Directive to Physicians

This directive is made this ______ day of ______ (month) _________ (year). I,________________________ being of sound mind, willfully and voluntarily make known my desire

___ (a) That my life shall not be artificially prolonged and

___ (b) That my life shall be ended with the aid of a physician under the circumstances set forth below, and do here by declare:

1. If at any time I should have a terminal condition or illness certified to be terminal by two physicians, and they determine that my death will occur within six months,

___ (a) I direct that life-sustaining procedures be withheld or withdrawn, and


___ (b) I direct that my physician administer aid-in-dying in a humane and dignified manner.

(You must initial (a) or (b) or both.)


___ (c) I have attached Special Instructions on a separate page to the directive. (Initial if you have attached a separate page.)

The action taken under this paragraph shall be at the time of my own choosing if I am competent.

2. In the absence of my ability to give directions regarding the termination of my life, it is my intention that this directive shall be honored by my family, agent (described in paragraph 4), and physician(s) as the final expression of my legal right to

___ (a) Refuse medical or surgical treatment, and

___ (b) To choose to die in a humane and dignified manner.

(You must initial (a) or (b) or both, and you must initial one box below.)

___ If I am unable to give directions, I do not want my attorney-in-fact to request aid-in-dying.

___If I am unable to give directions, I do want my attorney-in-fact to ask my physician for aid-in-dying.

3. If understand that a terminal condition is one in which I am not likely to live for more than six months.

4.(a) I, _______________________________________ do hereby designate and appoint _______________ as my attorney-in-fact (agent) to make health-care decisions for me if I am in a coma or otherwise unable to decide for myself as authorized in this document. For the purpose of this document, "health-care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition, or to administer aid-in-dying.

b) By this document I intend to create a Durable Power of Attorney for Health Care under The Oregon Death With Dignity Act and ORS Section 126.407. This power of attorney shall not be affected by my subsequent incapacity, except by revocation.

(c) Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health-care decisions for me to the same extent that I could make these decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health-care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining, refusing, or withdrawing life-prolonging care, treatment, services and procedures, and administration of aid-in-dying.

5. This directive shall have no force or effect seven years from the date filled in above, unless I am incompetent to act on my own behalf and then it shall remain valid until my competency is restored.

6.I recognize that a physician's judgment is not always certain, and that medical science continues to make progress in extending life, but in spite of these facts, I nevertheless wish aid-in-dying rather than letting my terminal condition take its natural course.

7. My family has been informed of my request to die, their opinions have been taken into consideration, but the final decision remains mine, so long as I am competent.

8. The exact time of my death will be determined by me and my physician with my desire or my attorney-in-fact's instructions paramount.

I have given full consideration and understand the full import of this directive, and I am emotionally and mentally competent to make this directive. I accept the moral and legal responsibility for receiving aid-in-dying.

This directive will not be valid unless it is signed by two qualified witnesses who are present when you sign or acknowledge your signature. The witnesses must not be related to you by blood, marriage, or adoption; they must not be entitled to any part of your estate; and they must not include a physician or other person responsible for, or employed by anyone responsible for, your health care. If you have attached any additional pages to this form, you must date and sign each of the additional pages at the same time you date and sign this power of attorney.


Signed: ____________________________________________________

City, County, and State of Residence ___________________________


(This document must be witnessed by two qualified adult witnesses. None of the following may be used as witnesses: (1) a health care provider who is involved in any way with the treatment of the declarant, (2) an employee of a health care provider who is involved in any way with the treatment of the declarant, (3) the operator of a community care facility where the declarant resides, (4) an employee of an operator of a community care facility who is involved in any way with the treatment of the declarant.)


The Oregon Death with Dignity Act, Oregon Revised Statutes, Chapter 97, 1990.