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Oregon statutory end-of-life request form
Download the August 2026 Oregon Death with Dignity Act medication request packet under ORS 127.897 for the patient written request used in the Act process. Get the statutory request form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific death with dignity act medication request packet, reviewed against the current Oregon statute and ready for instant secure access.
The instrument tracks ORS 127.897, including the terminal-disease statement, informed-request language, INITIAL ONE family-notification elections, and the two-witness declaration.
Oregon advance care planning uses the separate ORS 127.529 advance directive. This request is only the patient form used under the Death with Dignity Act.
Download the files, complete them on your own device, then print, initial, and sign before two qualified witnesses. Your personal details are never entered into an online form builder.
This download includes 1 document in editable Word and fillable PDF formats. Use the Word version for editing; the fillable PDF can be completed on screen, then printed and signed.
Review the complete statutory request text below before purchasing. Your Word and fillable PDF download is delivered after checkout.
REQUEST FOR MEDICATION TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER
Oregon Death with Dignity Act · ORS 127.897
I, ____________________________________________, am an adult of sound mind.
I am suffering from ____________________________________, which my attending physician has determined is a 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 the feasible alternatives, including comfort care, hospice care and pain control.
I request that my attending physician prescribe medication that will end my life in a humane and dignified manner.
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
Signature: ____________________________________________
Date: ____________________________
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 under duress, fraud or undue influence;
(d) Is not a patient for whom either of us is attending physician.
Witness 1
Witness Signature: ________________________________________
Date: ________________________
Printed Name: ________________________________________
Witness 2
Witness Signature: ________________________________________
Date: ________________________
Printed Name: ________________________________________
NOTE: One witness shall not be a relative (by blood, marriage or adoption) of the person signing this request, shall not be entitled to any portion of the person's estate upon death and shall not 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 long-term health care facility, one of the witnesses shall be an individual designated by the facility.
This is the patient's written request under the Oregon Death with Dignity Act (ORS 127.800 to 127.897). It is not an advance directive under ORS 127.529 and does not appoint a health care representative. Eligibility, waiting periods, physician duties, and other Act requirements are separate from this form.
Legal currency, verified
This form is the patient's written request for medication under the Oregon Death with Dignity Act. It tracks the statutory request form in ORS 127.897. It is not a living will and not an advance directive. Oregon's advance directive for health care is a separate product under ORS 127.529.
The Oregon Death with Dignity Act is ORS 127.800 to 127.897. Section 127.897 supplies the written request form. A valid request must be in substantially that form, signed and dated by the patient, and witnessed by two individuals in the patient's presence under ORS 127.810. The form text was last amended in 1999. Related Act amendments in 2023 (chapter 241) removed the residency requirement from eligibility rules but did not change the § 127.897 form text. This packet was verified against Chapter 127 and the Oregon Health Authority patient request form in August 2026.
You identify yourself, state the terminal disease determination, confirm you were informed of diagnosis, prognosis, risks, expected result, and alternatives including comfort care, hospice, and pain control, and request that your attending physician prescribe the medication. You initial exactly one family-notification election. Two witnesses complete the declaration. The download is editable Word and true fillable PDF.
Sign and date the request. Two witnesses must sign in your presence. One witness must not be a relative by blood, marriage, or adoption, must not be entitled to any portion of your estate, and must not own, operate, or be employed at a health care facility where you are a patient or resident. If you are an inpatient at a long-term health care facility, one witness must be an individual designated by the facility. Neither witness may be your attending physician. There is no notary alternative for this request. Initials and wet signatures stay handwritten after you print.
Your purchase includes the Oregon Death with Dignity Act medication request in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference. The Oregon Health Authority also publishes a free patient request form.
This form is not legal advice. The Act has separate eligibility, oral-request, waiting-period, and physician duties that this form does not replace. Confirm requirements for your situation before relying on it.
ILRG is committed to top quality legal forms that are valid in all states. If you are not 100 percent satisfied after purchase, contact us for a full refund.
No. Despite the old product name, this form is the Oregon Death with Dignity Act written request under ORS 127.897. It is not a living will and not the ORS 127.529 advance directive.
Sign and date the request. Two witnesses must sign in your presence under ORS 127.810. One witness must meet the independent-witness rules. If you are an inpatient at a long-term health care facility, one witness must be designated by the facility. There is no notary alternative for this form.
No. The Act has separate eligibility, oral-request, waiting-period, and physician duties. This form is only the written request component. Confirm the full Act process with your attending physician.
Yes. The Oregon Health Authority publishes a free patient request form. This paid packet provides editable Word, true fillable PDF, and an optional completed sample.
Both contain the same form text. Word is editable and the PDF is fillable before printing. Complete initials and wet signatures after printing.