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Patient Preferences/Goals Form
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Patient Preferences/Goals Form
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Patient Preferences / Goals of Care
Patient First Name
*
Patient Last Name
*
Email Address
*
Phone Number
*
Medical Record Number (MRN)
Date of Birth:
Date Form Completed
What is your current understanding of your health condition(s)?
How much information about your condition and prognosis do you wish to know?
All details, including potential risks and statistics
Enough to make informed decisions
Only basic information
Let my designated person/family know first
Who do you rely on most for support and decision-making regarding your health?
Support person's Name
Support person's Relationship
Support person's Phone
Quality of Life & Priorities:
Life Priorities: Please rank the following areas (1 = Most Important, 5 = Least Important)
Remaining mentally clear and aware
Being able to recognize and interact with family/friends
Having minimal pain and physical suffering
Maintaining independence for daily activities (e.g., feeding, dressing)
Being at home/in a familiar environment
Personal Values
What makes life meaningful or enjoyable for you right now? (e.g., Hobbies, relationships, faith, pets)
What are you most worried about regarding your health and the future?
What would be an unacceptable quality of life for you? (What medical outcomes would make you feel that "it's time to stop treatment"?)
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Goals of Care (Focus on Medical Treatment)
This section helps match treatment options to the patient's overall goals.
Goal is to use all available medical interventions (e.g., ICU, surgery, ventilators) in an effort to prolong life as much as possible, accepting potential side effects.
Goal is to use some life-sustaining treatments, but to primarily focus on treatments that manage symptoms and maintain function/quality of life. Avoid interventions with poor chance of benefit.
Goal is to maximize comfort and manage symptoms (pain, nausea, breathlessness). No life-prolonging treatments (e.g., ventilation, dialysis). Primary focus is palliative care/hospice.
Specific Treatment Preferences
Cardiopulmonary Resuscitation (CPR)
I Would Want This
I Would Not Want This
Mechanical Ventilation (Breathing Machine)
I Would Want This
I Would Not Want This
Artificial Nutrition (Feeding Tube)
I Would Want This
I Would Not Want This
Artificial Hydration (IV Fluids)
I Would Want This
I Would Not Want This
Intensive Care Unit (ICU) Stay
I Would Want This
I Would Not Want This
Blood Transfusions/Dialysis
I Would Want This
I Would Not Want This
Location of Care
If you are nearing the end of your life, where do you most want to be?
Home
Hospital
Skilled Nursing Facility
Hospice/Inpatient Unit
Other (Specify):
What spiritual/cultural/religious beliefs or practices should be respected during your care?
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Advance Directives (Legal Documentation)
Living Will/Treatment Instructions
Yes, I have one
No, but I want information
Date Completed
Durable Power of Attorney for Health Care (Health Care Proxy)
Yes, I have one
No, but I want information
Date Completed
Signatures & Review
Patient/Surrogate
Use your mouse or finger to sign in the box below.
Clear Signature
Witness
Discussing Clinician
Next Review Date: (Recommended: 6-12 months or upon significant change in health status)
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