Page 19 - Chatham-Kent Hospice
P. 19

   Resident Care Agreement
1. I _________________________________________ , request admission for myself/or for ____________________________________ to Chatham-Kent Hospice's residential care program. It is understood that this program is for people in their last days/weeks of life. My Health Care Provider has discussed my diagnosis and expected course of illness with me.
2. I agree to abide by the policies and procedures of the Hospice. I understand that the goals of the Hospice focus on comfort and do not seek to hasten death.
3. I understand it is my responsibility to appoint a Power of Attorney to handle my medical and legal affairs in the event I become incapable to do so. Otherwise the Substitute Decision Maker (SDM) hierarchy has been explained to me in accordance with the Health Care Consent Act (1996) and it will be used to determine my SDM should I become incapable.
4. I give permission for appropriate personal health information to be collected and shared with health care professionals within the Circle of Care (community nurses, physicians, pharmacy, LHIN-Home and Community Care etc) and with those personal contacts I have identified for the purposes of ensuring continuity of care.
5. I understand that care is available 24 hours a day, 7 days per week, by a team of physicians, nurses, personal support workers, volunteers, and other health care professionals. I accept that volunteers and students are an integral part of the Hospice and may assist the health care professionals in my care.
6. As a part of my care, regular assessments will be completed and the Hospice team will collaborate with me and/or designates regarding my care plan.
7. Should my condition improve or stabilize to the point where I no longer require the residential hospice environment, I understand that members of the team will work with me and my family on developing a discharge plan in which my care needs can be met in the appropriate setting.
8. I understand that, consistent with my wishes for palliative care, life-saving measures including cardiopulmonary resuscitation (CPR) will not be initiated.
9. I agree the Hospice is not responsible for my safety if I leave the Hospice property.
10. I understand that Hospice is not responsible for:
a. the loss of money, valuables or personal effects.
b. any care provided to me other than by employees and agents of the Hospice.
Resident/SDM.....................................................................................................................................................................................
Signature Print Name
Witness ..................................................................................................................................................................................................
Signature
Date
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