Terminal Illness Medical Attestation (CPP)

Specialty: Physician Terminal Illness Medical Attestation for Disability Benefits Application under the Canada Pension Plan **Patient Information:** Full Name: Ms. Eleanor Vance Date of Birth: 15/03/1960 Health Card Number: 1234-567-890-AB **Medical Professional Information:** Full Name: Dr. Sarah Chen Specialty: Oncology College of Physicians and Surgeons Registration Number: 98765 Business Address: 456 Oak Avenue, Suite 200, Toronto, ON M5A 1B2 Telephone Number: (416) 555-1234 Fax Number: (416) 555-1235 Email Address: sarah.chen@exampleclinic.ca **Diagnosis of Terminal Illness:** Primary Diagnosis: Stage IV Pancreatic Adenocarcinoma with extensive liver metastases. Date of Diagnosis: 10/06/2024 Relevant ICD-10 Code: C25.9 **Prognosis:** It is my professional opinion that Ms. Eleanor Vance is suffering from a grave and irremediable medical condition. Her current medical condition is expected to lead to death within six months. This prognosis is based on: Rapid progression of disease despite systemic chemotherapy, significant weight loss, intractable pain, and declining performance status (ECOG 3). **Functional Limitations and Impact on Activities of Daily Living (ADLs):** Ms. Vance experiences severe fatigue, nausea, and abdominal pain daily. She requires significant assistance with personal care (e.g., bathing, dressing) and can no longer perform household chores. Her mobility is severely limited, and she is primarily bed-bound or chair-bound. She is unable to work in any capacity due to her debilitating symptoms and rapidly deteriorating health. **Medical Treatments and Interventions:** Current treatments include palliative chemotherapy (Gemcitabine/Nab-paclitaxel, which has recently been discontinued due to lack of efficacy and increased toxicity), pain management with opioid analgesics (e.g., hydromorphone), antiemetics, and nutritional support. No further curative treatment options are available. **Supporting Documentation:** (List of attached medical reports and investigations): 1. Oncology Consultation Report (dated 10/06/2024) 2. CT Abdomen/Pelvis Scan Report (dated 01/09/2024) 3. Liver Biopsy Pathology Report (dated 15/06/2024) 4. Progress Notes from Palliative Care Team (ongoing) **Declaration:** I declare that the information provided in this attestation is accurate and complete to the best of my knowledge and belief. Signature of Medical Professional: Dr. Sarah Chen Date: 01 November 2024