Personal tools

End Of Life Planning

Forms for End of life planning
CPR Advisor
This pulls from different sources/calculators to help guide patients in their different choices for resussitation options. This can be a standalone but is also linked to the MOST form.
End of Life care eForms 2014
For those who have taken/will take the End of Life (aka Palliative) Care Physician Support Program - these two forms were felt to be useful, especially the PPS one. The PPS one uses an unaltered background, as per the request of Victoria Hospice Society. I have approval from the Society to post it, with the request the background is unaltered. The ESAS form had to be flipped “backwards”, as I could not figure out how to get the drawing function to work on the 2nd page of a multi-pagers. Seems all the drawing forms used to date are on page 1. If someone can figure it out, I’ll be happy to reverse the pages to their original. Adding PPS to measurements is recommended for the PPS form. JohnY
Medical Orders for Scope of Treatment (MOST) form updated 2020
Contains available MOST for various Health Authorities: FHA, VCH, VIHA. Some have customization - e.g. fax cover page for the Fraser Health Authority ACP repository. Included hyperlinks to the Government web pages for Representation Agreements, section 7 and section 9. Created by JohnY.
FHA Palliative Patient Community Rx (aka "Drug Kit"). Text digitized to allow for proper spacing.
Revera End of Life Orders: please consider using the V2 update
End of life order sheet for Revera operated residential care facility. Created initially for Royal City Manor in New Westminster, BC.
Revera End of Life Orders:
Updated for increased consistency with FHA EOL (Actively Dying) orders.
Revera End of Life Orders:
Similar to V2, except the drug quantities are set to reduce pharmacy phone calls.
FHA Actively Dying Protocol for residential care (EOL orders): V3
This one includes digital wet signature and signature stamp if that is set up.
DNR No CPR eFORM: V12_Jan26_2021_FNW_version
This version is customized for Fraser Northwest members - with links to Substitute Decision Maker eFORM designed with assistance from Dr. Charlie Chen, Notification of Expected Home Death, MOST, and ACP Record FHA version. Corrected signature save function when some, but not all signatures are completed on eFORM.
DNR No CPR eFORM: V13_Jan26_2021_FNW_version
Same as V12, but with signature stamp option.
DNR No CPR eFORM: V12_Jan26_2021_FHA_generic_version
This version removes the FNW references. Works best with addition of Notification of Expected Home Death eFORM - see link below. Fix saveSig glitch where last signature not saved if first two are blank. Signature stamp option added.
Substitute Decision Maker:
This new tool was developed in Fraser Northwest Division to enhance Advanced Care Planning in the community. It is meant to be a conversation starter for the patient and their significant others. It is linked to the updated Complex Care Lite form and the FNW version of DNR form. Feedback is welcome. JohnY
Link to Notification of Expected Death in Home eFORM
Link to Advance Care Planning eFORM, FHA version
Can be submitted to FHA ACP fax line

Document Actions


Download button



eForms button


 Customize button



Subscribe Button



Help button