Form Jv-Dss-2 - Hospital Ethics Committee Recommendation - Massachusetts Trial Court

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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

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