CIMS. Heart Transplant Clinic A PATIENT GUIDE CIMS NABL. Certificate No. M-0500 NABL

Transcription

1 CIMS Heart Transpant Cinic CIMS NABL Certificate No. M-0500 NABL

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3 CIMS Heart Transpant Cinic IMPORTANT: Before You Arrive: Pease read everything in this booket - CAREFULLY - pease ca the office with any questions. You must have a support person with you for the evauation. If you use suppementa oxygen, you must inform your oxygen provider regarding your trave pans. Pease wear oose fitting cothes and comfortabe shoes. Pease contact the office at with any questions or concerns. 1

4 CIMS Heart Transpant Cinic NEW PATIENT BINDER CONTENTS This binder incudes the foowing sections that wi hep to guide you through your transpant journey. Wecome Letter Your Transpant Journey...Tab 1 Caregiver Expectations...Tab 2 Getting Ready for Your Transpant...Tab 3 Medicines and Aergies...Tab 5 Review of Systems and Conditions...Tab 6 Record Reease Forms...Tab 7 Your Transpant Team... Tab 8 Testing for Transpant Evauation...Tab 9 Patient First Aways 2

5 CIMS Heart Transpant Cinic Transpantation Services Cardiothoracic Transpant Dear Mr. / Ms. Wecome to CIMS Transpant Services. At CIMS, we are committed to the quaity of care and want you to have a positive experience. We have incuded a new patient binder compied especiay for you. In it you wi find: Your Transpant Journey (Itinerary) This is your persona road map of your visit as you navigate through CIMS for your transpant evauation. Caregiver Expectations Pease have your caregiver(s) review this section as they make the commitment to hep you during your transpant journey. Getting Ready for Your Transpant You wi find a consent form for transpant. Pease read it over, but do not sign it. Your doctor wi go over the content with you, give you an opportunity to ask questions and you wi sign it at the time of your evauation. Medicines and Aergies Kindy note down ist of your medicines, dosages, prescribing doctor(s), and for what reason you are taking each. Pease incude any over-the-counter medicines, dietary suppements, and herba suppements. *Pease fi competey and give it to your transpant coordinator during your evauation. The Transpant Team During your evauation, you wi meet with various members of the team who wi expain their roes in the transpant process. Diagnostic Testing for Transpant Evauation Incuded is a ist of tests that may be incuded as part of your evauation. If you have any questions, pease ca the Transpant OPD at Ext Sincerey, Cardiothoracic Transpant Team 3

6 CIMS Heart Transpant Cinic Persona Information: Name: Date of Birth: Pace of Birth: Address: City: State: Zip: How ong does it take you to get to CIMS Hospita? Do you drive? NO YES Does your Primary Caregiver drive? NO YES Phone Numbers: Home Ce Work Emai Address: Reigion: Education Competed (check highest eve): Schoo Graduate Post Graduate Other Occupation: Check the one that cosest appies to your situation: Job Business Unempoyed Disabed Retired Marita Status: Singe Married Widowed Separated Divorced With whom do you ive? List any specia needs: Visuay impaired Hearing impaired Reading Impaired Reationship: Physicay impaired Did anyone hep you to compete this paperwork? NO YES Who? Can you speak: Engish Hindi Gujrati Pease specify: Can you write: Engish Hindi Gujrati Pease specify: Do you have a Living Wi? NO YES In what kind of dweing do you ive? 1 Leve Home Muti Leve Home Apartment Number of stairs: Car to front door Front door to bathroom to bed room Do you have a fu bathroom accessibe on the first foor? NO YES Have you ever traveed outside the INDIA? NO YES Where/When: 4

7 CIMS Heart Transpant Cinic Providers: Famiy Doctor: Loca Cardioogist: Pharmacy: Loca Laboratory: Home Care Agency: Ambuance Service: Loca Hospita used for emergency: Equipment Suppier: Phone: Phone: Phone: Phone: Phone: Phone: Phone: Phone: Emergency Contact: Name: Address: Reation: Phone: Socia History: Have you ever smoked cigarettes? NO YES Date Quit: Packs per day: Have you ever used other tobacco products? NO YES Date Quit: Product: Have you ever used recreationa drugs? NO YES When did you ast use? / / Do you drink acoho? NO YES How many drinks per day? Do you have any pets? NO YES Type? What are your hobbies? Denta History: When was your ast denta exam? / / How often do you go? Every 6 mo. Every 12 mo. Do you wear dentures? NO YES Fu dentures Partia Pate 5

8 CIMS Heart Transpant Cinic Prosthetic and Access Devices: Do you currenty use any of the foowing: Eyegasses or contacts NO YES Specify: Impants NO YES Specify: Pacemaker/defibriator NO YES Brand and Seria #: Artificia imb NO YES Specify: Joint repacement NO YES Specify: Do you use: Waking Stick WALKER WHEELCHAIR Oxygen Use: Do you currenty use oxygen? Exercise: NO YES Liters: Rest: NO YES Liters: Seep: NO YES Liters: At a times: NO YES Liters: CPAP/BiPAP: NO YES Setting: Nutritiona Assessment: Do you foow a specia diet? NO YES Specify: Have you had a recent change in weight? NO YES Specify oss/gain (in pounds): Do you attend physica rehab or NO YES Where: other exercise program? Do you drink tea/coffee? NO YES How much per day? Do you drink sugar drinks/soda/pop? NO YES How much per day? Pain Assessment: Do you have pain? NO YES Location/Intensity: How do you manage your pain, if appicabe? Are you treated by an MD for pain? What doctor manages this pain? 6

