage or adoption;\n(ii) be entitled at the time the "Request for Medication to End My Life"\nis signed by the patient to any portion of the estate of the patient\nupon death under any will or by operation of law, or otherwise in a\nposition to benefit financially from the patient's death; (iii) be an\nowner, operator, employee or independent contractor of a health care\nfacility where the patient is receiving treatment or is a resident;\nprovided that an employee or independent contractor whose job\ndescription at the health care facility includes interpreter services or\nwho is trained to provide interpreter services and who has been\nrequested by the patient to serve as an interpreter under this article\nshall not be prohibited from serving as an interpreter under this\narticle; (iv) be a domestic partner of the patient, as defined in\nsubdivision seven of section twenty-nine hundred ninety-four-a of this\nchapter; (v) be an agent, as defined in subdivision five of section\ntwenty-nine hundred eighty of this chapter, under the patient's health\ncare proxy; or (vi) be an agent, as defined in section 5-1501 of the\ngeneral obligations law, acting under a power of attorney for the\npatient.\n * NB Effective August 5, 2026\n