Question Title

1. My name

Question Title

2. Three factors must be present to help patients using the Now Care Planning protocol. Please indicate if ALL are present by clicking below:

Question Title

3. My relationship with the patient living with advanced dementia is (click all that apply):

 

Question Title

4. I have used a checklist or have been advised that if the patient has a living will, it is not clear or specific enough to adequately indicate WHEN she would want all life-sustaining treatment to cease.

Example:  Her living will might cite the condition, "No longer able to recognize loved ones and family members." 
But
the patient and her loved ones can still enjoy spending time together and no one is suffering, let alone suffering severely.
If I used this simple criterion, the patient would die earlier than wanted because it would sacrifice a life that still could give and receive joy, or the physician would not comply for this reason.

Question Title

5. I have used a checklist or have been advised that if the patient has a living will, it does not offer an intervention that will be effective to allow her to die of her underlying disease.

Example: The patient has "No Plug to Pull," which means that sustaining her life does not depend on any high-tech treatment.
Her living will states, “I would not want any care that would me keep me alive longer.” Or, "Focus on Comfort Measures Only."

But her treating physician refuses to withdraw help with spoon-feeding because the term, "any care," is too vague, or because some authorities consider spoon-feeding to be "basic care."


Question Title

6. I feel qualified to serve as a surrogate decision-maker since I learned the patient's values and treatment preferences directly from her before she lost capacity.

Question Title

7. Below I have listed the names of ALL individuals I am aware of who might claim legal standing to make end-of-life decisions on behalf of the patient:

Question Title

8. Below I have listed the names of ALL individuals I am aware of whom I believe the patient would not want to have any influence in making end-of-life decision on her behalf.
(Write none, if applicable; and if you wish, WHY.)

Question Title

9. DO you consent to serve as a member of the patient's Decision Committee?

(You are currently completing Step 1 of this Protocol. The other steps are described below.)

==>Please read these steps carefully.
==> Checking a box with a numbered step means you promise to participate in this step.
==> To serve, you must consent to Steps 1 to 5.
(Step 6 requires actions of the treating physician and a consultant , not of you.)

Question Title

10. There are other issues I feel need to be discussed, including:
(Write none, if it applies.)

Question Title

11. Today's date

Date / Time

Question Title

12. I  have known the patient for ____ years:

Question Title

13. Please enter this information if you want a counselor to contact you regarding the patient about whom you are concerned:

Question Title

14. Do you want a counselor to contact you about the person who is now living with dementia, is dying slowly, and might be suffering?

0 of 14 answered
 

T