Get Checklist For Surrogate Selection - West Virginia Center For End-of ... - Wvendoflife

This guide provides a detailed, step-by-step approach to filling out the Checklist For Surrogate Selection required by the West Virginia Center for End-of-Life. By following these instructions, users will be able to complete the form accurately and efficiently.

Follow the steps to complete the surrogate selection checklist.

1. Click the ‘Get Form’ button to access the Checklist For Surrogate Selection online. This will open the document for you to work on.
2. Begin filling out the initial section. Indicate whether the surrogate agrees to submit this form to the West Virginia e-Directive Registry and share it with treating health care providers by selecting the appropriate option in the INITIAL box.
3. Complete the personal information fields to the right, including the last name, first name, middle name, and full address—city, state, and zip code. Provide your date of birth and last four digits of your social security number, and indicate gender.
4. In section A, determine if the Health Care Decisions Act is applicable by answering the questions related to the patient's age and capacity. Provide responses to the yes/no questions, and if applicable, fill in the physician details for the incapacity determination.
5. For section B, start identifying potential surrogates based on the questions provided. Enter names in the order of priority for individuals identified as qualified to act as surrogates, starting from a committee or guardian down to close friends.
6. For each potential surrogate, assess their qualifications by answering the questions about their knowledge of the patient's wishes, interests, regular contact, and ability to participate in decision-making. Fill in necessary details for those assessed positively.
7. Confirm the availability and willingness of the selected surrogate to serve. If they are not willing, select the next most qualified individual and record their name.
8. Ensure that the person designated as a surrogate is the highest priority according to the earlier section. If not, provide reasons for their selection based on the criteria from step 5.
9. If the patient is conscious, document the date and time they were notified about the incapacity and the identity of the surrogate. Record their response.
10. Check if any objections were raised by potential surrogates. If there were objections, document the individual's name and basis for objection as well as notify them of their rights to challenge the selection.
11. Finalize the form by obtaining the appropriate signatures, including the physician's, and the surrogate's acceptance of their role. Ensure all contact numbers are provided for communication regarding the surrogate.
12. Once all sections are completed, review the form for accuracy. Save changes securely, and you may choose to download, print, or share the completed document as needed.

Complete your surrogate selection checklist efficiently by filling out the form online today.