11 .au (Affix identification label here) URN: Family name: Right Heart Catheter (Internal Given name(s): Jugular Vein Approach) Address: Date of birth: Sex: M F I Facility: A. Interpreter / cultural needs • Abnormal heart rhythm that continues for a long time. This may need an electric shock to correct. An Interpreter Service is required? Yes No • The carotid artery (in the neck) is accidentally If Yes, is a qualified Interpreter present? Yes No punctured. This may require surgery to repair. © The State of Queensland (Queensland Health), 20 A Cultural Support Person is required? Yes No Rare risks and complications (less than 1%) If Yes, is a Cultural Support Person present? Yes No include: • Infection. This will need antibiotics. B. Condition and treatment • Allergic reaction to the local anaesthetic. This The doctor has explained that you have the following may require medication to treat. Permission to reproduce should be sought from [email protected] condition: (Doctor to document in patient’s own words) • Blood clot in the neck vein. This may need medication to treat. .................................................................................................................................................................... • Embolism. A blood clot may form and break off .................................................................................................................................................................... from the catheter. This is treated with blood This condition requires the following procedure. thinning medication. • (Doctor to document - include site and/or side where Air in the lung cavity. A chest tube may need to relevant to the procedure) be put in to the chest to drain the air. • Damage to the vein in the neck causing bleeding. .................................................................................................................................................................... This may need surgery to repair. The following will be performed: • Air embolism. Oxygen may be given. The vein in your neck is found with ultrasound. • A hole is accidentally made in the heart or the You will be given an injection of local anaesthetic. A heart valve. This will need surgery to repair. fine tube (catheter) is put into the vein in the neck. You may feel pressure on your neck while the tube is • Unable to position the balloon catheter into the lung vessels or around the heart. The procedure placed in the vein. It is passed down until it reach es F CONSENT PROCEDURAL would be cancelled if this occurred. This is more E IN THIS BINDING MARGIN the heart and then goes up into the blood vessels of the lungs. This is usually painless. The doctor uses x- common if there are congenital malformations of ray imaging to see the catheter. the heart. Pressures in the lungs and the heart are recorded. A • Damage to the lung blood vessel causing sample of blood is taken to look at the oxygen level bleeding. This may need surgery to repair. • DO NOT WRITDO and other levels. A stroke. This may cause long term disability. At the end of the procedure, the catheter and sheath • Death as a result of this procedure is extremely are removed. rare. C. Risks of a right heart catheter (internal D. Significant risks and procedure options jugular vein approach) (Doctor to document in space provided. Continue in In recommending this procedure your doctor has Medical Record if necessary.) balanced the benefits and risks of the procedure against the benefits and risks of not proceeding. Your .................................................................................................................................................................... doctor believes there is a net benefit to you going .................................................................................................................................................................... ORM ahead. This is a very complicated assessment. /2011 2 0 There are risks and complications with this procedure. E. Risks of not having this procedure – They include but are not limited to the following. (Doctor to document in space provided. Continue in v5.00 Common risks and complications (more than 5%) Medical Record if necessary.) include: .................................................................................................................................................................... • Minor bleeding and bruising at the puncture site. • Abnormal heartbeat lasting several seconds, .................................................................................................................................................................... which settles by itself. Uncommon risks and complications (1- 5%) F. Anaesthetic include: This procedure may require an anaesthetic. (Doctor to • Unable to get the catheter into the neck vein. The document type of anaesthetic discussed) procedure may be changed to a different approach eg an arm or a leg vein. .................................................................................................................................................................... Page 1 of 2 Continues over page ►►► (Affix identification label here) URN: Family name: Right Heart Catheter (Internal Given name(s): Jugular Vein Approach) Address: Date of birth: Sex: M F I Facility: G. Patient consent I request to have the procedure I acknowledge that the doctor has explained; Name of Patient: .................................................................................................................... • my medical condition and the proposed Signature:..................................................................................................................................... procedure, including additional treatment if the Date: ................................................................................................................................................ doctor finds something unexpected. I understand the risks, including the risks that are specific to Patients who lack capacity to provide consent me. Consent must be obtained from a substitute decision maker/s in the order below. • the anaesthetic required for this procedure. I understand the risks, including the risks that are Does the patient have an Advance Health Directive (AHD)? specific to me. • other relevant procedure/treatment options and Yes Location of the original or certified copy of the AHD: their associated risks. ........................................................................................................................................................ • my prognosis and the risks of not having the procedure. No Name of Substitute Decision Maker/s: .......................................................................................................... • that no guarantee has been made that the NOT WRITEDO IN THIS BINDING MARGIN procedure will improve my condition even though Signature: ............................................................................................................................... it has been carried out with due professional care. Relationship to patient: ............................................................................................ • the procedure may include a blood transfusion. Date: .................................................... PH No: ............................................................... • tissues and blood may be removed and could be Source of decision making authority (tick one): used for diagnosis or management of my Tribunal-appointed Guardian condition, stored and disposed of sensitively by the hospital. Attorney/s for health matters under Enduring Power of Attorney or AHD • if immediate life-threatening events happen Statutory Health Attorney during the procedure, they will be treated based on my discussions with the doctor or my Acute If none of these, the Adult Guardian has provided Resuscitation Plan. consent. Ph 1300 QLD OAG (753 624) • a doctor other than the Consultant may conduct the procedure. I understand this could be a doctor H. Doctor/Delegate statement undergoing further training. I have explained to the patient all the above points I have been given the following Patient under the Patient Consent section (G) and I am of Information Sheet/s: the opinion that the patient/substitute decision- Local Anaesthetic and Sedation for Your maker has understood the information. Procedure Name of Doctor/delegate: ..................................................................................................................... Right Heart Catheter (Internal Jugular Vein Approach) Designation: ............................................................................................................................... • I was able to ask questions and raise concerns Signature:..................................................................................................................................... with the doctor about my condition, the proposed Date: ................................................................................................................................................. procedure and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction. I. Interpreter’s statement • I understand I have the right to change my mind I have given a sight translation in at any time, including after I have signed this form but, preferably