Table 3.
*1. Does the patient have capacity to make decisions about life-sustaining treatments? |
2. Who is the person authorized under VA policy to make decisions for the patient if/when the patient loses decision-making capacity? |
3. Have you reviewed available documents that reflect the patient’s wishes regarding life-sustaining treatments? Examples: advance directives, state-authorized portable orders (e.g., POLST, MOST), life-sustaining treatment notes/orders. |
4. Does the patient (or surrogate) have sufficient understanding of the patient’s medical condition to make informed decisions about life-sustaining treatments? |
*5. What are the patient’s goals of care? • Patient’s goals of care in their own words, or as stated by the surrogate: • To be cured of:__________________________ • To prolong life • To improve or maintain function, independence, quality of life • To be comfortable • To obtain support for family/caregiver • To achieve life goals, including: ________________________ |
6. What is the current plan for use of life-sustaining treatments? • FULL SCOPE OF TREATMENT in circumstances OTHER than cardiopulmonary arrest. • Limit life-sustaining treatment • No life-sustaining treatment in circumstances OTHER that cardiopulmonary arrest. *CARDIOPULMONARY RESUSCITATION (CPR) ○ Full Code: Attempt CPR ○ DNAR/DNR: Do not attempt CPR ○ DNAR/DNR with exception: ONLY attempt CPR during the following procedure:_____________________. • Artificial Nutrition • Artificial Hydration • Mechanical Ventilation • Transfers between Levels of Care • Limit other life-sustaining treatment as follows (e.g., blood products, dialysis) |
7. Who participated in this discussion? |
*8. Who has given oral informed consent for the life-sustaining treatment plan outlined above? |
indicates required field