Standards › Standard 10 › Forms
Form · HSP-FRM-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 10.11
Purpose
Records any decision to limit resuscitation or transfer to hospital, so every clinician who may be called can see it.
How to complete
- Record the decision, the date and the reason.
- Display it at the point of care and in the record.
- Review it when the condition changes.
Checks
| Check | Entry |
|---|---|
| Decision: no resuscitation (yes or no) | Yes |
| Decision: no transfer to hospital (yes or no) | Yes |
| Reason and who was involved | Yes |
| Date made and reviewed | Yes |
| Displayed at point of care (yes) | Yes |
| Signed by clinician and date | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care fact sheet and the Lancet Commission on the Global Access to Palliative Care and Pain Relief (2017). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Patient Identification, Informed Consent and Patient Rights (T-07)
- Healthcare Ethics for ASF Accreditation (A-07)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)