Page 35 - TERMINAL DISCHARGE GUIDELINE FIRST EDITION 2023

Chapter 7
Terminal Discharge Pathway

7.2 Terminal Discharge Consent

Terminal Discharge Consent – Patient

Hospital Kuala Lumpur
Consent For Terminal Discharge

I, (Name), ____________________ (NRIC/ID)
of (Address)
hereby agree and consent to undergo Terminal Discharge which includes telemedicine for
follow up.
I fully understand the purpose of Terminal Discharge is to bring me home and I am deemed
to be dying. The processes and consequences of Terminal Discharge has been explained
to me by Dr. _________________________________ (Staff’s name) through
interpretation by (if any) (Name).
• I understand that my caregiver or myself can contact Hospital Kuala Lumpur at
_________________________ (Tel) if we have any queries.
• I understand that I can come back anytime to Hospital Kuala Lumpur via Emergency
Department.

Patient Witness (Staff) Interpreter (If any)
Signature Signature Signature
____________________ ____________________ ____________________
Name Name Name
____________________ ____________________ ____________________
NRIC / ID NRIC / ID NRIC / ID
____________________ ____________________ ____________________
Date Date Language Used
____________________ ____________________ ____________________
Date
____________________

Medical Practitioner: I confirm I have explained the purpose, process and details
including the Terminal Discharge Checklist.

Signature : ____________________
Name : ____________________
MMC No. : ____________________
Date : ____________________

HOSPITAL KUALA LUMPUR 35
TERMINAL DISCHARGE GUIDELINE 2023