Palliative Care Ethics Interview Form
Use this form to request and organize an ethics interview related to palliative care. Please provide the case context, ethical concern, and follow-up preferences.
Interview Identification
Respondent role in the case
*
Please Select
Clinician
Nurse
Social worker
Chaplain
Family member
Patient advocate
Other
Department or team involved
*
Date of ethical interview request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Case Context
Brief case summary
*
Current care setting
*
Hospital
Hospice
Home care
Long-term care
Other
Main ethical concern category
*
Goals of care
Decision-making capacity
Surrogate decision-making
Treatment burden vs benefit
Communication conflict
Withdrawal/withholding treatment
Other
Ethics Interview Details
Questions or issues to be addressed
*
People to involve in the discussion
Patient
Family member
Primary clinician
Palliative care team
Nurse
Social worker
Chaplain
Ethics consultant
Other
Urgency level
*
Routine
Soon
Urgent
Preferred follow-up method
*
Phone
In-person
Video
Email
Coordinated team meeting
Submit
Should be Empty: