. is (CHINESE GENERAL HOSPITAL I and MEDICAL CENTER “ALLOW NATURAL DEATH” FORM Name of Patient: Date: (Pangalan ng Pasyente) Attending Physician: (Duktor) After thorough deliberation with patient's Attending Physician/s and the immediate members of the above-named patient's family, we agree to the following: (Please check appropriate box/es). (Matapos ang masusing pagninilay-nilay kasama ang Duktor na tumitingin at ang mga malalapit na kamag-anak ng pasyente, kami ay sumasang-ayon sa mga sumusunod: (Lagyan ng tsek ang nararapat na kahon). | 1 No Cardiopulmonary Resuscitation in case of cardio-respiratory arrest [1 No intubations in case of arrest [ 1 Continue all present medication including inotropics [ 1 Consume all inotropics [ ] Consume all present medications [ ] Discontinue all present medications [ 1 Discontinue inotropies [ 1 Discontinue mechanical ventilator (1 No defibrillation procedure [1 No more laboratory examinationiprocedure/CBG monitoring [ ] Others, please specify ‘The natural and possible consequences of this decision have been explained and understood. (Ang mga natural at posibleng kahihinatnan ng naturang desisyon ay nalpaliwanag at naunawaan.) Next of Kin/ Representative! Guardian Signature over Printed Name (Pangalan at Lagda ng Kapamilya/Kamag-anak/Tagapagbantay) In the presence of ) eine Re cl WITNESS (Sal WITNESS (Saks!)