Friday, July 1, 2011

Consent form for Adenoidectomy


CONSENT INFORMATION – PATIENT COPY

ADENOIDECTOMY

PLEASE READ THIS SHEET BEFORE YOU CONSENT FOR YOUR PROCEDURE

This information sheet provides general information to a person having an Adenoidectomy. It does not provide advice to the individual. It is important that the content is discussed between the patient and the concerned doctors who understand the level of fitness and medical condition.


What are the “adenoids”?
Adenoids are small lumps of tissue in the back of the throat that help fight ear, nose and throat infections in younger children. It's thought that after age three they are no longer needed. Adenoids usually reach their maximum size when your child is between three to five-years-old, and then begin to shrink by age seven and can hardly be seen by the late teens.


What is Adenoidectomy?
Adenoidectomy is the surgical removal of the adenoids.

 Why have an adenoidectomy?
When children have a cold or a throat infection the adenoids can become infected and swell up. They can block the nose and make it difficult for your child to breathe, especially when asleep. This can cause sleep problems, such as sleep apnoea or snoring.
Swollen adenoids can also block the Eustachian tube, which is a tube that connects the back of the throat to the middle part of the ear. Blockage of the Eustachian tube can lead to ear infections and a build-up of sticky fluid in the ear - called glue ear. This can make it difficult for your child to hear properly and, as a result, can cause learning problems. Adenoidectomy along with a tube in your child's ear (grommets) is effective in the treatment of glue ear.
Swollen adenoids are often associated with tonsillitis (infected tonsils) and may be removed as part of an operation to remove the tonsils. When both the adenoids and tonsils are taken out the procedure is called an adenotonsillectomy.

How is the diagnosis made?
Your doctor may examine the adenoids by looking in the back of your child's mouth using a light and mirror or a flexible telescope. X-ray images can also show enlarged adenoids.
What are the alternatives to surgery?
The adenoids will shrink as your child gets older, so an operation may not be necessary. An adenoidectomy removes the cause so the symptoms are relieved sooner than the child growing out of the problem. Antibiotics only provide temporary relief and are not used for long-term treatment.
How do I prepare for my child's operation?
An adenoidectomy is usually done as a day-case, but sometimes your child may be kept overnight in hospital. If your child has a cold or infection in the week before the operation, please let the hospital know. The operation may need to be postponed until your child has fully recovered.
The operation is always done under general anesthesia. This means your child will be asleep during the procedure and will feel no pain. Typically, your child must not eat or drink for about six hours before a general anesthetic. Often the operation will be planned for the morning, so that your child will only have to miss breakfast.
When you and your child arrive at the hospital, a nurse will ask you questions about your child's general health. The nurse will also check that your child has not had anything to eat or drink and measure your child's heart rate and blood pressure. You must tell the nurse if your child has ever had any allergic or unusual reactions to medicines in the past.
The doctor will usually visit your child before the operation. Please tell the doctor if your child has any loose teeth or any history of bleeding problems in the family.
If you have parental responsibility for the child, you will be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.
What happens during the procedure?
The operation takes around 15 to 30 minutes.
Once the anesthetic has taken effect, the doctor will use special instruments to remove the adenoids from the back of the throat via the mouth.
To stop the blood vessels in and near the adenoids from bleeding, a pack made up of gauze is applied with pressure by the doctor to the area where the adenoids are removed. When the bleeding stops the pack is removed and the operation is finished. Your child will be woken up from the anesthetic once the bleeding has stopped.
 What happens after the operation?
Your child will be monitored for a short while and will need to rest on their side until the effects of the anesthetic agent have passed. Your child will be groggy, and may feel or be sick.
Your child may complain of a sore throat, and pain in their nose and ears. The doctor will usually prescribe painkillers for a day or two, and may send your child home with a week's course of antibiotics. Before you take your child home, you will be given an appointment for a follow-up visit.
Recovering after an adenoidectomy
Once home, follow the doctor's advice about pain relief. You can usually give your child over-the-counter painkillers such as paracetamol or ibuprofen syrup.
It may be difficult, but your child must drink plenty of fluids so that they do not become dehydrated. Also get your child to eat. It's best to start with soft or liquid foods which are easier to swallow. Giving your child a dose of pain relief half an hour before meals may help make eating more comfortable. Encourage your child to brush their teeth thoroughly, as usual.
Your child should rest for a few days and stay at home to avoid contact with possible infections at school. Also keep your child away from crowded and smoky places, and from people with coughs and colds. Complete recovery takes about one week.
A small nosebleed is common after surgery. However sniffing or sneezing shouldn't cause any bleeding. Call your doctor if you have any concerns or if your child has any sign of bleeding in the nose or throat, develops a high temperature or complains of worsening pain.
Prognosis:
Most children have less trouble breathing through the nose and fewer and milder sore throats and ear infections after adenoidectomy. In rare cases, adenoid tissue that has been removed may grow back, but this usually does not cause a problem.
General Risks of having the procedure:
These have been mentioned in the “Anesthesia Consent Form.” Please discuss this with your Anesthetist before signing the Anesthesia Consent Form.
What are the risks of the procedure?
While majority of patients have an uneventful procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:
There are some risks/ complications, which include:
(a) Bleeding. This may happen either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require re-admission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
(b) Injury to the teeth, lips, gums or tongue
(c) Adenoids may grow back.
(d) Infection. Persistent bad breath or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above
(e) Permanent damage to the tube that connects the middle ear to the back of the throat. This can cause pain, loss of hearing and dizziness.
(f) Incompetence of the palate. Nasal speech and leakage of food or fluids through the nose may occasionally occur in the early post-operative period. This usually gets better but rarely it may not, and further surgery or speech therapy may be needed.


Consent Acknowledgement:
* The doctor has explained my medical condition and the proposed surgical 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 prognosis and the risks of not having the procedure.
* I have been given an Anesthesia Informed Consent Form.
* I have been given a Patient Information Sheet about the Condition, the Procedure, and associated 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 / blood product transfusion.
* 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 as appropriate.
* It has been explained to me, that during the course of or subsequent to the Operation/Procedure, unforeseen conditions may be revealed or encountered which may necessitate urgent surgical or other procedures in addition to or different from those contemplated. In such exigency, I further request and authorize the above named Physician / Surgeon or his designee to perform such additional surgical or other procedures as he or they consider necessary or desirable.
On the basis of the above statements,
I REQUEST TO HAVE THE PROCEDURE.
Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………….
Signature………………………………………
Date………………………………………………
Name of the Witness…………………………
Relationship/Designation………………………
Signature………………………………………..
Date……………………………






















INFORMED CONSENT: ADENOIDECTOMY


Patient Identification Label to be affixed here








A. INTERPRETER
An interpreter service is required.Yes______________No_______________
If Yes, is a qualified interpreter 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)
_______________________________________________and I have been advised to undergo the following treatment/procedure____________________________________________________________________________________________________________________________________________________________
See patient information sheet- "Adenoidectomy” for more
C.ANAESTHETIC
Please see your “Anesthesia Consent Form”. This gives you information of the General Risks of Surgery. If you have any concern, talk these over with your anesthetist.

D.RISKS OF THIS PROCEDURE
While majority of patients have an uneventful surgery/procedure and recovery, few cases may be associated with complications. These are seen infrequently and not all the ones listed below are applicable to one individual. However it is important that you are aware of the complications/risks that may arise out of this procedure which are as below:

There are some risks/ complications, which include:
(a) Bleeding. This may happen either at the time of surgery or in the first 2 weeks after surgery. Delayed bleeding may require re-admission to hospital and may require another operation to stop the bleeding. A blood transfusion may be necessary depending on the amount of blood lost.
(b) Injury to the teeth, lips, gums or tongue
(c) Adenoids may grow back.
(d) Infection. Persistent bad breath or delayed bleeding may indicate an infection. This is usually treated with antibiotics. Delayed bleeding is treated as outlined above
(e) Permanent damage to the tube that connects the middle ear to the back of the throat. This can cause pain, loss of hearing and dizziness.
(f) Incompetence of the palate. Nasal speech and leakage of food or fluids through the nose may occasionally occur in the early post-operative period. This usually gets better and rarely they may not, and further surgery or speech therapy may be needed.

SIGNIFICANT RISKS AND RELEVANT TREATMENT OPTIONS:F. SIGNIFICANT RISKS AND
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. )

PATIENT CONSENT: 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 Anesthesia.
* I have been given the patient information sheet regarding the condition, procedure, risks and other associated information.
* 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 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 maybe 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 above statements,
I hereby authorize Dr……………………………………………………………………and those he may designate as associates or assistants to perform upon me the following medical treatment, surgical operation and / or diagnostic / therapeutic procedure…………………………………………………………..

I REQUEST TO HAVE THE PROCEDURE

Name of Patient/Substitute Decision Maker…………………………………………….
Relationship …………………………………………………………………………………….
Signature……………………………………………Date……………………………………….

Name of the Witness…………………………………………………………………………
Relationship/Designation………………………………………………………………………
Signature……………………………………………Date………………………………………
FERENCES
INTERPRETER’S STATEMENT:
I have given a translation in……………………………………………………………………
Name of interpreter…………………………………………………………………………….
Signature……………………………………………Date………………………………………

DOCTOR’S STATEMENTS
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/ Guardian 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.

Name of doctor…………………………………………………………………………..
Designation………………………………………………………………………………
Signature………………………………………Date……………………………………





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