9 CIMS Heart Transpant Cinic Heath Maintenance Assessment: Have you had a chest x-ray? NO YES Date/Location: Have you had a DEXA scan? NO YES Date/Location: Have you had a mammogram? NO YES Date/Location: Have you had a pap- smear? NO YES Date/Location: Have you had a coonoscopy? NO YES Date/Location: Were you ever vaccinated for? Fu / H1N1 NO YES Date: Chicken Pox NO YES Date: Mumps NO YES Date: Hepatitis A NO YES Date: Hepatitis B NO YES Date: Pneumonia NO YES Date: Meases NO YES Date: Shinges NO YES Date: Tetanus NO YES Date: Rubea NO YES Date: Other NO YES Date: Other: In the past (3) months, have you had physica difficuties affecting your iving activities? NO YES Pease describe what activities are imited: Death in the Famiy NO YES Job issues NO YES Financia Difficuties NO YES Famiy member with heath issues NO YES Other NO YES Pease describe: Have you ever had a bood transfusion? NO YES, If Yes Specify Date: Woud you accept bood products? NO YES 7

10 CIMS Heart Transpant Cinic Famiy History Famiy Member Present Age Age at Death Medica History Father Mother Brother Brother Brother Brother Sister Sister Sister Sister Spouse/Partner Son Son Son Son Daughter Daughter Daughter Daughter Paterna Grandfather Paterna Grandfather Materna Grandfather Materna Grandfather Other 8

11 CIMS Heart Transpant Cinic Transfer to Hospita Genera Checkup, Speciaized Checkup & Drug prescription Pre Surgery Care - Surgery - Post Surgery Care Way to your Sweet Home CAREGIVER EXPECTATIONS Pease have your caregiver(s) review this section as they make commitment to hep you through your transpant journey. 9

12 CIMS Heart Transpant Cinic CAREGIVER PLAN PLAN OVERVIEW This pan outines the foowing information: The roe of your caregiver. Famiy and friends who wi be invoved in caring for you after your transpant. Toos for organizing the caregivers when you are recovering. When an organ becomes avaiabe, you wi immediatey trave to Ahmedabad for your transpant. You wi stay in the hospita unti you sufficienty recover from your transpant surgery. When you eave the hospita, you may need to stay in. You have many options for odging near the CIMS campus. These options are outined in the provided attachments. The main goa of the pan is to have one of your caregivers be with you at a times, unti such time your transpant surgeon deems you abe to be on your own. Hopefuy, each caregiver wi be abe to stay for 5-7 days. It wi be hepfu for caregivers to overap for a portion of a day to reay information. THE CAREGIVER ROLE The primary caregiver wi accompany you for your evauation in Ahmedabad. Your Caregiver Team, however, can be many peope. Caregivers can be famiy members or friends. They do not have to be a nurse or medica professiona but someone who knows you and can hep you with such things as preparing meas, reminding you about taking medicines, doing aundry, and arranging transportation to cinic appointments. You initiay wi have weeky appointments. You aso need to have someone stay with you during your appointments. It is required that you have a caregiver stay with you after your transpant, foowing your discharge from the hospita. A caregiver is required to be with you 24 hours a day, 7 days a week. This coud be for period as short as 2 weeks, as ong as 6 weeks, or onger, depending on your recovery. You are not permitted to drive for 6 to 8 weeks after your transpant. The transpant surgeon wi et you know when you may begin driving again. Your Caregiver Team wi hep you with transportation unti that time. Many peope can share the roe of caregiver and take turns staying with you. It is important to understand that you shoud not be aone unti the transpant team determines it is safe for you to resume your independence. BEING A CAREGIVER The caregiver roe is not a "nursing" roe, but it is that of a nurturing famiy member or friend. Their caregiving wi incude: Heping you to get to and from the bathroom, if needed, after you eave the hospita after transpant surgery. Making sure you are taking medicines at the right time and in the right amounts. Making sure you are measuring and recording a of the information the transpant team has requested. Making sure you get to a of your schedued cinic appointments and/or testing. Noticing if you are behaving in an unusua or abnorma way. Contacting your nurse coordinator if anything seems wrong. Shopping for food and preparing meas in accordance with given dietary guideines. Running errands as needed (for exampe, fiing prescriptions), Providing support, encouragement, and entertainment. Heping to keep friends and famiy informed of your status according to your needs and wishes. Heping you to compy with a parts of your treatment pan. 10

13 CIMS Heart Transpant Cinic CAREGIVER CONTACT INFORMATION How wi your caregivers be contacted? How much time can they give? What is their roe in your ife? Do they need hep with expenses that buid up whie providing care? When you get the ca from CIMS that an organ is avaiabe and you are on the way to the hospita, pease et your caregivers know. NAME ROLE (FAMILY/ FRIEND) AVAILABILITY NEEDS HELP WITH EXPENSES PHONE#1 PHONE#2 PHONE#3 GETTING READY FOR YOUR TRANSPLANT Pease take some time and read your consent form for transpant. Do not sign the form unti you are with the doctor or transpant coordinator. Attached, pease find an informed consent providing you with information regarding your potentia transpant. We ask that you take the time to read this consent prior to your evauation and bring the consent aong with a ist of any questions you may have to your evauation appointment. At the time of your appointments your heath care team incuding a transpant surgeon wi review the consent with you and provide you the opportunity to answer any questions you may have. At the time of your appointment you and the physician wi review and sign the consent. Thank you 11

