Life-Sustaining Treatment Termination Request Form
Use this form to request termination of life-sustaining treatment and provide the essential details needed to process the request.
Requestor and Patient Information
Requestor Full Name
*
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Spouse/Partner
Parent
Adult Child
Sibling
Other Family Member
Legal Guardian
Healthcare Proxy
Other
Requestor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requestor Email Address
*
example@example.com
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Location / Facility Name
*
Treatment Termination Details
Life-Sustaining Treatment(s) to Terminate
*
Mechanical ventilation
Cardiopulmonary resuscitation (CPR)
Dialysis
Artificial nutrition and hydration
Other
Request Type
*
Immediate
Scheduled
Requested Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Effective Time
Hour Minutes
AM
PM
AM/PM Option
Acknowledgment and Signature
Acknowledgment
*
I understand this is a formal request to terminate life-sustaining treatment.
I confirm the information provided is accurate to the best of my knowledge.
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Request
Submit Request
Should be Empty: