Form Jv-Dss-2 - Hospital Ethics Committee Recommendation - Massachusetts Trial Court Page 2
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2Date: ___________________
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
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