14 CIMS Heart Transpant Cinic I,, have been asked to carefuy read (name of patient or substitute decision-maker) a of the information contained in this consent form and to consent to the procedure described beow on behaf of. I have been tod that I shoud ask (name of patient) questions about anything that I do not understand. (If the decision-maker is not the patient, references to "I," "my" or "me" shoud be read as if referring to "the patient," when appicabe). I have indicated a desire to undergo a heart transpant. I understand that this procedure woud incude the impantation of a heart from a brain dead donor. I acknowedge that my physician(s) expained to me which type of heart I am ikey to receive. I understand that I am being given information about a heart transpant, its risks and aternatives to hep me make an informed decision whether to vountariy and freey undergo the procedure. The information in this consent form, in addition to discussions with my physicians and other heath care providers and any other written materia they may provide, is intended to give me the information I need to make my decision. By signing this consent form, I wi be acknowedging that I have read and understood a of the information given to me and that I vountariy choose to undergo a heart transpant. I know that I am free to change my mind and withdraw my consent at any time prior to the procedure. Evauation Process: I wi be evauated before surgery by the transpant team consisting of, but not imited to surgeons, medica speciaists, transpant coordinator, socia worker, financia coordinator, and dietician to hep determine if I can successfuy undergo a heart transpant and the urgency of my need for a transpant. As part of the presurgica evauation process, I wi need to be avaiabe and wiing to undergo any or a of the foowing tests and procedures and any other tests or procedures the physicians may beieve are necessary: HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Bood tests to hep determine the extent of my heart disease, and to determine my bood type for organ matching. My bood wi aso be tested for the presence of or immunity to specific viruses to determine the risk of certain inesses and the possibe need for treatment after transpantation. Ongoing drug and acoho testing may be performed in connection with both the medica and psychosocia components of the evauation process and post-transpant monitoring. Cardiac tests that may incude eectrocardiogram (EKG), echocardiogram, MUGA scan, stress tests and/or heart catheterization. My physicians wi review these test resuts to determine if the severity of my heart disease. (If I have a cardiac catheterization, the persons performing the procedure shoud give me more information about the procedure and its risks.) Metaboic Exercise Testing to measure the degree to which my heart imits my activities. This is one way to determine-if my heart is sick enough to consider being paced on the heart transpant ist. 12

15 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Pumonary Function tests (breathing tests) to hep anayze my ung function. Utrasound (pictures created by sound waves). To screen for diseases of my iver, pancreas and other abdomina organs. Periphera Arteria Doppers of my extremities (sound waves bounced off bood vesses to my extremities) this test heps to show if I have hardening of the arteries or bockages in the circuations to my arms and egs. Carotid Arteria Doppers (sound waves bounced off bood vesses in my neck) to check for any probems with the main bood suppy to my brain. CT Scan/MRI/Chest x-ray (compex x-rays that show detaied pictures of my organs) Hep to determine the presence of or extent of disease in other organs or bood vesses in my body and to hep surgeons pan for the surgery (If have CT Scan/MRI, the person(s) performing the CT Scan/MRI shoud give me more information about the scan and its risks.) Heart biopsy (remova of a tiny portion of my heart through a catheter and examination of this portion through a microscope) to hep determine the nature of my disease and its severity. (If I have a heart biopsy, I wi receive a separate expanation of the heart biopsy and its risks and be asked to sign a separate consent form.) Socia and/or Psychiatric Evauation (interview) to assist in determining my abiity to cope with the stress of transpantation and to foow a rigorous treatment pan. Other testing requested may incude; mammogram (specia x-ray to check for cancer of the breast), Pap smear (an examination of tissue from the cervix), PSA (bood test to check for cancer of the prostate), pregnancy test (for women of chid bearing age), coonoscopy and denta exam. I understand that as I progress through the pre-surgery evauation process, the doctors may decide at any time that I am not a heart transpant candidate. If the doctors decided that I am not a heart transpant candidate they wi notify me of their decision and other possibe treatment options wi be discussed. I know that if I am isted for heart transpant that I am free to change my mind and withdraw my consent at any time prior to the procedure. 13

16 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Listing: It has been expained to me that there are more peope waiting for heart transpants than there are avaiabe hearts. Factors that wi be considered if and when I receive a transpant incude my need for transpant, my bood type, body weight/height and the ength of time I have been on the waiting ist wi contribute to the possibiity of obtaining a donated heart. Need for transpant is determined by a Status based upon my test resuts with 4 possibe types: 1A top priority criticay i, requiring pacement of invasive monitoring, intravenous medications or a temporary support pump. Some patients may aso be this status if they have a mechanica assist device (heart pump). 1B require specia intravenous medications (inotropes) to hep the heart function adequatey whie waiting either in the hospita or at home or be supported without compications on a mechanica assist device (heart pump) 2 does not require specia intravenous medications to maintain adequate heart function usuay waiting at home 7 on the ist but not currenty in the active ist (infection, patient request, etc.) The rues for being isted and my position on the ist are determined by an Indian Govt Laws for HOTA/THOA. Upon competion of my evauation the mutidiscipinary team wi utiize the patient seection criteria and the resuts of my testing to determine my suitabiity for pacement on the waiting ist for transpantation. Competing the evauation process and being isted with NOTTO as a candidate for transpantation does not guarantee that I wi receive a transpant. I coud become inactive on the waiting ist if there is a significant change in my medica condition that may temporariy prevent me from receiving a transpant. I am aso aware that I coud become too i to undergo transpant or die of my disease before an organ is avaiabe. 14

