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. Author manuscript; available in PMC: 2020 Jun 23.
Published in final edited form as: J Gerontol Nurs. 2019 Mar 1;45(3):21–30. doi: 10.3928/00989134-20190211-03

Table 3.

Life Sustaining Treatment Decisions Template

*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