Connecticuts Obligation to the Terminally Ill:

Death with Dignity

By Abbie Zadrozny
G Block
Ms. Kirkpatrick
February 26, 2016

Table of Contents
ABSTRACT,...2
SCOPE OF THE PROBLEM,.2-4
MISSION STATEMENT...4
GOALS AND OBJECTIVES..4-5
EVALUATING RESOURCES5-7
IMPLEMENTING THE PLAN....7-9

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EFFECTIVENESS OF SOLUTION...9
GAINING SUPPORT..10-14
FINAL CALL TO ACTION..14
LETTER TO THE READER15
WORKS CITED...16-17
ANNOTATED BIBLIOGRAPHY....18-24
APPENDIX...24-24
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

SURVEY QUESTION AND RESULTS.. 25-33

INTERVIEW TRANSCRIPT....34-42
PATIENT REQUEST FORM....43-44
PHYSICIAN FORM.......44-45
CONSULTING PHYSICIAN FORM....45-48
ALZHEIMER WILL CLAUSE...49
ALZHEIMER AGREEMENT CONTRACT..50
MAP.........51
ALS PATIENTS (IMAGE)..........................................52
ALZHEIMER'S PATIENT (IMAGE).........................53
BRAIN TUMOR (PATIENT).....................................54

Abstract
Connecticut's current health care system for terminally ill patients fails to accommodate
the dying wishes of thousands of suffering patients. If Connecticut passed the Death with
Dignity Act, patients that have exhausted curative options will no longer have to tolerate the
traumatic experience of losing their dignity and autonomy while witnessing their loved ones
suffer alongside them. Through a survey of Connecticut Citizens, it was apparent that this act is
essential for the majority of patients who are terminally ill and desire death to end their suffering.

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This Act is specifically beneficial at ALS, Alzheimer, and brain tumor patients as it eliminates
the agonizing pain and loss of self during the final stages of their life; it is not applicable to any
other disease. To demolish the agonizing deterioration of these patients and establish Connecticut
as a morally respectable state, it is imperative that Connecticut passes Death with Dignity
legislation.

Implementing the Plain

At this very second, thousands of patients suffering from ALS, brain tumors, and
Alzheimer's Disease are being told their condition is fatal. Currently in the state of Connecticut,
these patients are being forced to prolong their life through the use of unnatural drugs, causing
months and even years of agonizing pain and suffering as they deteriorate, losing their quality of
life. In the twenty first century, it is imperative to ensure all citizens the choice to leave this earth
mentally and physically at peace. The Death With Dignity Program, which entails the painless
killing of a patient suffering from the incurable and painful diseases of ASL, brain cancer, and
Alzheimers Disease, will successfully honor the dying wish of terminally ill patients by
avoiding future torture and despair (Death) .
Citizens against legalizing the Death with Dignity Act for Alzheimer's, ALS, and brain
tumor patients are frequently unaware of what the diseases truly entails, therefore not fully
grasping its demand. Alzheimers disease is a progressive, degenerative brain disease that
slowly erodes memory and thinking skills(Alzheimers1). Patients with this illness are
eventually robbed of their sense of self and ability to carry out simple everyday tasks, including
talking, controlling bowel movements, eating, and bathing (Appendix J). Dani Kenefick, a loved
one of an Alzheimer's patient, described her grandmother's experience with this disease as
essentially reverting back to life as a baby (Kenefick). Amyotrophic lateral sclerosis (ALS),

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also commonly known as Lou Gehrig's Disease, is a progressive, neurodegenerative disease that
affects nerve cells in the brain and the spinal cord(ALS). As this disease progresses, patients
rapidly lose the strength in their limbs, most commonly resulting in the inability to walk
(Appendix I). In addition, these patients also suffer from swallowing difficulties that ultimately
result in respiratory failure. Although this disease doesnt affect one's cognitive skills,
maintaining their mental capability is almost more detrimental to patients because their
thoughts are prevailing, yet they are unable to express themselves(Kirkpatrick). For this reason,
in a study conducted by Dr.Sullivan, ALS was the second most demander of Death with
Dignity (Akhtar). Terminal Brain Tumors are masses of abnormal cells in the brain that cause
the body to withhold constant seizures and nausea while also altering the patients mental status
and ability to speak (Brain1). This disease is very painful for patients because the expansion of
the brain tumor is restricted by the skull, causing constant pressure and headaches (Brain2).
Although the unknown after death is commonly feared, when patients are put under these
circumstances, unbearably suffering with no other option, it is clear that they should have the
right to choose to live or die.
The cruelty of forcing the traumatic experience of witnessing terminally ill patients
wither away upon families can no longer be an option. As a state, we must turn to the Death
with Dignity Act to assist these patients and provide closure for their loved ones. Leaving these
families oppressed, sitting beside their loved one day by day until they gasp for that last, final
breath is pure ignorance. Knowing that there's is no way to kill these horrid diseases, patients
should be given the alternative to die at peace. Brittany Maynard, a patient who decided to Die
with Dignity in Oregon, reveal online moments before her death, ...Today is the day I have
chosen to pass away with Dignity in the face of my terminal illness, this terrible brain tumor that

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has taken so much from me but would have taken so much more. As described by Maynard,
there's no way out of this disease and it only continues to exacerbate. Logically, there is no
benefit from suffering through this unbearable pain, and therefore our state must show
compassion for all that these patients have already lost.

Mission Statement
Currently the state of Connecticut fails to provide the respect and dignity terminally ill
patients suffering from ALS, brain cancer, and Alzheimers Disease both need and deserve.
Connecticut is culpable of treating patients against their will, holding our state representatives
responsible for the devastating, and sustaining inhumane quality of life for these patients. The
terminally ill, as well as their loved ones, are in desperate need of emotional and financial relief
as they seek compassion from the state of Connecticut in a time of grievance. It is Connecticut's
professional and moral obligation to respect the request of those suffering from ALS,
Alzheimer's, and brain tumors by allowing them to departure from this world with a strong spirit
by implementing the Death With Dignity Program to ultimately prove their loyalty to their
citizens.

Goals and Objectives

Legalize the use of physician-assisted suicide for patients with terminal brain
cancer, ALS, or Alzheimer's in the state of Connecticut by the year 2018
Obtain access to secobarbital in all 42 hospitals in Connecticut
Evaluate a patient with a team of two certified doctors before
granting seconal or nembutal
Require doctor to fill out Doctor End of Life Choice Report
Require patient to fill out Patient End of Life Choice Report
Require 2 witnesses to co-sign

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Implement an Article X:Alzheimers Death with Dignity Clause section in Will

Form for all citizens (patients who become mentally impaired due to their illness but are
able to die with dignity if previously stated in will)
Signed by patients executor (listed in will)
Primary Physician , other 2 certified doctors, and one executor
must sign the Alzheimer's Death with Dignity Agreement Contract

Evaluating Resources
I.