17 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Confidentiaity: CIMS is required by aw to maintain the privacy/confidentiay of my heath information. A information that is obtained in connection with this procedure, which can be inked to me, wi remain as confidentia as possibe within the requirements of state and centra government aw. Records wi be kept regarding this procedure and wi be made avaiabe for required reviews/audits by representatives of reguarity agencies (HOTA, NOTTO and Department of Heath) and my insurance provider. Hospita personne who are invoved in the course of my care may review my medica records. NOTTO Registry: I understand that if I do become a transpant candidate, state and centra government reguations require that some persona heath information about me be sent to the NOTTO registry. Financia Issues: I have been advised that a financia counseor is avaiabe to tak to me about the costs associated with the surgery and the medications needed during and after surgery and to answer questions about sources of payment. I understand that I wi have to arrange for payment of the costs that may not be covered by insurance. I aso understand that I may not be abe to undergo a transpant if I have not made acceptabe financia arrangements for payment of costs when a suitabe heart becomes avaiabe. Risks Invoving Medica Costs and Insurance: I understand that after I have a heart transpant, heath insurance companies may consider me to have preexisting heart disease or other transpant reated medica probems and refuse to pay for medica care, treatment or procedures reated to those conditions. I aso understand that because of my condition, after the surgery, my heath insurance and ife insurance premiums coud be raised and remain higher and that in the future, insurance companies coud refuse to insure me. Source of Organ: I wi be paced on an organ waiting ist to receive a heart from the agency that coordinates the retrieva and distribution of organs for transpantation. Hearts are obtained from patients whose heart is sti beating, but the patient is determined to be brain dead. Government has estabished rues governing who can be isted as a prospective heart recipient and who wi receive organs as they become avaiabe. I understand that competing the evauation process and being isted for transpantation does not guarantee that I wi receive a transpant. 15

18 CIMS Heart Transpant Cinic Because there are more peope waiting for transpants than there are avaiabe donated organs, CIMS evauates a avaiabe donors for suitabiity for transpantation. I understand that there may be organ donor risk factors that affect the success of the transpanted organ or my overa heath. These may incude but are not imited to the donor s medica and socia history (high risk behaviors), oder aged donors, the presence of the human immunodeficiency virus (HIV) or other infectious diseases that may not be detected in an infected donor, as we as organs with a onger ength of time from donation to transpantation. There is a sma risk that a cancer in the donor is far too eary for diagnosis or was being adequatey prevented by the doctor. Such an occut cancer may be contained within the transpanted organ and be initiay unabe to detected. A surgeon wi discuss with me the particuar risk factors reated to my identified donor prior to transpantation. At that time I woud be abe to accept or decine the heart offer based upon the information presented to me. Surgery: HEART TRANSPLANT CONSENT FORM (ADULT) When a donor organ becomes avaiabe I wi be expected to come to the hospita as soon as possibe. I understand that I may be caed in for transpant and at any time the surgery can be canceed if the transpant team determines that the donor is not appropriate for me. At the time of surgery the surgica risks wi be reviewed with me and a separate consent for the procedure wi be obtained. The type of anesthesia and the risks of the anesthesia wi be expained to me by a representative of the anesthesia department and I wi be asked to sign a separate consent form. I wi be put under genera anesthesia, which means that I wi be given drugs to put me to seep, bock pain and parayze parts of my body. I wi aso be paced on a machine to hep me breathe. A catheter may be paced in my wrist to continuousy monitor my bood pressure. Intravenous ines may be paced in a arge vein in my neck, shouder, or groin (centra ines) for fuid administration. The surgeon(s) wi make an incision in my chest as arge as necessary to safey ocate and remove my organs and safey impant the donated organs. Through this incision my heart wi be removed and a donated heart wi be paced into my chest. Whie I am sti in the operating room, drains wi be put into my body to aow fuids to be removed and hep me to hea. These drains may remain after the surgery at the discretion of the surgeon. Specia massaging seeves wi be used to keep bood fowing through my egs to prevent dangerous bood cots. The entire operation shoud take approximatey six (6) to tweve (12) hours. Patient Name: Identification Number: 16

19 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Risks of Surgery: I understand that there are inherent risks in a surgeries, especiay surgeries conducted under genera anesthesia. The risk of having some type of compication (probem), minor or major, from heart transpant surgery is reativey common. Most compications are minor and get better on their own. In some cases, the compications are serious enough to require another surgery or medica procedure and there is the potentia for one or more compications to cause serious injury or death. Immediatey foowing the surgery, I wi experience pain. My pain wi be carefuy monitored and controed under the guidance of the transpant team. I understand that my individua response to the newy transpanted organ cannot be predicted. There may be a deay in the fu function of my transpanted heart (graft dysfunction). Such a deay may increase the ength of my hospita stay and increase the risk of other compications. There is a possibiity that the transpanted heart wi not function (primary graft faiure) appropriatey, this dysfunction may be very mid dysfunction to severe. If heart dysfunction is severe ife-sustaining treatments such as a ventricuar assist device (VAD heart pump) or Externa Corporea Membranous Oxygenation (ECMO) may be needed. These devices woud be used unti my transpanted heart recovers or a second transpant may be needed. I have been tod that there is a sma risk after heart transpant that the upper portion of my vena cava (the main vein returning bood to the heart) may become narrowed, or that tricuspid regurgitation (the heart vave between the right upper heart chamber and the right ower heart chamber does not cose competey when the right ower heart beats) may occur. I have been tod that there is about an 8% risk that my transpanted heart may deveop coronary artery vascuopathy, which is a narrowing of the coronary arteries, within the first year foowing transpantation. The greatest risk of coronary artery vascuopathy occurs at 5 years and 10 years post-transpant, when the rate rises to approximatey 31% and 52% respectivey. Drugs to prevent rejection and certain characteristics of the donated heart may contribute to coronary artery disease. Other risks associated with the surgery incude: Death. I understand that my particuar risk of death may vary based upon my medica history and condition. I acknowedge that a physician has spoken to me about my individua risk of death. 17

