Surrogate Selection Checklist Form (Page 2 of 4) in pdf

Surrogate Selection Checklist Form Page 2

Patient Name ______________________________________________ Hospital # _____________________

B. SELECTION OF A SURROGATE

4. Identification of potential surrogates (If yes, enter name(s) in order of priority)

Does the patient have:

a. Spouse? Name: _________________________________________________________________

b. Any adult child of the patient? Names: _______________________________________________

c. Either parent of the patient? Names: ________________________________________________

d. Any adult sibling of the patient? Names: _____________________________________________

e. Any adult grandchild of the patient? Names: __________________________________________

f. A close friend of the patient? Names: _______________________________________________

g. Such other persons or classes of persons including, but not limited to, such public agencies, public

guardians, other public officials, public and private corporations, and other representatives as the

department of health and human resources may from time to time designate?

Names: __________________________________________________________________________

5. Who is best qualified to act as surrogate? Name: ________________________________ Why?

Does this person:

a. Know the patient’s wishes, including religious and moral beliefs? Yes ____

No ____

If yes, basis:

b. Know the patient’s best interests? Yes ____

No ____

The determination of knowing the patient’s best interests was based on a discussion regarding

(check if yes):

1. The patient’s medical condition ____

2. Prognosis ____

3. The dignity and uniqueness of the patient ____

4. The possibility and extent of preserving the patient’s life ____

5. The possibility of preserving, improving or restoring the patient’s functioning ____

6. The possibility of relieving the patient’s suffering ____

7. The balance of the burdens to the benefits of the proposed treatment or intervention ____

8. and, such other concerns and values as a reasonable individual in the patient’s circumstances

would wish to consider ____

c. Have regular contact with patient?

Yes ____

No ____

If yes, enter nature and frequency of contact:

Surrogate Selection Checklist Form Page 2