Previous Attempts to Legalize Death With Dignity

Within the last three years, twenty-seven states in the United States have taken significant
steps towards legalizing The Death with Dignity act (Appendix H). Currently, five states have
successfully passed this act, including California, Washington, Oregon, Montana, and Vermont
(Death). The State of Connecticut has attempted to pass this law in both 2013 and 2014, but
has been quickly withdrawn due to fear of protests from religious groups and disability advocates
(McGaughey) . Indicated through the states previous decisions, it is evident that Connecticut has
been distracted from the proposal at hand. The truth of the matter is the proposal does not state
that all patients suffering from these diseases must die, it just simply states that patients have the
option to Die with Dignity if they choose. Professor and author Peggy Battin agrees that
terminally ill are accorded the right to determine what is to be done to him or her and if that
entails Dying with Dignity, their decision shall be respected (Henig). It is also important to
clarify that the Death With Dignity option does not target disabilities, but the quality of life of
the patients. If patients are unable to talk, swallow, walk, eat, or use the restroom properly, their
evaluation on life may not fulfil their needs, indicating that the only person who can truly
measure the patient's value of life is the patient themselves. In addition, we must highlight the
confidence of this procedure and its irrelevence to suicide. The death with dignity procedure is a

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deliberate process that ensures that the decision is not impulsive; patients pursuing this procedure
must wait a total of 15 days after submitting a formal written request and re-commit to the
procedure to ensure their certainty before it is finalized. Therefore, no component of Death with
Dignity can be defined as an impulsive decision.
II.

Financial Aspect

A main concern of the public and state officials when a new bill is proposed is its
financial aspect. Although it is expected that an additional medical treatment means an additional
charge, that is not the case. In fact, it is more costly to prolong a patient's life than to allow them
to die with dignity. Legalizing this bill will free patients from unbearable pain and suffering
while also saving loved ones and the state of Connecticut money. Alzheimer's, ALS, and brain
tumor patients spend an outrageous amount of money on a daily basis just to stay alive. Peggy
Battin, a spouse of a terminally ill ALS patient admits that she pays $250,000 a year for her
husbands caregivers alone, pleading that she doesnt know how many more years they will be
able to sustain this level of 24-hour care due to its expense (Henig). Prolonging patients lives
using unnatural medical devices and prescriptions is not only a financial burden to patients and
their loved ones, but also the state. In 2009, Medicare paid $50 billion just for doctor and
hospital bills during the last two months terminally ill patients' lives, which is more than the
budget of the Department of Homeland Security or the Department of Education (The). In
comparison, the Death with Dignity treatment costs between $125 to $1,000, saving patients,
Connecticut, and their loved ones hundreds of thousands of dollars (Engber). Therefore, by
placing this law in effect, Connecticut will also be able to budget more money towards
enhancing the state and the success of future generations.

Implementing the Plan

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I.

Gaining Access for ALS and Brain Tumor Patients

Terminal ALS and brain tumor patients who wish to participate in the Death with
Dignity procedure must be of 18 years of age and a Connecticut resident. The patient have
authorization to change their mind at any time throughout the process. Once a patient has
decided to pursue with the procedure, they must make a formal, oral request to their doctor. 15
days later, the patient must then file a written request using the Death with Dignity Formal
Patient Requestreport form that is signed by two witnesses to avoid the chance of fraud or a
mistake (Appendix C). After the request is evaluated and approved by the primary physician
using the Death with Dignity Formal Physician Report Form, the case must be approved by
two other physicians to ensure the this procedure is in the best interest of the patient using the
Death with Dignity Consulting Physician Report Form (Appendix D&E). Two days after the
written request, the doctor is permitted to prescribe the lethal dose. The doctor is to not
physically administer the drug into the patient. The patient must take the drug at their home in
the presence of at least one healthcare provider.
II.

Gaining Access for Alzheimer Patients

Due to the mental state of Alzheimer's patients and their incapability of making logical
decisions, different measures must be taken in the Death with Dignity procedure than those
suffering from terminal brain tumors and ALS. Alzheimer's patients must state in their will their
decision to die with dignity PRIOR to being diagnosed with the disease. To achieve this goal, a
10th article, labeled Article X: Alzheimers Death with Dignity Clause (OPTIONAL) must be
assembled (Appendix F). This article will contain an optional checklist including the stages of
progression of Alzheimer's disease. The testator will be instructed to check off the stage at which
they agree to the Death with Dignity procedure if they wish. If the tester becomes diagnosed

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with alzheimer's and reaches all stage described, the patient's primary physician and 2 other
certified doctors must sign the Alzheimer's Death with Dignity Agreement Contract (Appendix
G). In addition, at least one executor of the will must sign the agreement contract as well.
III.

Medication

There are two barbiturates that will achieve the Death with Dignity procedure. Patients
can decide which drug they want based on personal preference. Seconal is a substances that
possesses anaesthetic, anticonvulsant, anxiolytic, sedative, and hypnotic properties (Engber). A
lethal 10 gram dose painlessly halts the activity of your brain and nervous system. Patients will
be issued 100 caplets by their physician. At the patient's home, they must crush the pills to
produce approximately 3 tablespoons of powder. Patients most commonly stir the powder into
pudding or applesauce to hide the bitter taste, but it can also be mixed with water. Although it is
rare for insurance to cover lethal drugs, a 10 gram dose of seconal costs patients $125, a cheap
price in comparison to the alternative of living expenses (Engber). After consumption, it is
estimated in 5 minutes the patient will enter a coma and after 30 minutes, death will occur.
Nembutal is a liquid solution that contains pentobarbital sodium, propylene glycol, and alcohol.
This form of the Death with Dignity procedure must be employed by a doctor because it needs
to be injected into the body using a needle (Engber) . After an injection of 9 grams of nembutal,
it generally takes 2 hours for the patient to painlessly pass away. Nembutal is more expensive
that Seconal, costing the patient $1,000 for a 9 gram dose (Engber).

Effectiveness of Solution
Currently in Connecticut, terminally ill patients are limited to hospice care. Hospice care
is designed to enable terminally ill patients to die free from pain and achieve their quality of life
during their final phases of life (Hospice) . However, this goal is not achieved. In hospice,

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terminally ill patients prolonged death lasts on an average of 67 days, forcing the patient to
suffer for an extensive period of time(OReilly). The suspense of waiting for death to occur is
terrifying to patients. In addition, during this process patients are stripped of any medical devices
and medication that previously assisted them, leaving them in antagonizing pain. As a result,
many patients receive pain medication. But, this medication frequently alters the patient's
cognitive skills, such as their personality and awareness (Death). Therefore, hospice care does
not provide patients with the quality of life because patients die without their true identity.
However, the Death with Dignity act ensures that patients deaths will be sudden and painless
while also guaranteeing their unaltered cognitive skills.

