Bethell Hospice Residential Admission Agreement - Consent for Service

Residential / Client Information:

Preferred Pronoun *

Other

First Name *

Last Name *

Address Street *

PO Box

City *

Province *

Postal Code *

Primary Phone *

Secondary Phone

Email

Healthcard Number (if applicable)

Emergency Contact Information:

Relation to Client *

Type of SDM *

SDM by Hierarchy

POA Property

POA Personal Care

Emergency Contact

Preferred Pronoun (Emergency Contact)

Other (Emergency Contact)

First Name *

Last Name *

Address Street *

PO Box

City *

Province *

Postal Code *

Primary Phone *

Secondary Phone

Email

Bethell Hospice strives to provide Hospice Palliative Care in a “home-like” environment according to but not limited to the World Health Organization’s definition of Palliative Care: “prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” A holistic approach is used to provide symptom management and comfort in all the domains of issues: physical, disease management, psychosocial, spiritual, practical, death management, grief and bereavement. The focus is on the resident’s goals of care and quality of life, not hastening or postponing death. This is provided in collaboration with a multidisciplinary team that includes support 24 hours a day, 7 days a week onsite professional staff including RNs, RPNs, PSWs, social workers and volunteers where family and friends are welcome. Medical Assistance in Dying is not provided on Bethell Hospice premises.

Consent for Service *

Consent for Service

I, or my substitute decision maker (SDM), consent to receive services from Bethell Hospice. I understand that I may withdraw this consent at any time by verbal notification, which will result in discontinuation of hospice services.

Release of Information *

Release of Information

• I give consent for my personal and medical information to be shared with Bethell Hospice Residential Program and with Bethell Hospice Community services.
• For the purposes of ensuring continuity of care, I authorize Bethell House/Hospice to receive and to share my personal health information with all healthcare partners within my circle of care.
• I understand that if at any time I no longer wish my personal or medical information to be shared with others, as stated above, then I must notify Bethell Hospice in writing of my request.

Persons Served RIGHTS AND RESPONSIBILITIES *

Persons Served RIGHTS AND RESPONSIBILITIES

I acknowledge that I have been informed of my rights and responsibilities as a Bethell Hospice client. A copy of the Bethell Hospice policy Rights of Person Served has been given to me.

PRIVACY and Confidentiality *

PRIVACY and Confidentiality

• I understand that all personal information will be treated as private and confidential as per the Personal Health Information Protection Act, 2004.
• I understand that information sharing between Bethell Hospice personnel shall be for the sole purpose of providing quality service to meet my needs and those of my family. I understand that all personal information will be treated as private and confidential. Safety supersedes confidentiality when persons are at risk.
• I acknowledge that during my stay at Bethell Hospice that I may become aware of some of the private information of other residents. No one including other residents or families may share confidential information that they have become aware of. The staff and volunteers sign confidentiality agreements.

VOLUNTEERS *

VOLUNTEERS

I understand that volunteers are part of the Bethell Hospice team who are trained to work for specific areas with the hospice and contribute to your experience while you are at Bethell Hospice. These include in the areas of residential support, reception, kitchen, facilities and gardens.

WAIVER *

WAIVER

• I understand and accept the conditions noted above. I agree to release and indemnify Bethell Hospice or any directors, officers, volunteers, agents and employees from all claims and liability for any of the following:
1. Personal injury, illness, incapacity, or death that occurs, or
2. The loss of money, valuables and personal effects unless held in safe keeping by the Hospice
3. Loss of property or damage (unless intentionally committed)
4. Any care provided to me other than by the employees and agents of the Hospice
• I agree to release Bethell Hospice along with its directors, officers, volunteers, agents and employees of all actions, claims or demands of any nature or kind arising out of, or in any way connected with the provision of services by Bethell Hospice except if claims arise from intentional or deliberately harmful or criminal actions.

ARRANGEMENTS PRIOR TO ADMISSION *

ARRANGEMENTS PRIOR TO ADMISSION

Do Not Resuscitate (DNR), Substitute Decision Maker and funeral arrangements have been established prior to admission.

