Bijlage 2 Regeling modelformulieren levensbeëindiging op verzoek en hulp bij zelfdoding BES

Regeling modelformulieren levensbeëindiging op verzoek en hulp bij zelfdoding BES

To be used by an attending physician in notifying the physician appointed by the island executive pursuant to section 4 of the Act of a death resulting from termination of life on request or the provision of assistance with suicide. In reporting a non-natural death due to termination of life on request or the provision of assistance with suicide to the physician appointed by the island executive pursuant to section 4 of the Act, the attending physician is required to submit a well substantiated report compiled on the basis of the following model. The term attending physician refers to the physician who performed the termination of life on request (euthanasia) or provided assistance with suicide. The model is based on the due care criteria set out in section 2 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. The review committee can only assess whether the due care criteria were complied with if you substantiate your answers. It may be useful to provide additional information, such as: If you need more space to answer a question in full, please attach an appendix. Please remember to indicate clearly to which question or questions the information contained in each appendix refers. This model document uses the term ‘termination of life on request’ to refer to both euthanasia and assisted suicide. In the case of euthanasia, the euthanatics are administered by the attending physician. In the case of assisted suicide, the patient himself/ herself administers the euthanatics provided by the attending physician. Initials: Surname prefix (e.g. ‘van, ‘de’ or ‘del’) Surname: Sex: □ male □ female Name of hospital/ institution: (where applicable) Work address: Post code and town/city: Tel.: Mobile tel.: Email address: Position: □ general practitioner □ consultant → speciality: □ geriatrician □ other physician, namely: Initials: Surname prefix (e.g. ‘van, ‘de’ or ‘del’) Surname: Sex: □ male □ female Date of death: Date of birth: In what municipa