Gaining Support
I.

Death with Dignity Survey

A survey of 81 Connecticut residents of a wide range of age, race, and gender clearly
indicate that Death with Dignity legislation is desired by most Connecticut residents. The
survey concluded that 96.3% of residents believe that patients suffering from ALS,
Alzheimer's,or brain tumors should have the legal right to make their own decisions when
pertaining to their body. Patients with these diseases who wish for the Death with Dignity
procedure frequently plead that there quality of life, which was defined by residents as when a
person is of sound mind, capable of breathing on their own, awake, not at vegetative state, is not
meant due to their inability to be active (Appendix A). 89.5% of residents agreed that physical
activity is important to them and therefore revealing that their quality of life would not be
reached if they were bed bound, waiting for their time to departure from the world. Another
98.8% of these citizens would support their loved ones decision to Die with Dignity if their
loved one was in unbearable pain, losing themselves. Ultimately, the Death with Dignity

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proposal fights for pro-choice, therefore indicating that it does not need complete support; the
small population that does not approve simply does not have to participate. For this reason,
82.5% of Connecticut citizens are supportive of legalizing the Death with Dignity Act in
Connecticut.
II.

Officials Support
The support among lawmakers regarding the Death with Dignity proposal has

continued to increase since its initial appearance in 2013 (Compassion). This year, 15 political
figures have publicly supported the bill, including Senator Eric Coleman and Attorney General
George Jepsen. Kevin Lembo, the state's Comptroller, pleads, I support this legislation because
I want this choice. Whether or not I exercise my choice would be decided among me, my family,
and my physician. (Compassion). In addition to lawmakers, the New York Times continues to
advocate for Death with Dignity legislation in Connecticut, highlighting the success of
recently implemented Death with Dignity acts in America. They specifically bring attention to
Oregons, emphasizing its ability to give peace of mind to dying Oregonians without any case
of abuse or coercion(Compassion).
III.

ALS Interviews
Sara Bragdon, a senior at Windham tech, reports that her uncle suffer from from ALS and

on a daily basis she watches him deteriorate from this disease. After her uncle's initial diagnosis,
her family was heartbroken to say the least.Within the first year after his diagnosis, Bragdon
realized her uncles disease was a slow, destructive progression. First, his legs became weak and
he was unable to walk without assistance. Within a short time his condition worsened and he
became non ambulatory and bedridden. This transition of losing his physical ability was just the
beginning of her uncles misery. Soon after, he suffered from respiratory failure, regressed to

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only being able to consume pureed food, and lost his ability to talk. Bragdon described her
experience of watching someone you love so much fade away as absolutely horrible and
heartbreaking for her and her family (Bragdon). Knowing their is no cure for the disease and it
only exacerbates is unsettling to Bragdon, claiming that she has been devastated by the whole
experience. (Bragdon). Throughout the progression of her uncles disease his emotional
presentation has also been impacted.At times he displays anger, constantly questioning why it
had to be him (Bragdon). For example, due to his inability to talk, when he attempts to spell
words out he often becomes frustrated when he is not understood. Evidently, Bragdons uncles
quality of life is far from being fulfilled. Due to his terminal diagnosis, the Death with Dignity
act will allow Bragdons uncle, as well as patients that suffer from similar experiences, to leave
the earth in a healthy state of mind versus having to succumb to the debilitating effects of the
disease.
Jean Grey, a loving daughter, recently lost her mother through a of rare onset of ALS
called Bulbar Onset. Through this disease, Greys mother lost her ability to speak, eat,
swallow,walk, get dressed, bathe herself, and brush her hair independently. Her daughter
described her mother's illness as a constant challenge, revealing that her mother had trouble
accepting where she was at in the disease. Although she eventually got a feeding tube, she was
resistant until it became a necessity. When she eventually faced difficulty breathing due to the
deterioration of the muscles in her lungs, her family faced the hardest decision of their lives; they
had to decide whether to put her on a breathing machine or to let her live independently until she
gasped for her last breath. They did not want to put their mother through the horror of panicking
just to breath, but they also didn't want her to become a breathing vegetable (Grey). Although
they decided that it was her time, it was a traumatic experience for both her mother and her loved

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ones, being the biggest challenge they have ever faced. Even though her mother is gone, she is
still haunted by what her mother experienced and is desperate for a new option for patients like
her mother. If the Death with Dignity act was legalized, Grey would have not been forced to
live through this nightmare and her mother would have had the choice to go in peace.
Alzheimer's Interviews
Kevin Clancys grandfather, Mr.Clancy, a resident of Coventry, Connecticut, suffered
from Alzheimer's Disease. In his earlier stages, he lost his mobility, frequently experiencing
minor falls and misplaced items around the house. But, as the disease progressed, he lost several
major bodily functions including the control of his bowel movements, mobility, emotions, and
recognition of immediate family members. During the last two weeks of his life, Kevin shared
that he just lied there unable to interact with anyone (Clancy). Seeing his grandfather in this
condition wasvery difficult and it was tough on the entire family (Clancy). There were times
when Mr. Clancy did not know who his family was or why they were intruding. Kevin recalled
one experience he had with his grandfather when he was babysitting him. He yelled at Kevin and
tried to kick him out of his house, referring to him as a stranger (Clancy). He would frequently
get angry at those who were just trying to help him, yelling, I dont need to be babysat!. This
was difficult for Clancys family because they cared and wanted to help their grandfather, but he
rejected them. A once very capable man who was as smart as they come behaving with a
childs state of mind was so out of character for their grandfather. That transition was traumatic
for Mr. Clancys loved ones to witness because they knew Mr. Clancy would have never wanted
them to see him like that. In addition, Mr. Clancys wife struggled financially through her
husbands disease because she paid an excessive amount of money for him to live in a nursing
home until she became well enough to care for him independently. In addition, she paid workers

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$20 an hour to watch him if she needed to leave the house. Not only was this a financially strain
for his wife, but it was also took a physical toll on her due to the 24/7 physical care he needed.
Although Clancy loved his grandpa deeply, he did not support the decision to keep him alive
while he was essentially a vegetable. Ending the interview, Clancy demonstrating his strong
desire for the Death with Dignity Act, pleading that it is more selfish to want your family
member to be alive lying in bed motionless and not being able to recognize anyone than
wanting them to be in a better place, pain free after saying your final goodbyes (Clancy). The
idea of Death with Dignity would have allowed Mr. Clancy to die with pride being the man he
always was, while giving his family the closure of knowing their loved one passed peacefully,
dismissing years of misery.

