Enrolment in the Special Patient Program Form
Preamble:
When complete, this constitutes a legally valid physician order (when signed by the Provincial Medical Director) for EHS
paramedics, for care of the individual named in this document. This complements any existing Advance Directive but is not
intended to replace that document. A patient with capacity for health care decisions can, at any time, request alternative
treatment or revoke the plan outlined in this form. A legally recognized substitute decision maker can also do so, based on the
desires of the patient or if unknown, acting in the patients’ best interests if the patient lacks capacity.
Demographics
1.
2.
3.
4.
5.
6.
Is this a:
Patient’s name:
Gender identity:
Date of Birth:
Health card number:
Patient’s mailing address:
7. Patient’s physical address
(if different from above):
8. Patient telephone:
9. A) Next of kin:
8. A) Substitute decision maker
(if applicable)
New Enrolment
First
Middle
Day
Month
Update/revision
Last
Year
Street
Apartment/unit
City
Street
Province
City
Home telephone (
Name
Home telephone (
First
Relationship
Postal Code
Apartment/unit
Province
Postal Code
Cell/Alternate (
)
Relationship
Cell/Alternate (
)
Middle
Last
Tel (
)
)
)
B) Substitute decision
maker (if applicable)
9. A) Current contact for
provider submitting this
application form
10. A) Current contact for
follow-up/ongoing care
provider/team/physician
First
Relationship
Name
Phone
Middle
Tel (
Name
Phone
Email
Title
Fax (
)
B) Current contact for followup/ongoing care
provider/team/physician
11. Who was involved with
decision-making regarding
the wishes in this enrolment
form? (check all that apply):
12. Specific religious or cultural
wishes/considerations:
Name
Phone
Email
Patient (has decision-making capacity)
Patient’s family/caregiver
Patient (does not have decision making
Title
Fax (
)
Fax (
)
Last
)
Title
Email
Substitute decision maker
Other
capacity)
History
13. Allergies:
14. Medications:
Current mediation list available in the home chart
15. Past medical
history:
Current diagnosis category:
Expected event(s)/risk(s):
Specific diagnosis
Notable concerns with blood work (hemoglobin,
calcium, etc.):
Cardiac arrest (if patient has no pulse and is not breathing)
16. Choose one:
Attempt resuscitation/CPR/ artificial ventilation
Allow natural death/do not attempt
resuscitation
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If no home chart, please list medications:
Medical interventions
17. If patient is not in cardiac arrest/has a pulse, please select the most appropriate goal of treatment:
Full Treatment
Selective Treatment:
Comfort-focused treatment
- Primary goal of prolonging life by all medically - Goal of treating acute reversible medical conditions - Primary goal of maximizing patient comfort.
effective means.
while avoiding burdensome measures.
- Relieve pain and suffering with medication by any route as
- In addition to treatment described in selective - In addition to treatment described in comfortneeded, use oxygen, suctioning and manual treatment of
treatment and comfort-focused treatment, use
focused treatment, use medical treatment,
airway obstruction. Do not use treatments listed in full
intubation, airway interventions, and mechanical
antibiotics, IV fluids as medically indicated. Use of
and selective treatment unless consistent and required to
ventilation as indicated. All usual care will be
cardioversion. Do not intubate. May use nonmeet comfort goals. Comfort measures will always be
provided unless specific instructions given otherwise.
invasive positive airway pressure. Avoid intensive
provided; please indicate if there are specific things you
↓
care. Please indicate if there are any specific
would not want, or certain ways you would prefer to
treatments you would/would not wish to have or
receive those treatments.
Please describe diagnosis & therapeutic protocols:
any helpful details about how you would like to
receive those treatments.
Please complete the following table to provide additional detail regarding desired care
Selective Treatment:
Airway/Breathing
a) Specific treatment for respiratory distress, specifics regarding secretions:
b) Appropriate therapy for breathlessness:
c) Whether would require supplemental oxygen: Yes
No
d) Appropriate/desired therapy if respiratory distress requiring ventilatory support/machines or tubes to breathe
for you (non-invasive – no intubation):
Circulation
e) Whether to treat other non-arrest rhythms/shock or give medication to abnormal heart rhythms that still have a
pulse:
Yes
No
f) Whether require want IV access: Yes
No
Adjunct Investigations (will need arrangements beyond EHS)
g) Whether would want tests requiring venipuncture/needle to draw blood: Yes
No
h) Whether would want tests requiring diagnostic imaging/tests in the x-ray department, ultrasounds, cat scans
etc:
Yes
No
Comfort-focused treatment:
Airway/Breathing
a) Specific treatment for respiratory distress, specifics
regarding secretions:
b) Appropriate therapy for breathlessness:
c) Whether would want supplemental oxygen: Yes
No
Circulation
d) Whether would want IV access:
No
Comfort Measures
e) Specific directives about hydration (route, rate etc):
f) Specific directives about pain control (route, dose etc):
Other decisions
g) Please specify:
Comfort Measures
Yes
i) Specific directives about hydration (route, rate etc):
j) Specific directives about pain control (route, dose etc):
Condition-Specific Actions (will need arrangements beyond EHS)
k) Whether would want antibiotics: Yes No
Other decisions
l) Please specify:
_____________________________________________________________________________________
Destination Decisions
18. Transport (if no, skip):
Never
Yes
Only if needs cannot be
met in the current location
Transport if:
Transport when:
Where to (NOTE: all efforts will be made to accommodate
location of choice; however, in some cases this may not be
feasible):
Environment & Psychosocial Needs (Palliative Patients ONLY)
19. Preference for place of death:
At home
In hospital
Unknown
20. Preferred location of care:
At home
In hospital
Unknown
21. A) Funeral home (name and contact
information):
B) Which doctor has agreed to
complete death certificate?
22. Organ donation:
23. Tissue donation:
Unknown
Yes
Yes
No
No
Unknown
Unknown
24. Additional details:
I have developed and reviewed this care plan with the patient/family/substitute decision maker
This patient/family/substitute decision maker agrees to be followed up for the purpose of research
and/or evaluation to help to improve the SPP and the palliative care paramedics provide
General Guidelines:

Directives should include medical and plain language terminology

The directive should be about the specifics of treatment itself not the location where it might take place

In the absence of specifics, usual care applies
COMPLETED FORMS may be sent to the attention of Tanya Fraser by fax to 902-424-1781 or mail to:
Emergency Health Services
Suite 160, 237 Brownlow Ave
Dartmouth, NS, B3B 2C5
For questions about the SPP please contact Tanya at 902-424-1729
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Please allow 10 business days for SPP applications to be processed and cards issued by mail