Form JV-DCF-1 "Treating Physician's Recommendation Form" - Massachusetts

What Is Form JV-DCF-1?

This is a legal form that was released by the Massachusetts Juvenile Court Department - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 25, 2008;
  • The latest edition provided by the Massachusetts Juvenile Court Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JV-DCF-1 by clicking the link below or browse more documents and templates provided by the Massachusetts Juvenile Court Department.

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Download Form JV-DCF-1 "Treating Physician's Recommendation Form" - Massachusetts

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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: _____________________________________________________________________
************************************************************************************************************************
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:
__________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
JV-DCF-1 Physician's Treatment Recommendation (08/25/08)
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: _____________________________________________________________________
************************************************************************************************************************
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:
__________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
JV-DCF-1 Physician's Treatment Recommendation (08/25/08)
Date:
Child’s Name: ____________________________
________________________________________________________________________________
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:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5.
Additional comments or information: _________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
______________________________ ______________________________
___________________
(Treating Physician Signature)
(Print Name)
(Date)
____________________________________________________
_____________________________
(Hospital)
(Telephone)
JV-DCF-1 Physician's Treatment Recommendation (08/25/08)
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