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: _____________________________________________________________________

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1.Please indicate below, the steps you carried out to arrive at your recommendation:

  Examined the child
  Spoke with caregiver(s)

Reviewed the child’s relevant medical records

Discussed the pertinent medical issues with the

  Spoke with the child’s parent(s)
  Spoke with the child regarding his/her wishes
  Spoke with the child’s Guardian Ad Litem, if any
  Other, please describe: 

child’s medical providers

  Reviewed medical consultation report(s)
  Spoke with DCF staff

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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.

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  JV-DCF-1 Physician's Treatment Recommendation (08/25/08)

Date:             

  

  
      

  
      

  
      

  
      

  
      

  
      

          

Child’s Name: ____________________________

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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: 
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5.Additional comments or information: _________________________________________________

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______________________________   ______________________________
(Treating Physician Signature)

(Print Name)

 ___________________

(Date)

____________________________________________________      _____________________________
(Hospital)

(Telephone)

  JV-DCF-1 Physician's Treatment Recommendation (08/25/08)