Standards › Standard 10 › Forms
Form · HSP-FRM-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 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
No e-learning course is linked to this document yet.
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)