Fillable Jv Dcf Md Treating Physician Recommendation Form (Commonwealth of Massachusetts)

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Jv Dcf Md Treating Physician Recommendation Form (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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The Commonwealth of Massachusetts
Trial Court
Juvenile Court Department
TREATING PHYSICIAN’S RECOMMENDATION FORM
Recommendation to Forgo or Discontinue Life Sustaining Medical Treatment
Date: ____________________ Check box if child in the custody of the Department of Children and Families
Child’s Name: _____________________________________ Date of Birth: __________________
Location of Child: _____________________________________________________________________
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1.Please indicate below, the steps you carried out to arrive at your recommendation:
Examined the child Reviewed the child’s relevant medical records
Spoke with caregiver(s) Discussed the pertinent medical issues with the
child’s medical providers
Spoke with the child’s parent(s) Reviewed medical consultation report(s)
Spoke with the child regarding his/her wishes Spoke with DCF staff
Spoke with the child’s Guardian Ad Litem, if any
Other, please describe:
__________________________________________________________________
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2.Diagnoses: Please provide the following information regarding each of the child’s diagnoses:
DIAGNOSIS BASIS FOR THE DIAGNOSIS
3.Treatment Options and Prognoses: Please list below the treatment options you believe to be available
for this patient. For each option, describe the potential benefits and potential for restoration of function and
the degree and likelihood of suffering.
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JV-DCF-1 Physician's Treatment Recommendation (08/25/08)
Date: Child’s Name: ____________________________
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4.Recommendations for discontinuing or forgoing medical treatment: Please check those
interventions below that you recommend discontinuing or forgoing:
Cardiac medications Supplemental Oxygen Ventilator Central IV line
Administer pressors Bi Pap/C Pap IV nutrition Oral antibiotics
Chest compressions Intubation Enteral nutrition IV antibiotics
Cardioversion Tracheotomy IV hydration
Other: ________________________________________________________________________
Please explain the medical rationale for these recommendations, including any medical research
information, experience or other resources you believe are pertinent to the recommendation:
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5.Additional comments or information: _________________________________________________
_________________________________________________________________________________
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______________________________ ______________________________ ___________________
(Treating Physician Signature) (Print Name) (Date)
____________________________________________________ _____________________________
(Hospital) (Telephone)
JV-DCF-1 Physician's Treatment Recommendation (08/25/08)
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Jv Dcf Md Treating Physician Recommendation Form (Commonwealth of Massachusetts)

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Completed 26 July 2020

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