TREATMENT *

TREATMENT

• Curative or invasive medical treatments including but not limited to Intravenous (IV) Therapy, Diagnostic Imaging, bloodwork, chemotherapy are not part the Palliative/End of Life care provided at Bethell Hospice.
• A physician will be available to support my ongoing care during my admission to and stay at Bethell Hospice.
• Medications will be dispensed by Shoppers Drug Mart (11965 Hurontario St., Brampton) and/or Calea Pharmacy (Mississauga). Ontario Drug Benefit coverage will be provided by the Central West Local Health Integration Network (CW LHIN).
• At times, bed rails may be necessary to ensure resident safety. Bed rails may be used to prevent residents from falling out of bed, repositioning and increasing a sense of security and comfort. The resident or SDM may or may not consent to the use of bed rails, however, do so at their own risk. Each bed has a bed alarm for further safety.
• I understand that as part of my care at Bethell Hospice, that regular assessments will be made. If my condition improves or stabilizes to the point where I no longer require the environment of the residential program at Bethell Hospice, a meeting will be arranged to discuss discharge to an alternate location (for example: home, long term care) that I can be cared for comfortably. I acknowledge that this agreement does not fall under the Residential Tenancies Act, Ontario 2006, rather than my access is based on my end of life needs.

NUTRITION/INTAKE *

NUTRITION/INTAKE

Staff and volunteers assist residents with an offering of light food available any time during their stay. Food specific for resident needs can be brought in by family/friends. Prepared foods can be brought in, stored in resident’s room mini fridge and can be heated by staff and volunteers. Food intake decreases significantly at end of life and often switches to food consistency, thickeners and no eating or drinking will occur eventually. Mouth care will continue. Safety is of utmost importance, thus, staff will monitor appetite and safe swallowing throughout the resident’s stay.

BEHAVIOUR *

BEHAVIOUR

Bethell Hospice endeavors to provide a safe and respectful environment. Deliberate aggressive and/or threatening behaviour (physical, emotional, psychological, sexual) is not tolerated towards staff and volunteers of Bethell Hospice, nor other residents, families and friends. If this occurs, a warning will be issued, police may be called and/or the individual involved may be banned from Bethell Hospice property.

VISITORS/PETS: *

VISITORS/PETS:

• Visitors are allowed 24 hours a day 7 days. Visitors are required to sign in on arrival and are encouraged not to visit if they are sick or feeling unwell. Visitors may be limited, required to wear protective equipment (face masks, gloves and so on) or sign agreements during specific circumstances (outbreak/pandemic, and so on).
• Pets are allowed and must be kept under control in the resident’s room at all times for short visits. It is expected that the visiting animal(s) has up to date vaccinations, have had flea/tick treatments and a copy is to be provided for the resident chart. Pet visits may be stopped under certain circumstances (ie: during outbreak/pandemic).

FEES FOR SERVICE *

FEES FOR SERVICE

I understand that the services of the residential and community programs are provided at no cost thanks to the generosity of donors, community partners and government funding. Some medications may incur a cost and this will be reviewed prior to admission or at the time they are ordered by a doctor. Financial donations, in-memoriam donations and bequests are gratefully accepted. To discuss donation opportunities, please contact the Foundation office at foundation@bethellhospice.org.

Bethell Hospice Foundation

Bethell Hospice programs and services are provided free of charge due in part from the generosity of donations to Bethell Hospice Foundation. Contact information for clients and their emergency contact/substitute decision maker is shared with Bethell Hospice Foundation for the purpose of receiving updates and news.

I do not wish my information to be shared with Bethell Hospice Foundation and would like someone to contact me to discuss.

In addition to my emergency contact/substitute decision maker, please notify the following person of any gifts made in my honour or memory:

PREFERRED PRONOUN:

Other

First Name

Last Name

Street Address

PO Box

City

Province

Postal Code

Primary Phone

Secondary Phone

Email

AODA Statement *

AODA Statement

Bethell Hospice is committed to providing an accessible experience in which all individuals have equal access to our services and facilities as required by the Accessibility for Ontarians with Disabilities Act, 2005.

I agree to all provisions of this agreement and understand their meaning. *

CLIENT OR

SUBSTITUTE DECISION MAKER

PRINT Name *

Dated *

SECONDARY SUBSTITUTE DECISION MAKER

Print Name

Dated

Comments

Please forward a copy of this completed form to the following email address for my records: *

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication.

For more information, please refer to our Bethell Hospice Privacy Statement.

Residential Admission Agreement – Consent for Service

Upcoming Programs & Events

Coping with Grief During the Holidays

The Art of Moving Through Grief

Thanks to our Funders