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General Practitioner Template

VAD Consulting Assessment

A professional General Practitioner template for healthcare professionals.
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About this template

Looking for a clear and concise way to document VAD consultations? This template is designed for General Practitioners and helps you create comprehensive Voluntary Assisted Dying assessments. It covers essential areas like patient information, medical history, eligibility, and recommendations. Streamline your documentation process and ensure all necessary details are captured with this easy-to-use template. Perfect for GPs navigating the complexities of VAD assessments, this template ensures you have all the necessary information at your fingertips.

Preview template

Consulting Assessment: Patient Information: - John Smith - 12/03/1950 - 12 Acacia Avenue, Sydney NSW, 2000 (Resident for 20 years in this address and in NSW) - 1234567 - Present for consultation: Wife, Mary Smith Consultation Details: - 1 November 2024 - Consulting clinician name and title: Dr. Jane Doe, General Practitioner - Referring clinician name and title: Dr. Robert Green, Oncologist Reason for Consultation: - Request for Voluntary Assisted Dying (VAD) assessment. - Diagnosis: Stage IV metastatic lung cancer with a poor prognosis. Prognosis is estimated to be 2-3 months. Medical History: - Past medical history: Hypertension, COPD, previous myocardial infarction. - Previous surgeries: Coronary artery bypass graft (2010), Right upper lobectomy (2022). - Current medications: Ramipril 5mg daily, Salbutamol inhaler as needed, Morphine Sulphate 10mg every 4 hours. - Allergies: Penicillin. Social History: - Smoker for 40 years, quit 2 years ago. Lives with wife. Supportive family. Family History: - Father died of lung cancer at age 70. Mother has diabetes. Medical Team - Dr. Robert Green (Oncologist), Dr. Jane Doe (GP), Dr. Sarah Brown (Palliative Care Specialist). Review of Systems and Symptoms: - Patient reports severe shortness of breath, chronic pain (7/10), fatigue, and loss of independence. Patient is unable to perform activities of daily living. Treatment Options: - Patient has been receiving chemotherapy and radiation therapy, but the cancer has progressed. Palliative care is being provided to manage symptoms. Patient has been informed of the outcomes of the care and treatment. VAD administration options: - Method preference: Self-administered oral medication. - Contact person: Mary Smith - Administration will cause death Competency - Competent: Patient is oriented to time, place, and person. Demonstrates a clear understanding of the VAD process and the implications. Elligibility: - Elligible - "I found John Smith's request enduring and no evidence that there has been any external pressure or duress placed to request VAD". Recommendations: - Proceed with the VAD process as per NSW legislation. Follow-Up: - Schedule a follow-up appointment to discuss the next steps and provide the necessary paperwork.
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Specialty

General Practitioner

Used

5 times

Type

Note

Last edited

5/9/2025

Created by

Erika Jaensch

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