20 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Rejection. Rejection of my transpanted organ may occur immediatey after surgery or anytime foowing transpantation. The reasons for rejection are varied and compex. The treatment for rejection is aso compex. It may be necessary for me to take additiona drugs or to increase the amount of drugs I am aready taking to treat the rejection and maintain organ function. I understand that the treatment to counter rejection may not be successfu and my transpanted organ may cease to function necessitating further medica treatment. Bood cots. These cots usuay deveop in the egs and can break free and move through the heart to the ungs. In the ungs, they can cause serious interference with breathing, which can ead to death. Bood cots are treated with bood-thinning drugs that may need to be taken for an extended period of time. There is a possibiity that the chest wi be eft open for severa days foowing heart transpant or very rarey that the sternum (breast bone) wi not be abe to be cosed due to the size of the heart and the space in the chest from my diseased heart. In this case my chest is cosed using the musces from the chest wa and skin. A heart transpant recipients come out of the operating room with temporary pacing wires to secure that the heart rhythm is strong enough. If the heart does not return to a norma rhythm consideration is given to impant a permanent pacemaker. Beeding, either during surgery or after surgery that may, in a sma percentage of cases, requires bood transfusions or bood products. The use of bood products is extremey unikey. These risks incude, but are not imited to beeding, which may require the use of bood or bood products, infection, stroke, heart attack or death. If needed, bood and/or bood products have the foowing genera risks; reactions resuting in itching, rash, fever, headache or shock; respiratory distress (shortness of breath); kidney damage; systemic infection; exposure to bood borne viruses incuding hepatitis (an infammatory disease affecting the iver) and Human Immunodeficiency Virus (HIV, the virus that causes AIDS); and death. Aternatives to transfusion incude the use of devices that fiter and return bood ost in surgery to me or by providing medications that boost my bood count prior to an eective procedure. Beeding and/or severe anemia coud put my ife in danger or cause permanent brain damage. I understand that substitutes for bood or pasma might not work we enough. Bood and/or bood products might offer the ony chance to preserve my ife. I refuse the transfusion of bood or bood products. Infection, incuding surgica incision site, chest cavity, respiratory and urinary tract infections. Infections can resut from bacteria, viruses or fungi. The risk of infection is higher for transpant recipients than other surgica patients because the treatments needed to prevent rejection make the body ess capabe of fighting infection. The sites where tubes are paced in my body (e.g., tubes to hep me breath, tubes in my veins to provide fuids, nutrition and to monitor important body functions) may cause pneumonia, bood infections and oca infections where the tubes enter my body. Injury to structures within the surgica area. 18

21 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: Damage to nerves, either by direct contact within the chest or from pressure or positioning of the arms, egs or back during the surgery. Nerve damage can cause numbness, weakness, paraysis and/or pain. In most cases these symptoms are temporary, but in rare cases they can ast for extended periods or even become permanent. Sometimes proonged mechanica ventiation is needed to provide support for the ungs. If I require a ventiator for a proonged period consideration wi aso be given to having a tracheostomy (temporary surgica hoe into the windpipe) performed to hep promote airway cearance. Maignancy: the risk of some cancers is higher for transpant patients than for the genera popuation. This is because the medications needed to prevent rejection aso make the body ess capabe of resisting cancer. Skin cancer is the most common type of cancer seen in transpant recipients. Some viruses that cause common inesses in the genera popuation remain in the boodstream. These viruses are associated with cancer in patients who are on immunosuppressant (anti-rejection) drugs. There is aso a sma chance of a maignancy coming with the transpanted organ. There is a chance that my kidney function may deteriorate and require temporary or permanent diaysis as a resut of my transpant surgery. Pressure sores on the skin due to positioning. Burns causes by use of eectrica equipment that may be needed to stop beeding or other equipment. Damage to arteries and veins. Heart attack. Stroke. Permanent scarring at the site of the incision. My physicians cannot predict how my body wi respond to the heart transpant. It is aso not known whether and how the condition that caused my underying heart disease wi adversey affect the transpanted heart. 19

22 CIMS Heart Transpant Cinic Post-Surgica Care and Recovery: After the surgery, I wi be cared for by a speciaized transpant team. This may occur in either an intensive care unit, speciaty recovery unit or transpant ward where I wi be cosey monitored. My ength of stay in the hospita wi depend on the rate of my recovery. I wi remain in the hospita as ong as my physician(s) fee hospitaization is necessary for my recovery. The hospitaization time can vary depending on the severity of my iness prior to transpant or compications after surgery. After I eave the hospita, I wi sti be recovering. I understand it wi probaby take four (4) to six (6) weeks before my physician(s) wi aow me to resume norma activity, incuding driving a care. If I experience any post-operative compications, my recovery time coud be onger. During the recovery period, a team of physicians wi foow my progress. Initiay the transpant team wi see me frequenty with decreasing visits based on my recovery. I understand that I wi need to be monitored on a ong-term basis, and I agree to make mysef avaiabe for examinations, aboratory tests and biopsies to monitor my transpanted heart. My primary care physician wi be given information about my progress and the transpantation team wi make every effort to transition my routine medica care to my primary care physician. However, the transpant team wi continue to foow me for immunosuppression management and monitoring of any transpant associated compications. I understand that it is necessary to have a primary care physician who wi continue to care for my genera heath needs. Transpant coordinators and physicians are avaiabe 24 hours a day to assist my oca doctor in caring for me. HEART TRANSPLANT CONSENT FORM (ADULT) Risks Associated with Use of Medication and Bioogicas: The goa of various drugs and bioogica agents during and after transpantation is to hep my body toerate the donated organ. I understand that I may receive immunogobuin (bioogica agent), monocona antibody (bioogica agent) or simiar products before and/or during the surgery. The use of these drugs and biochemica is caed induction therapy, which may decrease the need for steroids and reduce the amounts of other medications needed to keep the heart from being rejected by my body. I acknowedge that the use of induction therapy has been discussed with me by my physicians and I understand that the risks of using this therapy incude, but are not imited to, anemia, reactions such as chis, fever, headache, hives, sudden sweating, shortness of breath, wheezing, chest tightness, increased risk of infection, increased risk of beeding, fast heart rate, decreased bood pressure, invountary musce movements (rigors) and/or decrease in white bood count. In rare cases, severe aergic response (anaphyaxis) may occur. Prior to induction therapy medications to reduce fever and prevent an aergic response may be given. Patient Name: Identification Number: 20

