Patient identifier/label
Name of proposed procedure or
course of treatment (include
brief explanation if medical term not clear)
Endovenous Laser
Ablation (EVLA) of the varicose veins leg(s)
Statement
of health professional (to be filled in by health professional with
appropriate knowledge of proposed procedure, as specified in consent policy)
I have explained the
procedure to the patient. In particular, I have explained:
The intended benefits …To treat the long saphenous vein in the thigh and therefore
remove the symptoms it causes.
Serious
or frequently occurring risks:.
Infection, bleeding, numbness of an area of skin, discolouration or burns to
the skin, failure of treatment to work, recurrence of the veins (25% chance at
5 years) and need for further treatment including avulsions or sclerotherapy
(50% chance).
Any extra procedures which
may become necessary during the procedure
ÿ blood
transfusion…………None……………..…….……………………………………….
ÿ other procedure (please specify)
………………………………...……...…………….…..…….
…………………………………………………………………………...………………….…..…….
I have also discussed what the
procedure is likely to involve, the benefits and risks of any available
alternative treatments (including no treatment) and any particular concerns of
this patient.
ÿ The following leaflet/tape has been provided Website information from www.bdb.org.uk
This procedure will involve:
Signed:…….…………………………………… Date .. …………………….……….
Name (PRINT) Mr BD Braithwaite Job
title Consultant Vascular Surgeon
Contact details (if patient wishes to discuss options later) Mr Braithwaite
07967636769
Statement of interpreter (where appropriate)
I have interpreted the
information above to the patient to the best of my ability and in a way in
which I believe s/he can understand.
Signed ………………………….……………………. Date ………………..…………….
Name (PRINT)
…………………..………………………………………………………………
Top copy accepted by patient: yes/no
(please ring)
Statement of patient Patient
identifier/label
Please read this form carefully.
If your treatment has been planned in advance, you should already have your own
copy of page 2 which describes the benefits and risks of the proposed
treatment. If not, you will be offered a copy now. If you have any further
questions, do ask – we are here to help you. You have the right to
change your mind at any time, including after you have signed this form.
Consent form for EVLA Page 2
I agree to
the procedure or course of treatment described on this form.
I understand that you cannot give me a guarantee that a particular
person will perform the procedure. The person will, however, have appropriate
experience.
I have been told about additional procedures which may become
necessary during my treatment. I have listed below any procedures which I do
not wish to be carried out without further discussion. …………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Patient’s signature
………………………………………….. Date…………………………..
Name (PRINT)
………………………………………………………………………………………
A witness should sign below
if the patient is unable to sign but has indicated his or her consent. Young
people/children may also like a parent to sign here (see notes).
Signature …………………………………………… Date ……………………..….………
Name (PRINT)
………………………………………………………………………………….…
Confirmation
of consent (to be completed by a
health professional when the patient is admitted for the procedure, if the
patient has signed the form in advance)
On behalf of the team
treating the patient, I have confirmed with the patient that s/he has no further
questions and wishes the procedure to go ahead.
Signed:…….…………………………………… Date .. …………………….……….
Name (PRINT) Mr BD Braithwaite Job
title Consultant Vascular Surgeon
Important notes: (tick if
applicable)
ÿ See also
advance directive/living will (eg Jehovah’s Witness form)
ÿ Patient has
withdrawn consent (ask patient to sign /date here) ……………...……….
Guidance to health professionals (to be read in conjunction with consent policy)
What a consent form is for
This form documents the patient’s agreement to go
ahead with the investigation or treatment you have proposed. It is not a legal
waiver – if patients, for example, do not receive enough information on which
to base their decision, then the consent may not be valid, even though the form
has been signed. Patients are also entitled to change their mind after signing
the form, if they retain capacity to do so. The form should act as an aide-memoire
to health professionals and patients, by providing a check-list of the kind of
information patients should be offered, and by enabling the patient to have a
written record of the main points discussed. In no way, however, should the
written information provided for the patient be regarded as a substitute for
face-to-face discussions with the patient.
The law on consent
See the Department of Health’s Reference guide to
consent for examination or treatment for a comprehensive summary of the law
on consent (also available at www.doh.gov.uk/consent).
Who can give consent
Everyone aged 16 or more is presumed to be competent
to give consent for themselves, unless the opposite is demonstrated. If a child
under the age of 16 has “sufficient understanding and intelligence to enable
him or her to understand fully what is proposed”, then he or she will be
competent to give consent for himself or herself. Young people aged 16 and 17,
and legally ‘competent’ younger children, may therefore sign this form for
themselves, but may like a parent to countersign as well. If the child is not
able to give consent for himself or herself, some-one with parental
responsibility may do so on their behalf and a separate form is available for
this purpose. Even where a child is able to give consent for himself or
herself, you should always involve those with parental responsibility in the
child’s care, unless the child specifically asks you not to do so. If a patient is mentally competent to give
consent but is physically unable to sign a form, you should complete this form
as usual, and ask an independent witness to confirm that the patient has given
consent orally or non-verbally.
When NOT to use this form
If the
patient is 18 or over and is not legally competent to give consent, you should
use form 4 (form for adults who are unable to consent to investigation or
treatment) instead of this form. A patient will not be legally competent to
give consent if:
·
they are unable to comprehend and retain information
material to the decision and/or
·
they are unable to weigh and use this information in
coming to a decision.
You
should always take all reasonable steps (for example involving more specialist
colleagues) to support a patient in making their own decision, before
concluding that they are unable to do so.
Relatives
cannot be asked to sign this form on behalf of an adult who is not
legally competent to consent for himself or herself.
Information
Information about what the treatment will involve, its
benefits and risks (including side-effects and complications) and the
alternatives to the particular procedure proposed, is crucial for patients when
making up their minds. The courts have stated that patients should be told
about ‘significant risks which would affect the judgement of a reasonable
patient’. ‘Significant’ has not been legally defined, but the GMC requires
doctors to tell patients about ‘serious or frequently occurring’ risks. In
addition if patients make clear they have particular concerns about certain
kinds of risk, you should make sure they are informed about these risks, even
if they are very small or rare. You should always answer questions honestly.
Sometimes, patients may make it clear that they do not want to have any
information about the options, but want you to decide on their behalf. In such
circumstances, you should do your best to ensure that the patient receives at
least very basic information about what is proposed. Where information is
refused, you should document this on page 2 of the form or in the patient’s
notes.