Final Call to Action

Connecticut provides its citizens with a safe environment for individuals to grow and
succeed; however, implementing Death with Dignity legislation for ALS, Alzheimer's, and
brain tumor patients would ensure comfort measures for the terminally ill and provide them with
compassion in a time of grievance. While many patients in the United States are currently
deteriorating, suffering unbearable pain during their prolonged death, Connecticut has the
opportunity to relieve them and their loved ones from the emotional and financial burden these
illnesses entail. It is Connecticuts professional and moral obligation to stop the suffering for
these helpless patients and allow them to leave the world with their sense of identity and dignity.
If this plea is neglected, terminally ill patients will continue to sustain an inhumane quality of life
while determining Connecticut as a cruel, freedom-restricted state.

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Letter to the Reader

Work Cited
Akhtar, Aysha. "Do Physicians of Amyotrophic Lateral Sclerosis (ALS) Patients Understand
Their Patients' Wishes Concerning End-of-Life Care?" CDR, n.d. Web.

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ALS Foundation."Symptoms and Diagnosis." ALSA.org. n.d. Web. 24 Jan. 2016.

Alzheimer's1 Association. "Suicide and Assisted Suicide." Ethical Issues in Alzheimer's
Disease. Suicide and Assisted Suicide (n.d.): n. pag. Suicide and Assisted Suicide. Web.
Bragdon, Sara. ""Death with Dignity"" Online interview. 30 Jan. 2016.
"Brain1 Tumor Statistics." Brain Tumor Statistics. American Brain Tumor Association, Nov.
2014. Web. 25 Jan. 2016.
"Brain2 Tumors and Brain Cancer Cedars-Sinai." Brain Tumors and Brain Cancer CedarsSinai. Cedars-Sinai, n.d. Web. 24 Jan. 2016.
Clancy, Kevin. ""Death with Dignity"" Online interview. 30 Jan. 2016.
"Connecticut News." Compassion Choices Connecticut News Category. N.p., 8 Mar. 2015.
Web. 25 Feb. 2016.
"Death with Dignity." Compassion & Choices. N.p., n.d. Web. 22 Feb. 2016.
Engber, Daniel. "How Does Assisted Suicide Work?" How Does Assisted Suicide Work?
Slate, n.d. Web. 11 Feb. 2016.
Grey, Jena. ""Death with Dignity"" Online interview. 30 Jan. 2016.
Henig, Robin Marantz. "A Life or Death Situation." New York Times 21 July 2013: 27-33.
Web.
"Hospice Care: MedlinePlus." U.S National Library of Medicine. U.S. National Library of
Medicine, 15 Feb. 2016. Web. 23 Feb. 2016.
Kenefick, Dani. ""Death with Dignity"" Online interview. 30 Jan. 2016.
Kirkpatrick, Meredith. "Writing Conference." Connecticut, Coventry. 23 Feb. 2016. Speech.
McGaughey, Jim. "OPA: Legalize Assisted Suicide? Not so Fast." OPA: Legalize Assisted

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Suicide? Not so Fast. Office of Protection and Advocacy for Persons with Disabilities, 7
Apr. 2015. Web. 24 Jan. 2016.
O'Reilly, Kevin B. "Average Hospice Length of Stay Is Falling." - Amednews.com. American
Medical News, 1 Feb. 2012. Web. 24 Feb. 2016.
"The Cost of Dying." CBSNews. CBS Interactive, 19 Nov. 2009. Web. 23 Feb. 2016.

Annotated Bibliography
Akhtar, Aysha. "Do Physicians of Amyotrophic Lateral Sclerosis (ALS) Patients
Understand Their Patients' Wishes Concerning End-of-Life Care?" CDR, n.d. Web. This
reliable source is written Aysha Akhtar, an educated master's degree student who attends
the University of North Carolina. Through the qualitative and quantitative data provided
by Aysha, my understanding of ALS was enhanced. This information allowed me to

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clearly define ALS in my Scope of the Problem and statistically prove that ALS patients
are one of the most prevalent demanders of Death with Dignity.
ALS Foundation."Symptoms and Diagnosis." ALSA.org. n.d. Web. 24 Jan. 2016. The
publisher of this source, the ALS Foundation, currently leads the world in intensive
research, care services, public education, and public policy regarding ALS. By providing
the public with guidance pertaining to this disease through its network, this association
ameliorated my understanding of ALS by enabling me to clearly define (qualitative data)
it in my Scope of the Problem section.
Alzheimer's1 Association. "Suicide and Assisted Suicide." Ethical Issues in Alzheimer's
Disease. Suicide and Assisted Suicide (n.d.): n. pag. Suicide and Assisted Suicide.
Web.This qualitative data enhances my interpretation of Alzheimers Disease and the
symptoms this disease entails. This data is reliable because it was published by the
Alzheimers Association, which is currently leading the voluntary health organization in
Alzheimer's care, support,and research in the world. This data was used in the Scope of
the Problem section of my proposal to define ALS.
Alzheimer's2 Disease."UCSF Memory and Aging Center.". University of California, San
Francisco, 6 Jan. 2015. Web. 24 Jan. 2016. This qualitative data enhances my
interpretation of Alzheimers Disease. This data is reliable because it was published by
the UCSF Memory and Aging Center. All members of this center are students at the
University of California, San Francisco and incorporates four professional schools. In
addition,the UCSF graduate programs consistently rank among the best in the country,
according to the latest surveys by U.S. News & World Report. This data provided me

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with extensive knowledge on Alzheimers Disease and was used in my Scope of the
Problem section to define Alzheimer's Disease.
Bragdon, Sara. ""Death with Dignity"" Online interview. 30 Jan. 2016. In my interview
with Sara Bragdon, a Connecticut resident, she revealed her uncles story as an ALS
patient. His traumatic experiences that Sara described intensified my Gaining Support
section by quantitatively validating my claim that it is imperative for these patients to
Die with Dignity due to their quality of life.
"Brain1 Tumor Statistics." Brain Tumor Statistics. American Brain Tumor Association,
Nov. 2014. Web. 25 Jan. 2016.This qualitative data enhances my interpretation of Brain
Tumors and was evident in the Scope of the Problem section of my proposal where I
defined Brain Tumors. This data is reliable because it was published by the American
Brain Tumor Association. The ABTA is the only national organization committed to
funding brain tumor research and providing valuable information and education. Within
the last 4 years, the ABTA has established comprehensive resources to support brain
tumor patients and has expanded their research program.
"Brain2 Tumors and Brain Cancer Cedars-Sinai." Brain Tumors and Brain Cancer CedarsSinai. Cedars-Sinai, n.d. Web. 24 Jan. 2016.This qualitative data enhances my
interpretation of Brain Tumors throughout my paper but was mainly used in my Scope
of the Problem section of my proposal to define Brain Tumors. This data is reliable
because it is published by Cedars-Sinai, one of the largest nonprofit academic medical
centers in the U.S. The this data is provided by their highly knowledgeable staff that
consists of 2,100 physicians, 2,800 nurses, and thousands of other healthcare
professionals and staff. Cedars-Sinai has also been named one of Americas Best

