Fill and Sign the Hospital Ethics Committee Recommendation Form

Date: ___________________ The Commonwealth of Massachusetts Trial Court Juvenile Court Department HOSPITAL ETHICS COMMITTEE RECOMMENDATION Forgoing or Discontinuing Life Sustaining Medical Treatment Child’s Name: _____________________________________Date of Birth: ____________________ Location of Child: _______________________________Hospital: ___________________________ *********************************************************************************************************************** 1.Has the committee had sufficient access to the relevant medical assessments and recommendations (including the Physician's Treatment Recommendation forms from the treating provider and the second opinion physician; the medical record; consultants’ reports; and input from nurses and other caregivers) to arrive at a recommendation regarding discontinuing or forgoing life sustaining medical treatment for this child? YES NO If no, please explain: _______________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 2.Has the committee had sufficient access to other ethically relevant information, such as information about the child’s religious and ethical views (if applicable), information about the religious and ethical views of family and friends who remain appropriately involved with the child, and input from DSS? YES NO If no, please explain: _______________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 3.Does the committee have sufficient understanding of the relevant medical assessments and recommendations and other information relevant to the case? YES NO If no, please explain what further information/clarifications are needed: ________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 4.Has the committee reviewed the available treatment options, and for each treatment option, evaluated the likelihood and degree of suffering and the potential for relief; the severity of dysfunction and the potential for restoration of function; the expected duration of life; the potential for personal satisfaction and enjoyment of life; and the likelihood that the child will develop self-awareness and the capacity for social relationships? YES NO If no, please explain: _______________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ JV-DSS-2 Hospital Ethics Committee Recommendation Issued: 9/2007 1 Date: ___________________ 5.Has the committee reviewed the recommendations as documented in the Physician's Treatment Recommendation forms from the treating provider and the second opinion physician? YES NO If no, please explain: ______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 6.What are the committee’s recommendation(s) regarding the forgoing or discontinuing of life-sustaining medical treatments for this child, and what is the rationale for the recommendation(s)? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7.Does the recommendation(s) of the committee differ from the recommendations made by either the treating or second opinion physician? YES NO If yes, please explain: ____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 8.What ethical principles, outlined in the following policy statements or other sources, support the Committee’s recommendations: American Academy of Pediatrics Committee on Bioethics “Guidelines on Forgoing life-Sustaining Medical Treatment”, Pediatrics 1994; 93:532-536, and the American Academy of Pediatrics, Committee on Child Abuse and Neglect and Committee on Bioethics, “Forgoing Life- Sustaining Medical Treatment in Abused Children”, Pediatrics, 2000 Nov., 106(5); 1151-3. Please explain: _________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Additional Comments: ______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Committee members consulted: (Please include non-physicians as well as physicians.) _____________________ _____________________ _____________________ _____________ (Print name) (Signature) (Title) (Date) _____________________ _____________________ _____________________ _____________ (Print name) (Signature) (Title) (Date) _____________________ _____________________ _____________________ _____________ (Print name) (Signature) (Title) (Date) _____________________ _____________________ _____________________ _____________ (Print name) (Signature) (Title) (Date) _____________________ _____________________ _____________________ _____________ (Print name) (Signature) (Title) (Date) JV-DSS-2 Hospital Ethics Committee Recommendation Issued: 9/2007 2