23 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: I understand that I wi be required to take medications and/or bioogica agents for the rest of my ife to prevent my body from rejecting the transpanted heart. My physicians wi determine the types and amounts of drugs I wi receive and may need to periodicay adjust my drug therapy. There are a number of ong term risks of transpantation reated to anti-rejection drug therapy. These incude: the deveopment of maignancies and rare neuroogic diseases, susceptibiity to certain common viruses, an increased risk of coronary artery disease (perhaps reated to eevated choestero) and kidney dysfunction. The risk of some cancers is higher for transpant patients than for the genera popuation. This is because the medications needed to prevent rejection aso make the body ess capabe of resisting cancer. Skin cancer is the most common type of cancer seen in transpant recipients. Some viruses that cause common inesses in the genera popuation remain in boodstream. These viruses are associated with cancer in patients who are on immunosuppressant (anti-rejection) drugs. Exampes of some of these medications and agents and some side effects or risks incude, but are not imited to, those isted beow. Foowing transpantation I wi be further instructed regarding the medications and agents specificay ordered for me. Steroids such as prednisone Tacroimus Siroimus Cycosporine Azathioprine Mycophenoic acid products Musce weakness, bone fragiity, unusua fat deposits, thinning hair, agitation, eevated bood sugar, weight gain, cataracts. Headache, tremors, numbness and tinging of the extremities, menta confusion, eevated bood sugar, eevated choestero, abnorma kidney function, anemia, decreased abiity of the bood to cot, hair oss. Headache, tremors, high bood pressure, abnorma kidney function, eevated choestero, rapid heart rhythm, cough, decreased abiity of the bood to cot, joint pain. Tremor, high bood pressure, abnorma kidney function, decreased abiity of the bood to cot, overgrowth of gums, excessive hair growth. Infammation of the pancreas, diarrhea, decreased abiity of the bood to cot. Anemia, decrease in abiity to fight infection, sweing of feet/ower egs, gastrointestina upset, diarrhea. Other medications may be required for the rest of my ife to treat or prevent various infections. My potentia need for these medications may be determined by the bood work obtained during the evauation process. I understand that in addition to the anti-rejection drugs, I may be required to take other drugs for choestero, bood pressure, and bood sugar contro. Foowing transpantation I wi be further instructed regarding the medications specificay ordered for me. 21

24 CIMS Heart Transpant Cinic Psychosocia Risks Reated to Transpantation: Possibe psychosocia risks may incude but are not imited to depression, Post Traumatic Stress Disorder (PTSD), generaized anxiety, anxiety regarding dependence on others and feeings of guit. Benefits: I understand that the benefit of heart transpantation to me is the hope of iving onger and at a greater eve of functioning than my underying disease woud have ikey permitted. I aso understand that this potentia benefit cannot resut from the surgery aone, but it dependent upon my foowing a rigorous treatment pan prescribed by my physicians. Aternatives: I understand that I have the choice NOT to undergo this surgery. If I choose not to undergo the surgery, treatment for my heart disease wi be returned to my referring physician and primary care physician (PCP) and continued by them. I acknowedge that the kinds of treatment avaiabe to me based on my particuar condition and my prognoses based on those treatments have been fuy expained to me. I understand that if I do not undergo the transpant surgery, my condition is ikey to worsen and imit my ife expectancy and or my quaity of ife. Transpant Program Changes: HEART TRANSPLANT CONSENT FORM (ADULT) If there are any changes within the transpant program, incuding vountary inactivation, which may impact transpantation, I wi be notified by a representative of the program. Patient Name: Identification Number: 22

25 CIMS Heart Transpant Cinic I understand my physician(s) wi perform or be present for the key portions of the surgery. Representatives of medica device companies may be present to provide devices, and observe and advise on their use. Who wi participate and in what manner wi be decided at the time of the procedure and wi depend on the avaiabiity of individuas with the necessary expertise and on my medica condition. I understand that the physician(s) or others may choose to photograph, teevise, fim or otherwise record a or any portion of my procedure for medica, scientific or educationa purposes. I consent to the photographing, teevising, fiming or other forms of recording of the procedure(s) to be performed, incuding appropriate portions of my body, body functions or sounds, provided my identify is not reveaed. I understand and agree that 1) any photographs, fims, or other audio or visua recordings created wi be the soe property of the faciity: and 2) the faciity or any appropriate staff member may edit, preserve, or destroy a or any part of the photographs, fims, or other audio or visua recordings. Such recordings are not part of the medica record and I understand I cannot obtain a copy. I authorize the disposa or retention, preservation, testing, or use for scientific, educationa or other purposes of a or any portion of specimens, tissues, body parts, or other things, incuding prostheses and medica/surgica appiances, that may be removed from my body. I understand the hospita may require that a jewery and/or body piercing hardware be removed prior to surgery. MY SIGNATURE BELOW ACKNOWLEDGES THAT: 1. I have read (or had read to me), understand and agree to the statements set forth in this consent form. 2. A physician or physician s representative has expained to me a information referred to in this consent form. I have had an opportunity to ask questions and my questions have been answered to my satisfaction. 3. A banks or statements requiring competion were fied in before I signed. 4. No guarantees or assurances concerning the resuts of the surgery have been made. 5. I am signing this consent vountariy. HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: 23

26 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: 6. I understand that I can withdraw my consent at any time prior to the surgery. 7. I herby consent and authorize Dr. ( my physicians(s) ) and/or those associates, assistants and other heath care providers designated by me physician(s) to perform the procedure(s) described in this consent form. I understand that during the course of the surgery, conditions may become apparent that require my physicians or their designees to perform additiona procedures or medica acts that they beieve are medicay necessary to achieve the desired benefits or for my we-being, incuding but not imited to the administration of bood or bood products. I authorize and request my physician(s) or their designees to perform any additiona medica products. I authorize and request my physician(s) or their designees to perform any additiona medica acts or procedures that they, in the exercise of their soe professiona judgment, deem reasonabe and necessary; and I waive any obigation on their part to stop or deay the continuation of my surgery in order to obtain additiona consent. Witness Signature of patient or person authorized to consent for patient Date Date Time Time Reationship to patient if signer is not patient 24