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Hospitals by USNews & World Report and received the National Research Corporations
Consumer Choice Award for 18 years in a row.
Clancy, Kevin. ""Death with Dignity"" Online interview. 30 Jan. 2016. Kevin Clancy, a
loved one of an Alzheimer's patient, provided me with extensive qualitative data that
captured his experiences with his grandfather as his disease progressed. Due to his
position as a loved one, Kevin was able to compare his grandfathers personality before
and during the disease, depicting the symptoms of this disease and the heartbreaking
impact it has on his family. This interview was used in the Gaining Support section of
my proposal.
"Connecticut News." Compassion Choices Connecticut News Category. N.p., 8 Mar.
2015. Web. 25 Feb. 2016. This organization advocates for the terminally ill to have a
voice pertaining to their own death, which is the objective of my proposal.This
qualitative and quantitative data provided me with extensive knowledge on the Death
with Dignity procedure that was used throughout my entire paper as the basis of my
proposal. This site provided me with empowering stories as well as specific information
regarding Connecticut lawmakers. This data was used in my Gaining SupportSection.
Suicide Work?" How Does Assisted Suicide Work? Slate, n.d. Web. 11 Feb. 2016.The
source is an description of the Gonzales v. Oregon case that took place in the U.S
Supreme Court. This sources goes in great depth of the Death with Dignity issue,
stating a potential procedure patients would follow to receive the Death with Dignity
treatment. This qualitative data elicited ideas that I used in my Implementing the Plan
section of my proposal that establishes the steps that need to be taken for patients to
receive the Death with Dignity procedure.

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Grey, Jena. ""Death with Dignity"" Online interview. 30 Jan. 2016.Jena Grey, a current
Connecticut resident, just lost her mother to ALS. Therefore, she was able to give an
extensive description of what the disease entails as well as describe the experience
through a loved one's perspective. Her interview contained mainly qualitative data
(description of disease), but also had informative qualitative data (statistic on breathing
machine). Jenas interview was captured in the Gaining Support section of my
proposal.
Henig, Robin Marantz. "A Life or Death Situation." New York Times 21 July 2013: 2733. Web.
Robin Henig, a reporter for the New York Times Magazine captured the story of
Peggy Battin, the wife of a terminally ill patient. Through this interview, Battin described
her extensive medical bills that are repercussions of her husband's illness. This
quantitative data is reflected upon in my Evaluating Resources section to provide an
authentic example of the intemperate expenses keeping a loved one alive entails.
"Hospice Care: MedlinePlus." U.S National Library of Medicine. U.S. National Library
of Medicine, 15 Feb. 2016. Web. 23 Feb. 2016.The National Library of Medicine, which
is the worlds largest medical library, provided qualitative information on hospice care
that amplified my understanding. Through this information, I was able to define hospice
care in my Effectiveness of Solution section of my proposal to further prove that
hospice care is not fulfilling its intended purpose.
Humphry, Derek. "Legalizing Euthanasia." Santa Clara University. Markkula Center for
Applied Ethics, 13 Nov. 2015. Web. 24 Jan. 2016.This article provides prime qualitative
data supporting my proposal to legalize the use of euthanasia for terminally ill patients

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due to unbearable heartache that is encountered throughout the ending stages of

terminally ill patients. This data focuses on all sections of my proposal. This data is
reliable because it is published by Santa Clara University and is written by Dr.Richard
Gula.
Kenefick, Dani. ""Death with Dignity"" Online interview. 30 Jan. 2016. Dani Kenefick is a
Coventry, Connecticut resident whose grandmother suffered from Alzheimer's. The
objective of this interview was to grasp the full extent of which Alzheimer's patients and
their loved ones suffer on a daily basis. As a loved one, Dani revealed the constant
struggles her family faced and described how the disease impacted her family and
grandmother, accurately demonstrating the symptoms of Alzheimer's. This qualitative
data can be found in the Scope of the Problem section of the proposal.
Kirkpatrick, Meredith. "Writing Conference." Connecticut, Coventry. 23 Feb. 2016.
Speech. Meredith Kirkpatrick is an English teacher at Coventry High School as well as a
Connecticut resident. The objective of this Writing Conference was to enhance my Scope
of the Problem section. During the conference, Ms. Kirkpatrick reflected upon a friend
who was diagnosed with ALS. She stressed their constant battle with themselves due to
their cognitive ability when the rest of their body couldnt perform. This interview
provided me with valuable qualitative data that strengthened my understanding of ALS.
McGaughey, Jim. "OPA: Legalize Assisted Suicide? Not so Fast." OPA: Legalize
Assisted Suicide? Not so Fast. Office of Protection and Advocacy for Persons with
Disabilities, 7 Apr. 2015. Web. 24 Jan. 2016. This qualitative data defines the current
laws in Connecticut pertaining to Death with Dignity. This source is valid because it is
posted on the official Connecticut Government Page and is written by Tim McGaughey, a

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Former Executive Director in the Office of Protection and Advocacy for Persons with
Disabilities. This article, which was used in the Evaluating Resources section of my
proposal, shows that the state of Connecticut has been diligently working on approving
the Death with Dignity act.
O'Reilly, Kevin B. "Average Hospice Length of Stay Is Falling." - Amednews.com.
American Medical News, 1 Feb. 2012. Web. 24 Feb. 2016.This source captures
information provided by the American Medical Association, which is a reliable
Association that establishes scientific advancements and strives to improved public health
The quantitative data gathered from this source was used in my Effectiveness of
Solution section of my proposal. With the statistics gained from this site, I was able to
prove the flaws of hospice care to ultimately prove that the Death with Dignity
procedure is more beneficial to patients that hospice care.
"Patient Choice and Control at End of Life." Department of Health. State of Vermont, 20
May 2013. Web. Vermont was the first state to legalize the Death with Dignity act. This
qualitative data includes the forms that are currently used in the state of Vermont
pertaining to the Death with Dignity procedure. These examples assisted me when
creating my own forms that are found in Appendix C-G because they forced me to take
all parts of the procedure into consideration and maintain professionalism.
"The Cost of Dying." CBSNews. CBS Interactive, 19 Nov. 2009. Web. 23 Feb. 2016.
This news article, published by CBS News, reveals the excessive amount of money
Connecticut spends on medicare yearly on terminally ill patients (quantitative data). This
information supports the Evaluating Resources section of my proposal, clarifying that
through the Death with Dignity procedure, our state could save billions of dollars.

