Promoting Excellence : Advance Care Planning Preference Questionnaire

Name:
Renal Palliative Care Initiative: Advance Care Planning Preference Questionnaire

Description:
This questionnaire is used for eliciting and documenting patient preferences regarding treatment for ESRD.

Category:
Clinical Care Tools - Advance Care Planning

Source:
Renal Palliative Care Initiative
Baystate Medical Center
759 Chestnut Street S2669
Springfield, MA 01199

Contact:
Lewis M. Cohen, M.D.
[email protected]

How the grantee used this instrument:
This questionnaire is administered in person to patients with ESRD at the dialysis center.

Keywords:
advance care plan, esrd, preferences

To use this tool:
You may print and copy this tool for your own use from this site. Please credit source.

References:
Developed specifically for this project by the project team.

To view this tool:
Left click on the download link to view the PDF document in your Web browser. Right-click on the download link to save the document to your computer.
pdf PDF 51 KB / 1 page (Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Posted April 2004

Baystate Medical Center overview page


# BMC3, type:advanced_care_planning


Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families. Visit PromotingExcellence.org for more resources.

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