27 CIMS Heart Transpant Cinic HEART TRANSPLANT CONSENT FORM (ADULT) Patient Name: Identification Number: I have expained to the prospective transpant recipient signing above a of the information contained in this consent form. No guarantee or assurance has been given by me as to the resuts that may be obtained. Signature of physician or physician's representative Date Time M.D M.D Print physician name or physician s representative 25

28 CIMS Heart Transpant Cinic MEDICINES AND ALLERGIES Pease ist your medicines, dosage, which doctor prescribed them, and what you are taking them for. Aso incude any over-the-counter medicines, incuding herba or dietary suppements and vitamins. Pease ist any medication aergies you have experienced in the past, and what those aergies have been. MEDICINES AND ALLERGIES LIST YOUR MEDICINES MEDICINES DOSE FREQUENCY PRESCRIBING MD REASON 26

29 CIMS Heart Transpant Cinic MEDICINES AND ALLERGIES DO YOU HAVE ANY ALLERGIES TO MEDICINES? ALLERGY WHAT KIND OF REACTION DO YOU HAVE? LIST THE HERBAL SUPPLEMENTS AND/OR VITAMINS THAT YOU TAKE Do you sef-administer your own medicines? If not, who heps you? 27

30 CIMS Heart Transpant Cinic REVIEW OF SYSTEMS AND CONDITIONS This review of systems and conditions wi hep us to understand the probems that affect you now. Pease indicate issues you have now or have had in the past. Pease read it over, but do not fi or sign it. Your doctor wi go over the content with you, give you an opportunity to ask questions, and you wi sign it at the time of your evauation. REVIEW OF SYSTEMS AND CONDITIONS This review of systems and conditions wi hep us to understand the probems that affect you now. Pease indicate items you have now or have had in the past. Leave the items that do not appy to you bank. CARDIOVASCULAR Check if Yes Hypertension Chest Pain Rheumatic fever Mitra vave proapse Phebitis/bood cots High Choestero Irreguar heartbeat Anemia Other GASTROINTESTINAL Check if Yes Stomach ucer Liver disease Acid refux Esophagea cancer Stomach cancer Coon cancer Other ENDOCRINE Check if Yes Diabetes Low bood sugar Thyroid disease Thyroid Cancer Other GYNECOLOGICAL DISEASES Check if Yes STD Breast cancer Abnorma Pap Smears Other 28

31 CIMS Heart Transpant Cinic INFECTUIOUS DISEASES Check if Yes HIV Meningitis Hepatitis Mono C-Diff MRSA Other RESPIRATORY Check if Yes Shortness of breath Persistent cough Wheezing Chronic ung disease Lung disease Lung cancer Other MUSCULODKELETAL Check if Yes Gout Joint pain/sweing Arthritis Leg pain/cramping NEUROLOGICAL Check if Yes Persistent headaches Seizures/concusions Stroke Numbness/tinging (hands/feet) Seep probems Brain tumor Other SKIN Check if Yes Open wounds/ucer Rashes Poor heaing Lesions Bruising Cancer: Type Other UROLOGICAL Check if Yes Bood in uriine Enarged prostate Difficuty passing urine Urgency/frequency Prostate cancer Badder cancer Other 29

32 CIMS Heart Transpant Cinic Patient Consent for Heath Information To be Communicated By E-Mai Emergency Contact: Name: Address: E-Mai Address: Teephone Number: 1. RISKS AND YOUR RESPONSIBILITY At the discretion of CIMS, it s staff, physicians and agents and upon your agreement to the terms outined within this consent form, you may use e-mai to communicate with CIMS. These e-mais may contain your persona heath information. If you decide to use e-mai to communicate with CIMS, you shoud be aware of the foowing risks and your responsibiities: a) As the Internet is not secure or private, unauthorized peope may be abe to intercept, read and possiby modify e-mai you send or are sent by CIMS. b) You must protect your e-mai account, password and computer against access by unauthorized peope. c) Since e-mai can be used to spread viruses, some which cause e-mai messages to be sent to peope who you do not intend to send e-mai messages to, you shoud insta and maintain virus protection software on your persona computer. d) Since e-mais can be copied, printed and forwarded by peope to whom you send e-mais, you shoud be carefu regarding whom you send e-mais. 2. CONDITIONS FOR THE USE OF By consenting to the use of e-mai with CIMS, you agree that: a) CIMS may forward e-mais as appropriate for diagnosis, treatment, reimbursement, and other eated reasons. As such, CIMS staff members, other than the recipient, may have access to e-mais that you send. Such access wi ony be to such persons who have a right to access your e-mai to provide services to you. Otherwise, CIMS wi not forward e-mais to independent third parties without your prior written consent, except as authorized or required by aw. b) Athough CIMS wi try to read and respond prompty to your e-mais, CIMS staff may not read your e- mai immediatey. Therefore, you shoud not use e-mai to communicate with CIMS if there is an emergency or where you require an answer in a short period of time. c) If your e-mai requires or asks for a response, and you have not received a response withina reasonabe time period, it is your responsibiity to foow up directy with CIMS. 30