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APPENDIX A: SURVEY QUESTIONS AND RESULTS

Survey Questions
What is your knowledge on the "Death with Dignity" legislation?
1

No idea

Extensive Knowledge

Do you believe patients should have the right to make their own decisions when pertaining to their own
body?*
yes
no
Are you aware that the "Death with Dignity" legislation has been legalized in California, Washington,
Oregon, and Vermont?
Yes
No
How do you define quality of life? * At what point is life not worth living?
Required

Would you want a loved one to suffer if they were terminally ill?

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yes
no

How important is being active to you? *

1

Not Important at All

Extremely Important

Would knowing when you're going to pass away provide you with closure?
yes
no
How important is saying goodbye to your loved ones before death?*
1

Not Important at All

5
Extremely Important

At what stages do you believe terminally ill patients should have a choice to "Die with Dignity"?*Please
select all that apply.
Never
Can't Swallow independently
Can't recognize immediate family
Can't eat without eating tube
Wears diapers
Can't communicate
Living off respirator
Bed bound
Need 24/7 assistance
How supportive are you of Connecticut legalizing the "Death with Dignity" legislation?

Very Supportive
Supportive
Somewhat supportive
Not at all supportive

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Survey Results

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APPENDIX B: INTERVIEW TRANSCRIPT

ALS Interviews
Question #1: Can you describe the steps/challenges your loved one faced as the disease
progressed?
Sara Bragdon (Uncle): At first it was his muscles in his legs that started getting
weaker and then he started using a cane and from that a walker and then his arms dont
work as good anymore and they are slowly moving and that ended him up in a
wheelchair. Then his throat muscles barely work. He can drink liquids that are semi-thick
like we have to add a liquid thinner (water). He can only eat semi-solid foods like mashed
potatoes and grounded up stuff.
Taylor Giuliano (grandfather): Well it first started when we noticed his speech
was becoming slurred. So first his speech and his ability to swallow and eat went, then it

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was his hands and arms, them his legs and feet, then his insides gave up and his heart
eventually stopped.
Question #2: What has it been like to witness this progression?
Sara Bragdon (Uncle): It hurts because this progression happened so fast. Its sad
and scary to see how much a disease can alter your body functions.
Taylor Giuliano (Grandfather): It was absolutely horrible to watch someone you
love so much fade away and know their isn't anything you can do.
Question #3: Can you describe the extent to which your loved one's personality changed as
a result of ALS?
Sara Bragdon (Uncle): His personality hasnt changed significantly but it has
altered because he can't do the same things he has or he cant talk to us. He spells
everything out for us and that frustrates him when we don't understand. He has become
more aggressive because of what he is going through.
Taylor Guiliano (Grandfather): My grandfather was a funny, loving, warm guy.
Even when he was diagnosed, he would still never fail to us laugh. He had a smile on his
face all the way until his last day.
Question #4: How would you describe your loved one's range of emotions to cope with this
disease?
Sara bragdon (Uncle): He understands it is what it is and everything but he doesn't
understand why it had to be him with this disease and I think that's what upsets him the
most.
Taylor Giuliano (Grandfather): He knew what was happening and he would
always find light in everything. He was happy all the time.
Question #5: To what extent was this illness a financial burden on your family?

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Sara Bragdon (Uncle): We struggle but half of it is covered by his insurance.

Taylor Giuliano (Grandfather): Insurance covered a lot of his technologies
Question #6: How would you describe your family member's reaction to the initial
diagnosis?
Sara Bragdon(Uncle): We were heartbroken.
Taylor Giuliano (Grandfather): ALS is basically a disease that attacked his body
parts one by one. It killed him slowly. We were heartbroken but we knew we had to stay
strong and have fun with him while we could.
Question #7: How would you describe your loved ones ability to stay hopeful?
Sara Bragdon(Uncle): We have visitors like old friends of his come over and we
have therapist go see him and get his mind off of it.
Taylor Giuliano (Grandfather): He was so great a doing so! Every Time we
would get sad, he would crack a joke and make us laugh. He knew it wasn't going away
but he had hope that he was going to love the little time he had left.
Question #8: What advice would you give to a family whose loved one just got diagnosed
with ALS? Is their any further information that you would like to share about this disease?
Sara Bragdon (Uncle): Stay hopeful and stick together through the rough times
and make sure everyone remembers all the good times and don't dwell on the bad times.
Taylor Giuliano (Grandfather): I would tell them that yes, it is horrible and
nobody should have to go through it. However, you cant be sad all the time because then
youll miss out on the good time that you have left with your loved one.
ALS Unique Interview
(The interviewer below preferred to explain her story):
Jena Grey (Mother): My Mom had a rare onset of ALS called the bulbar onset. This
meant her speech and swallowing was affected first rather than walking or any obvious muscle

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wasting. Because her onset was rare getting a correct diagnosis was the first step/ challenge we
faced. She kept getting misdiagnosed. It took around 9 months and a couple different
neurologists before we finally got her correct diagnosis.
Her speech was a huge challenge it was affected very early on. As ALS is progressive
she could talk with a slur in the very beginning which progressed to no speech at all. Her
swallowing was a huge challenge which eventually lead to her having to get a feeding tube. One
thing I would say is that for her excepting where she was at in her progression was a huge
challenge for her. For instance she needed a feeding tube long before she got one. She couldn't
accept that's where she was at. It took a lot of convincing and assuring her all would be well for
her to finally agree to get the feeding tube. The muscle wasting eventually made it so she
couldn't use her hands and feet. So she couldn't dress herself, brush her hair, bathe herself. She
needed a wheelchair, could not stand up from a seated position. Again, because of her onset she
could walk short distances a lot longer than most people with ALS. The reason being before her
muscle in her legs could fully waste away the muscles in her lungs wasted away, which
eventually took her life. One other challenge and step I will mention is when we were told her
breathing was really bad they gave her (us) the option for her to either get stretched and put on a
breathing machine, or go on hospice to prepare for the end of her life. You'd think obviously the
breathing machine at first but what you learn is that you basically become a vegetable but yet
you are still breathing and therefore alive. Your quality of life is so bad only 10% of ALS patients
choose this route. So you have to kind of decide on your own that you are going to pass away
without trying to stop it from happening. At least that's the decision my Mom made and it was
one of the biggest steps/challenges of them all.

