Summary sheet for physicians.

Family’s decision making and relationships
1. Who are the main family members making decisions for the patient? 2. Are there any intrafamily conflicts that may require attention?	What role do the family members prefer in decision making about goals of care? □ prefer to make final decision □ prefer to make the final decision after seriously considering the doctor’s opinion □ prefer that the doctor and family share equal responsibility □ prefer that the doctor makes the final decision but seriously considers family’s opinion □ prefer that the doctor decides
Family’s understanding of the patient’s prognosis
1. Likelihood of survival to hospital discharge
2. Likelihood of severe functional impairment in 6 months
Patient’s treatment preferences and values
1. Is there a written advance directive? (If so, summarize key points) 2. What is known about patient’s values and health care preferences?	3. Patient’s preferences about continuing life support if likely outcome is: - Living in a nursing home or with substantial care-giving burdens? - Being unable to think clearly or interact with others? - Being unable to do valued physical activities? - Being a burden on family (financially or care giving)? - Being attached to machines to be kept alive?
Family’s main questions