ECHO Case Discussion Form
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Email *
Presenter Name:
First & Last
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Location / City Presenting From:

Does the patient and/or family know that they are being presented in an ECHO session?:

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Is this patient connected to, or are you considering sending this patient to a palliative care specialist (MD/NP)?:
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What are you hoping to learn or get help with in presenting this case to the group?:

What are your Patient’s Expressed Goals of Care?:
Would you be surprised if this patient were to die in the next year?:
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What is the patient’s current PPS (Palliative Performance Scale) Score, if known?:
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