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1. My first and last name:

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2. Please answer these questions to see if the patient qualifies for the Now Care Planning protocol:

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

 

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4. I used a checklist (or someone advised me) that the patient's living will is not clear or specific enough to adequately indicate WHEN he or 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. Also, most physicians would refuse to comply for this reason.

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5. I  used a checklist (or someone advised me) the patient's living will does not offer an intervention that will be effective to allow her to die of her underlying disease.

Example: The patient's living will states, "Focus on Comfort Measures Only." But she has "No Plug to Pull" so sustaining her life does not depend on any high-tech treatment. Her treating physician argues that spoon-feeding is a comfort measure.

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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 the patient lost capacity.

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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:

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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.)

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9. DO you consent to serve as a member of the patient's Decision Committee? This will require you to complete Steps 2 to 5, described below, to which you must agree by checking each numbered box:

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

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11. Today's date

Date / Time

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12. I  have known the patient for ____ years:

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

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

0 of 14 answered
 

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