1. (a) An individual may request medication to end their life in a humane and dignified manner by making 2 oral requests and 1 written request to the individual’s attending physician or attending APRN.
2. (b) An individual must make the second oral request for medication to end their life in a humane and dignified manner no fewer than 15 days after making the first oral request for this medication. At the time of the second oral request, the individual’s attending physician or attending APRN must offer the individual an additional opportunity to rescind this request.

3. (c) An individual’s written request for medication to end their life in a humane and dignified manner must contain all of the following and use the form or be substantially similar to the form under subsection (f) of this section:

   1. (1) A request for medication that will end the individual’s life in a humane and dignified manner.
   2. (2) The individual’s signature, with the date signed.

   3. (3) The signatures of at least 2 adult witnesses who each attest to all of the following:

      1. a. The individual signed the document in the presence of the witness.
      2. b. To the best of the witness’ knowledge, the individual has decision-making capacity, is acting voluntarily, and is not being coerced to sign the document.

4. (d) No more than 1 of the witnesses under paragraph (c)(3) of this section may be any of the following:

   1. (1) A relative of the individual by blood, marriage, or adoption.
   2. (2) Entitled to any portion of the estate of the individual upon the individual’s death under a will or by operation of law at the time the request for medication is signed.
   3. (3) An owner, operator, or employee of a health-care institution where the individual is receiving medical treatment or is a resident.
5. (e) The individual’s attending physician or attending APRN at the time the individual signs the document under paragraph (c)(2) of this section may not provide a signature required under paragraph (c)(3) of this section.

6. (f) A written request for medication to end life in a humane and dignified manner under subsection (c) of this section must use the following form or be substantially similar to the following form:

   Request for Medication to End My Life in a Humane and Dignified Manner

   I, _________________, am an adult resident of Delaware with decision-making capacity.

   I have been diagnosed with _______________________, which my attending physician or attending APRN has determined is a terminal illness and has been medically confirmed by a consulting physician or consulting APRN. I have been fully informed of my diagnosis and prognosis of 6 months or less to live, the nature of the medication to be prescribed to end life in a humane and dignified manner, the potential associated risks of this medication, the expected result, and the feasible alternative, concurrent, or additional treatment opportunities available to me, including comfort care, palliative care, hospice care, and pain control.

   I request that my attending physician or attending APRN prescribe medication to end life in a humane and dignified manner that will end my life in a peaceful manner if I choose to take it, and I authorize my attending physician or attending APRN to dispense my prescription or to contact a pharmacist to dispense my prescription. I understand that I have the right to rescind this request at any time. I understand the seriousness of this request, and I expect to die if I take the medication prescribed to end life in a humane and dignified manner. I further understand that although most deaths occur within 3 hours, my death may take longer, and my attending physician or attending APRN has counseled me about this possibility.

   I make this request voluntarily, without reservation, free from coercion or pressure, and I accept full responsibility for my actions.

   Signed ________________

   Dated ________________

   ________________________________ Witness, Date

   ________________________________ Witness, Date

85 Del. Laws, c. 19, § 1