Renal Palliative Care Initiative: Advance Care Planning Preference Questionnaire
This questionnaire is used for eliciting and documenting patient preferences regarding treatment for ESRD.
Clinical Care Tools - Advance Care Planning
Renal Palliative Care Initiative
Baystate Medical Center
759 Chestnut Street S2669
Springfield, MA 01199
Lewis M. Cohen, M.D.
How the grantee used this instrument:
This questionnaire is administered in person to patients with ESRD at the dialysis center.
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.
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 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.