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DO NOT DOUBLE-SIDE FORMS Rev. 07/2013 DO NOT STAPLE FORMS Page 1 of 3 SDMC Form 220-B SURROGATE DECISION-MAKING COMMITTEE PROCEEDING FOR THE REVIEW OF THE NEED FOR SUPPLEMENTAL MEDICAL INFORMATION Declaration SDMC Use Only Patient s Name ALL QUESTIONS MUST BE ANSWERED TO PREVENT A DELAY IN PROCESSING THE CASE 1a. Current medications dosages frequency and mode of intake 1b. List any drugs requiring frequent blood level monitoring. Include copy Any known allergies Annual physical examination Must include copy Date Abnormal findings Most recent EKG Include copy if available Most recent Chest X-ray Most recent laboratory tests Has there been a second opinion If so what type Capacity Best Interest List any cardiac or pulmonary condition s List any major illness surgery and/or hospitalizations in the last year List any other known physical conditions Has this patient had general anesthesia before Date of most recent general anesthesia Any history of adverse reactions to general anesthesia Ye....

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If a person is unable to make decisions about personal health care, some other person or people must provide direction in decision making. The general term for such person is surrogate decision maker.

SDMC considers major medical treatment decisions and end of life care decisions for certain individuals who are unable to provide informed consent and have no authorized, willing, and available surrogate to act on their behalf. Surrogate Decision-Making Committee Services ny.gov https://.justicecenter.ny.gov › SDMC ny.gov https://.justicecenter.ny.gov › SDMC

Overall, surrogates predicted patients' treatment pREFERENCES with 68% accuracy (95% CI, 63-72).

In addition, sur- rogates often struggle with such issues as recognizing their own needs and values and identifying where these differ from those of the patient. Despite substantial evidence of surrogate inaccuracy, surrogates' decisions are understandably widely accepted.

If the patient has a health care proxy, the health care agent named in the proxy makes decisions. If a patient does not have a health care proxy, a legal guardian (or the person highest in priority from the surrogate list, known as “the surrogate”) makes decisions.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232