Download Consent Form

Consent refers to the provision of approval or assent, particularly and especially after thoughtful consideration. Proper consent from patient is essential draw in this era of Minimal Access Surgery and Medicolegal hostile behaviour of new generation of 21st century. At World Laparoscopy Hospital we have developed a proper Form to take the consent from patient who want to underwent laparoscopic surgery. This is very useful to mention all the points written below on a consent form for laparoscopic surgery.

1st Step of consent taking is:

A. INTERPRETER NEEDS :

First step is an interpreter is necessary if the patient does not understand the prescription language and consent Form.

• An Interpreter Service is required yes no
• If yes, is a qualified Interpreter present yes no
• A Cultural Support Person is required yes no
• If yes, is a Cultural Support Person present yes no

B. CONDITION AND PROCEDURE

The doctor has explained that I have the following condition: (Doctor to document in patient’s own words)

The following procedure will be performed:

__________________________Name of Surgery???____________________________

An inspection of the abdominal cavity laparoscopically i.e. with the help of a video camera through tubes in four very small cuts in the abdomen. Four tubes will be put through these cuts to pass the camera and instruments through. The doctor will fill the abdominal area with carbon dioxide gas to allow access for the operation. The doctor may need to remove the appendix or treat other problems in the abdominal cavity.

C. GENERAL RISKS OF A PROCEDURE

They include:

1. Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
2. Clots in the legs (deep vein thrombosis) with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
3. A heart attack, due to strain on the heart or a stroke.
4. Death is possible due to the procedure.

D. RISKS OF THIS PROCEDURE

There are some risks and complications, which include:

• Damage to large blood vessels causing bleeding which could require an emergency blood transfusion and abdominal surgery. (1 in 1000 people).
• Damage to gut and/or bladder when the instruments are inserted. This usually needs corrective surgery.
• Rarely, gas fed into the abdominal cavity can cause heart and breathing problems.
• The television method may not work (1 in 10 people) and the surgeon may need to do open surgery, which will require a larger cut in the abdomen.
• Deep bleeding in the abdominal cavity could occur and this may need fluid replacement or further surgery.
• Infections such as pus collections can occur in the abdominal cavity. This may need surgical drainage.
• Infection in the wound causing redness, pain and possible discharge or abscess. (1 in 20 people). This may need antibiotics.
• Possible bleeding into the wound with swelling and bruising and possible blood stained discharge.
• The wound may not heal normally. The wound can thicken and turn red. The scar may be painful.
• A weakness can happen in the wound with the development of a hernia (rupture). Further surgery may be needed to correct this.
• Symptoms experienced before surgery may persist after the surgery.
• Adhesions (bands of scar tissue) may form and cause bowel obstruction. This can be a short term or a long term complication and may need further surgery.
• Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
• Increased risk in smokers of wound and chest infections, heart and lung complications and thrombosis.

E. SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS

The doctor has explained any significant risks and problems specific to me, and the likely outcomes if complications occur. The doctor has also explained relevant treatment options as well as the risks of not having the procedure. (Doctor to document in Medical Record if necessary. Cross out if not applicable).

F. DOCTOR'S STATEMENT

I have explained

- The patient’s condition
- Need for treatment
- The procedure and the risks
- Relevant treatment options and their risks
- Likely consequences if those risks occur
- The significant risks and problems specific to this patient.

I have given the patient/ substitute decisionmaker an opportunity to

- Ask questions about any of the above matters
- Raise any other concerns which I have answered as fully as possible.

I am of the opinion that the patient/ substitute decision-maker understood the above information.

G. PATIENT CONSENT

I acknowledge that:

The doctor has explained my medical condition and the proposed procedure. I understand the risks of the procedure, including the risks that are specific to me, and the likely outcomes. The doctor has explained other relevant treatment options and their associated risks. The doctor has explained my prognosis and the risks of not having the procedure. I have been given a Patient Information Sheet on Anaesthesia. I have been given a Patient Information Sheet about the procedure and its risks. I was able to ask questions and raise concerns with the doctor about my condition, the procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I understand that the procedure may include a blood transfusion. I understand that a doctor other than the Consultant Surgeon may conduct the procedure. I understand this could be a doctor undergoing further training. I understand that if organs or tissues are removed during the surgery, that these may be retained for tests for a period of time and then disposed of sensitively by the hospital. The doctor has explained to me that if immediate life-threatening events happen during the procedure, they will be treated accordingly. I understand that photographs or video footage may be taken during my operation. These may then be used for teaching health professionals. (You will not be identified in any photo or video). I understand that no guarantee has been made that the procedure will improve the condition, and that the procedure may make my condition worse.

On the basis of the previous statements,

I REQUEST TO HAVE THE PROCEDURE.