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Alzheimers Questions
Question #1: What bodily functions did your loved one loose as a result of Alzheimer's
disease?
Kevin Clancy (Grandfather): In the earlier stages of my grandfather having
Alzheimers the bodily functions he lost was he mobility. He could not move/walk as
well as he used to. He would drag his feet and trip over things and he ended up falling
down the stairs and ending up in the hospital. He would also forget where he put things.
He would buy a christmas gift for my grandmother but forget where he hid it so the
family would always look for it on christmas day. Then as it progressed and got worse he
lost many bodily functions. He would not be able to control his bowel movements and
ended up having to wear diapers. He also could not stand up or really walk much at all.
Then at its worse he could not eat or really show any emotion or recognize anyone. For
the last 2 weeks of his life he could only just lie there and not really interact with
anyone.
Dani Kenefick (Nana): Eating meals, wanted to snack more on sweet things.
Needed assistance in bathroom. Diaper use. Shower with assistance. Living on her own
with ,y grandpa went to nursing home. Ability to get tired at the smallest act (more
napping). Phone calls ended or were very short. Restricted driving then taken away
completely
Question #2: Can you describe what it was like for your family to witness your loved one
losing their memory?

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Kevin Clancy(Grandfather): It was very difficult for the family to see my

grandfather lose his memory. It was very tough on the entire family. He was always a
quiet man but at times you knew he did not know who you were or why you were in his
house. There was one time when the family was taking turns watching him because my
grandmother was in the hospital and he would try to kick you and your girlfriend out of
his house because you were a stranger. Also the girlfriend he was referring to was a
family member's wife whom he use to know. It was also tough to see him lose his
memory because he was always a hard working very capable man who was as smart as
they come. The to see him in a child like state was very weird and heart breaking
because he would never want anyone to see him like that.
Dani Kenefick (Nana): Awful. Torture. Upsetting. Sad.

Question #3: To what extent did your loved one lose their sense of self and/or personality
because of this disease?
Kevin Clancy (Grandfather): My family noticed the lose of personality in my
grandfather because he went from being so independent and hardworking to so dependent
and useless. He was the type to never ask for help but when he had Alzheimer's he
needed so much help. It is hard to say if my grandfather lost a sense of self because he
was such a quiet man. I almost don't think he realized the change he was going through
because of what the disease was doing to his mind. I think this was a good thing though
because if he did actually realize how helpless he was becoming I think he would have
felt terrible about himself. The only time I kind of noticed him realizing he was losing a

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sense of self was when he would get a little angry with people helping him walk or when
we had to watch him he would tell us he did not need to be babysat.
Dani Kenefick (Nana): I would say almost 100% lost. My nana became quiet and
started speaking in italian when I have never heard her speak that way in 24 years. Its
almost like they revert back to their childhood.
Question #4: To what extent was this illness a financial burden on your family?
Kevin Clancy (Grandfather): This is a tough question for me to answer because I
did not really have to deal with this. My grandmother and her children (my mom being
one of them) had to take care of this. I do know that my grandparents had insurance but I
don't know what costs were covered. I also know that at times my grandmother was
paying a lot of money to have him in a home where he could live until my grandmother
was strong enough to take care of him. Also my grandmother would have to pay people
12 to 20 dollars an hour to watch him when she had to go out. Again I am not sure on the
exact amount of stress with the financial burden but I do know it was not cheap.
Dani Kenefick (Nana): I would say it was a burden but fortunately for my
grandfather it wasnt a severe financial hit. My grandfather had to pay out of pocket
monthly for her care at the nursing home, cutting to the savings he worked his whole life
for.
Question #5: How would you describe your loved ones ability to stay resilient?
Kevin Clancy (Grandfather): In the beginning he was very resilient and hopeful
because he was able to still function pretty well and know who people were. It was
simple things like forgetting where his glasses were or getting lost driving. When the
disease really took over I don't think he was hopeful because he didn't even know what
was happening to him. He just went day by day like it was no different and didn't realize

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the change that was happening to him. It is tough to say because maybe he did realize
and just didn't let anyone know and if that was the case then he was very resilient because
he never showed negative emotion or weakness to his family.
Question #6: What advice would you give to other families who have a loved one suffering
from Alzheimer's?
Kevin Clancy (Grandfather): My advice would be to enjoy every moment with
them and make as many memories as possible because even though that family member
might not be able to vocalize what they remember or enjoy it could still be making an
impact on them. Also don't get angry at that person because now you have to take care of
them like a child or the stress you out financially because again even though they might
not be able to vocalize it, they definitely appreciate it. Also it's okay to have the feeling
or desire to want to have them pass away. You don't want your family member suffering
and to have very little quality of life. That family member also probably would not want
to be seen or remembered for being childlike or a vegetable. At the very end for my
grandfather the last 2 weeks of his life were him lying there hooked up to machines. The
family knew it was a matter of time and it was nice we were able to all say our goodbyes
and make peace with everything. After that we wanted him to be in a better place and not
hurting or suffering. It sounds bad but we didn't want this poor quality of life to drag out.
The family and him were ready for the next step of him passing to happen. There is
nothing wrong with being prepared for what is going to happen. I believe it is more
selfish to want your family member to be alive lying in a bed motionless and not being
able to recognize anyone then wanting them to be in a better place pain and suffer free
after you have been able to say your final goodbye

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Dani Kenefick (Nana): This disease essentially ruined our lives and hers. We
missed out on 4 years of life with her because she was in a home and didnt remember us
anymore. I wish this disease on no one. ever.

APPENDIX C: PATIENT REQUEST FORM

CONNECTICUT
Death with Dignity Formal Patient Request

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I, __________________________________________________, am suffering from Amyotrophic Lateral Sclerosis/
brain tumor (circle one), which my prescribing physician has determined is a terminal disease.

I have been fully informed of my diagnosis; prognosis; the range of treatment options; all feasible end-of-life
services, including palliative care, comfort care, hospice care, and pain control; the range of possible results,
including potential risks associated with with taking the medication to be prescribed; and the probable result of
taking the medication to be prescribed; and the probable result of taking the medication to be prescribed.
I request that my attending physician prescribe seconal/nembutal (circle one) medication to be self-administered for
the purpose of hastening my death.

I understand that I have the right to rescind this request at any time.

Signature

Date

Declaration of Witnesses
By signing below, I attest that:
Witness 1
1. I am not an interested person*;
2. I am at least 18 years of age
3.The above-named person appears to understand the nature of this document and to be free
from duress or undue influence at the time this request was signed.
Print Name: Witness 1

Witness 2

Signature

Date

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1. I am not an interested person*;
2. I am at least 18 years of age
3.The above-named person appears to understand the nature of this document and to be free
from duress or undue influence at the time this request was signed.
Print Name: Witness 2

Signature

Date

* An interested person means: the patient's physician; a person who knows that he or she is a relative of the
patient by blood, civil marriage, civil union, or adoption; a person knows that he or she would be entitled upon the
patients death to any portion of the estate or assets of the patient under any will or trust, by operation of the law, or
by contract; or an owner, operator, or employee of a health care facility, nursing home, or residential care facility
where the patient is receiving medical treatment or is a resident.

