Fill and Sign the Treating Physicians Recommendation Form Recommendation to Forgo or Discontinue Life Sustaining Medical Treatment

The Commonw ealth of Massach usetts Trial Court Juve nile Court Department TRE ATIN G PHYSICI AN ’S RE COMMEND ATIO N FORM R ecomm endation to Forgo or Discontinue Life Sustaining Medical Treatment Dat e: _ _______ _____ _______ C heck b ox if child in the cus tody of th e De partm ent of Children and Fa milies Child’s Name: _________ _____ _______ _____ _______ ____ Date of Birth: ___________ _____ __ Locatio n of Child: ____________ _______ _____ _______ _____ _______ _____ _______ _____ _______ __ **** ****** ************************************************************************************************************** 1. Please indicat e belo w, the steps y ou carried out to arrive at your recomme ndatio n: Exam ined the child Review ed the child’s relevant medical records Spoke with caregiver(s) Dis cussed the pertin ent medical issues with the child’s medica l providers Spoke with the child’s parent(s) Review ed medical consultatio n report(s) Spoke with the child regard ing his/her wishes Spoke with DCF staff Spoke with the child’s Guardia n Ad Litem, if any Other, please describe: ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ __ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ 2. Diagnos es: Please provide the follow ing infor mation regard ing each of the child’s diagnoses: DI AGNOSIS BA SIS FO R THE DIA GNOSIS 3. Treatme nt Options and Prognoses: Please list below the treat ment opti ons you believe to be availa ble for this patient . For each option, describe the potent ial benef its and pote ntial for restorati on of function and the degr ee and likelih ood of suffering. ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ JV-D CF-1 Physician's Treatment Recommend ation (08/25/ 08) Dat e: Child’s Nam e: _______ _______ _____ _______ __ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ ____ 4. Recomm endations for disconti nuing or forgoing medical treatment: Please check those interven tions belo w that you recomm end discontin uing or forgoi ng: Cardiac medications Suppl emental Oxyg en Ventil ator Central IV line Admin ister pressors Bi Pap/C Pap IV nutrit ion Oral antibi otics Chest compressions Intub ation Entera l nutrit ion IV antibi otics Cardioversio n Tracheot omy IV hy drat ion Other: _________ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ ___ Please explai n the medical rationale for these recommen dations, includi ng any medica l research infor mation, exper ience or other resources you beli eve are pertin ent to the recomme ndatio n: ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ 5. A dd itio nal comment s or informatio n: ___ __________ _____ _______ _____ _______ _____ _______ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _______ _____ _____ ____ _______ _____ _______ _____ __ _____ __________ _____ _______ ___ ___ __________ _____ _ (Treatin g Physician Si gnature) (Print Name) (Date) ____ _______ _____ _______ _____ _______ _____ _______ _____ ____ _____ _____ _______ _____ ___ (Hospital) (Telep hone) JV-D CF-1 Physician's Treatment Recommend ation (08/25/ 08)