The Commonwealth of Massachusetts
Trial Court
Juvenile Court Department

Date: ___________________

HOSPITAL ETHICS COMMITTEE RECOMMENDATION

Forgoing or Discontinuing Life Sustaining Medical Treatment

Child’s Name: _____________________________________ Date of Birth: ____________________

Location of Child: _______________________________ Hospital: ___________________________
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1.Has the committee had sufficient access to the relevant medical assessments and recommendations
(including the Physician's Treatment Recommendation forms from the treating provider and the second
opinion physician; the medical record; consultants’ reports; and input from nurses and other caregivers) to
arrive at a recommendation regarding discontinuing or forgoing life sustaining medical treatment for this
child?  YES 

  NO 

If no, please explain: _______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

2.Has the committee had sufficient access to other ethically relevant information, such as information
about the child’s religious and ethical views (if applicable), information about the religious and ethical
views of family and friends who remain appropriately involved with the child, and input from DSS?  YES 
NO 

If no, please explain: _______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

3.Does the committee have sufficient understanding of the relevant medical assessments and
recommendations and other information relevant to the case?   YES 

   NO 

If no, please explain what further information/clarifications are needed: ________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

4.Has the committee reviewed the available treatment options, and for each treatment option, evaluated
the likelihood and degree of suffering and the potential for relief; the severity of dysfunction and the
potential for restoration of function; the expected duration of life; the potential for personal satisfaction and
enjoyment of life; and the likelihood that the child will develop self-awareness and the capacity for social
relationships?   YES 

   NO 

If no, please explain: _______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

  JV-DSS-2  Hospital Ethics Committee Recommendation

1

Issued: 9/2007

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 

Date: ___________________

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.)

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  JV-DSS-2  Hospital Ethics Committee Recommendation

2

Issued: 9/2007