Free Nursing Home Ethics Committee Report Form Template
Nursing Home Ethics Committee Report Form
Date of Report: [Report Date]
Ethics Committee Members Present:
-
[Ethics Committee Member 1]
-
[Ethics Committee Member 2]
-
[Ethics Committee Member 3]
Resident Information
|
Resident Name: |
[Resident's Name] |
|
Age: |
[Age] |
|
Room Number: |
[Room Number] |
|
Date of Admission: |
[Date of Admission] |
Description of Ethical Issue
|
[Resident's Name], a [X]-year-old resident with advanced dementia, has been refusing to eat and drink for the past week despite encouragement and assistance from staff. He has also expressed a desire to die and has made statements indicating he no longer wants to continue living. |
Persons Involved
|
Role |
Name |
Contact Information |
|---|---|---|
|
Resident |
[Resident's Name] |
[Contact Info] |
|
Family Member |
[Resident's Family Member] |
[Contact Info] |
|
Staff Member |
[Staff Member] |
[Contact Info] |
|
Others (if applicable) |
[Other Persons Involved] |
[Contact Info] |
Discussion
|
The committee discussed [Resident's Name]'s advanced dementia and his current refusal to eat and drink. Concerns were raised regarding his capacity to make autonomous decisions and the ethical implications of honoring his wishes in this state. The committee also considered the potential consequences of artificially feeding [Resident's Name] against his expressed wishes and the impact on his quality of life. |
Decision/Action Taken
-
The committee decided to consult with [Physician Name], [Resident's Name]'s primary physician, to assess his medical condition and capacity to make decisions.
-
Pending the physician's assessment, the committee recommended implementing additional supportive measures, such as hospice care and palliative interventions, to ensure [Resident's Name]'s comfort and dignity.
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The committee also recommended scheduling a family meeting to discuss [Resident's Name]'s wishes and involve them in the decision-making process.
Follow-Up
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[Nurse Name] to coordinate with [Physician Name] for a thorough medical assessment of [Resident's Name]'s condition within the next 48 hours.
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[Social Worker Name] to organize a family meeting with [Resident's Family Member] and other relevant family members within the week to discuss [Resident's Name]'s care plan and address their concerns.
-
[Administrator Name] to ensure that all staff members involved in [Resident's Name]'s care are briefed on the decision and understand their roles in implementing the recommended interventions.
Ethics Committee Signature:
[Ethics Committee Representative]
[Date]
This document is confidential and intended for internal use only. Unauthorized distribution or disclosure is prohibited.