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APPENDIX D: PHYSICIAN REPORT FORM

CONNECTICUT
Death with Dignity Formal Physician Report Form
A

PATIENT INFORMATION
PATIENTS NAME (LAST,FIRST,M.I.)

DATE OF BIRTH

MEDICAL DIAGNOSIS

PHYSICIAN INFORMATION
NAME (LAST,FIRST,M.I.)

TELEPHONE NUMBER

MAILING ADDRESS

CITY, STATE, AND ZIP CODE

ACTION TAKEN TO COMPLY WITH LAW

1.

ORAL REQUEST
DATE

The patient has made a formal oral request for medication to be selfadministered for the purpose of hastening death.
COMMENTS:

2. FORMAL WRITTEN REQUEST (Must be make 15 days or more after the oral
request)
Indicate compliance by checking boxes:

DATE

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Formal written request for medication to hasten death.

Patient informed of the right to rescind the request at any time.

3. PHYSICIAN DETERMINATIONS

Indicate compliance by checking the boxes (Both the attending and consulting physicians
must make these determinations.)
1. Determined that the patient:
a)

is terminally suffering with ALS or a brain tumor;*

b) is capable;**
c)

is making an informed decision;

d)

has made a voluntary request for medication to hasten his or her

death;
e)

is at least 18 years old and a Connecticut state resident***

2. Informed the patient in person, both verbally and in writing, of all the following:

a) the patients medical diagnosis;

b) the patients prognosis, including an acknowledgement that the physician's
prediction of the patients life expectancy is an estimate based on the physician's best medical judgement;
c) the range of treatment options appropriate for the patient and the patients diagnosis;
d) the range of possible results, including potential risks associated with taking the
medication to be prescribed; and
e) the probable result of taking the medication to be prescribed.

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3. Referred the patient to two other physicians for medical conformation.

4. Verified that the patient did not have impaired judgement based on my evaluation or
as a result of a referral of the patient to a psychiatric or psychological clinician.

MEDICATION PRESCRIBED AND INFORMATION PROVIDED TO PATIENT

To be prescribed no sooner than 48 hours after the last of the following:

1. Patients written request was signed;

DATE

2. Medical conformation from two other physicians.

DATE

2. Offering the patient the opportunity to rescind the request.

DATE

PRIMARY PHYSICIAN SIGNATURE

DATE

If comments in any section exceed the space provided, used an attached page.

* Terminal Condition means incurable and irreversible disease that would, within reasonable medical judgement,
result in death within six months.
** Capable means that a patient has the ability to make and communicate health care decisions to a physician,
including communication through persons familiar with the patients manner of communicating if those persons are
available.
*** Factors demonstrating residency include, but are not limited to: 1) Possession of a Connecticut driver's license;
2) Registration to vote in Connecticut; 3) Evident that a person leases/owns property in Connecticut; 4) Filing of an
Connecticut tax return for the most recent tax year. Only the attending physician is required to affirm Connecticut
residency.

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APPENDIX E: CONSULTING PHYSICIAN REPORT FORM

CONNECTICUT
Death with Dignity Consulting Physician Report Form
PATIENT INFORMATION

A
PATIENT'S NAME (LAST, FIRST, M.I)

REFERRING/PRESCRIBING PHYSICIAN INFORMATION

B
NAME

DATE

TELEPHONE NUMBER

CONSULTING PHYSICIAN DETERMINATIONS

Indicate compliance by checking the boxes. (both the attending and consulting physicians must make these
determinations.)
Confirmed the:
a) diagnosis and prognosis
b) patient in capable; *

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c) patient is making an informed decision;

d) patient has made a voluntary request for medication to hasten his or her death.

CONSULTANTS INFORMATION

D
NAME (PLEASE PRINT)

TELEPHONE NUMBER (with area code)

MAILING ADDRESS
CITY, STATE, ZIP CODE

To the best of my knowledge, all of the requirements under the Patient Choice at End of Life Act have been
met.
PHYSICIAN'S SIGNATURE

DATE

* Capable means that a patient has the ability to make and communicate health care decisions to a physician, including communication through persons
familiar with the patient's manner of communicating if those persons are available.

APPENDIX F: ALZHEIMER'S WILL CLAUSE FORM

Article X: Alzheimers Death with Dignity Clause (OPTIONAL)
Definition of Death with Dignity: A procedure that grants terminally ill patients the ability to die comfortably rather than suffer an unbearable,
prolonged death through the use of barbiturates.

In the case of being diagnosed with Alzheimer's, check off the stages of progression
below that you wish to receive the Death with Dignity Act. (To proceed with the procedure, all
checked stages MUST be achieved):

Cant swallow independently

Cant recognize immediate family
Living off respirator

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Bed bound
Needs 24/7 assistance
Cant eat without eating tube
Wear Diapers
Cant communicate
Testator Signature:

___________________________________________________________

Executor Signature:

___________________________________________________________

APPENDIX G: ALZHEIMER'S AGREEMENT CONTRACT

CONNECTICUT
Alzheimer's Death with Dignity Agreement Contract
__________________________________ (Patient's Name) has been medically diagnosed with terminal
Alzheimers Disease and has reached ALL stages of progression in which he/she has indicated in Article X:
Alzheimers Death with Dignity Clause. He/She is therefore ready to be self administered for the purpose of
hastening their death using the Death with Dignity procedure.

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DATE: _______________
I, __________________________________(Primary Physician) agree with the statement above and agree
that _______________________________ (Patients Name) is ready to receive Death with Dignity medication.

DATE:_____________
I, __________________________________ (Consulting Physician 1) agree with the statement above and
agree that ____________________________ (Patients Name) is ready to receive Death with Dignity medication.
DATE:____________
I, __________________________________ (Consulting Physician 2) agree with the statement above and agree that
____________________________ (Patients Name) is ready to receive Death with Dignity medication.

DATE: _____________
I, __________________________________ (Executor Signature) agree with the statement above and agree
that ____________________________ (Patients Name) is ready to receive Death with Dignity medication.

APPENDIX H: MAP
The map below indicates the current states that have legalized the Death with Dignity Act and
also those who are currently working to pass it.

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APPENDIX I : ALS PATIENT

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APPENDIX J : ALZHEIMER PATIENT

APPENDIX k : BRAIN TUMOR PATIENT

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