33 CIMS Heart Transpant Cinic d) You shoud carefuy consider the use of e-mai for the communication of sensitive medicainformation, such as, but not imited to, information regarding sexuay transmitted diseases, AIDS/HIV, menta heath, deveopment disabiity, or substance abuse. e) You shoud carefuy word your e-mai messages so that the information that you provide ceary describes the information that you intend to convey. f) You are responsibe for correcting any uncear or incorrect information. g) CIMS reserved the right to save your e-mai and incude your e-mai or information contained within your e-mai in your medica record. h) It is the patient s responsibiity to foow up and/or schedue an appointment if warranted or recommended by CIMS. i) E-mais may not be the ony form of communication that CIMS wi use to communicate with you. Additionay, CIMS may decide that it is not in your best interest to continue to communicate with you by e-mai. In such case, CIMS wi notify that it no onger intends to communicate with you by e-mai. 3. INSTRUCTIONS a) You sha immediatey inform those individuas with whom you communicate with at CIMS of changes in your e-mai address. b) You sha send e-mais ony to such CIMS e-mai addresses as instructed. c) You sha put your name and appropriate identifying information in the body of the e-mai. d) You sha incude the category of the communications in the e-mai s subject ine, for handing purposes (e.g. prescription, appointment, medica advice, biing question, etc.) e) Prior to sending the e-mai, you sha review the e-mai to make sure it is cear and that a reevant or requested information is provided. f) You sha withdraw your consent to communicate by e-mai by sending an e-mai to a of the e-mai addresses for which you had previousy communicated. 4. PATIENT ACKNOWLEDGEMENT AND ADREEMENT CIMS wi use reasonabe means to protect the privacy of your heath information sent by e-mai. However, because of the risks outined above, CIMS cannot guarantee that e-mai communications wi be confidentia. Additionay, CIMS wi not be iabe in the event that you or anyone ese inappropriatey uses your e-mai. CIMS wi not be iabe for improper discosure of your heath information that is not caused by CIMS's intentiona misconduct. I acknowedgement that I have read and fuy understand this consent form. I understand the risks associated with the communications of e-mai between CIMS and me, and consent to the conditions outined herein, as we as any other instructions that CIMS may impose to communicate with me by e- mai. Any questions I may have had were answered. Patient Signature Date 31

34 CIMS Heart Transpant Cinic YOUR TRANSPLANT TEAM During your evauation, you wi meet with many members of the team who have an important roe in your transpant process. YOUR TRANSPLANT TEAM TRANSPLANT COORDINATOR Your heart transpant coordinator wi introduce you to the transpant process and review your evauation schedue. The visit wi consist of a preiminary heath screening, medicine review, and overview of the transpant process. Your heart transpant coordinator is here to answer any questions you may have today and in the future, TRANSPLANT SURGEON Your transpant surgeon wi assess your physica capabiity and risks for transpant. The surgeon wi review your heart disease and the medica management of your diagnosis, and wi address a options avaiabe. TRANSPLANT SOCIAL WORKER Your socia worker wi discuss your support team at home, your prescription insurance coverage, and other socia parts of the transpant process. Most importanty, your socia worker is here to answer any questions you may have. TRANSPLANT PHARMACIST Your pharmacist wi meet with you to get a compete ist of a medicines and suppements you take, both prescription and nonprescription,and ask you how to take medicines. TRANSPLANT CARDIOLOGIST Your transpant cardioogist wi perform a medica history and physica, and wi focus on the signs and symptoms of your heart disease. The cardioogist wi assess other options besides transpant, incuding the medica management of your heart disease. TRANSPLANT NUTRITIONIST Your nutritionist wi assess your nutritiona status and dietary knowedge, and wi provide education on recommendations for your diet. The nutritionist aso wi hep you to deveop, begin, and maintain a nutritiona program. 32

35 CIMS Heart Transpant Cinic TESTING FOR TRANSPLANT EVALUATION The tests in this section may be a part of your evauation. Your doctor may aso decide that you need additiona testing based on the test resuts. EVALUATION TESTING FOR YOUR HEART TRANSPLANT The tests beow may be a part of your evauation. Your transpant coordinator wi mark the tests that appy to you. ARTERIAL BLOOD GAS Arteria bood gas is when bood sampes are drawn to determine the content of oxygen and carbon dioxide in your bood BLOOD TESTS Bood tests are when bood sampes are taken to determine your bood type and the status of mutipe body systems. BONE DENSITY SCAN (DXA SCAN) A bone density scan tes us whether you have moved forward to any stage of osteoporosis or may be at risk for bone fractures. The scanning process takes about 20 minutes, and you have to ie fat on a bed whie a ow dose x-ray arm moves around your whoe body. CHEST X-RAY A chest x-ray is a procedure used to evauate organs and structures within your chest for symptoms of the disease. COLONOSCOPY A coonoscopy aows a view of the entire inner ining of the coon (arge intestine) and the rectum. The procedure invoves the use of a ong, fexibe, tubuar instrument (the coon scope) to take tissue sampes whie you ie on your eft side with knees drawn toward your abdomen. You shoud te your doctor about any aergies you ve had with medicines or anesthetics, any beeding probems, any medicines you are taking, or if you are pregnant. Do not eat any soid food for 24 to 48 hours before the test. Ony eat or drink ceariquids, such as juices, broth, and geatin. You wi have to take a strong axative the night the test. CT ANGIOGRAM (COMPUTED TOMOGRAPHY ANGIOGRAM) A CTA procedure may be requested to visuaize bood fow and pinpoint any specific circuatory issues or associated disease states. You wi ie on a narrow exam tabe and side into and out of an x- ray tube. To prepare for the exam, you shoud not eat or drink anything for severa hours beforehand. Inform your doctor about a medicines and aergies. CT SCAN (COMPUTED AXIAL TOMOGRAPHY SCAN) A CT scan is an x-ray procedure. You have to ie fat on a bed whie passing through a donut-shaped x- ray machine to view inside your body. Pre-test preparations may te you not to eat, drink, or take anything by mouth for 3 hours before testing if you are having an abdomina scan, pevic scan, or any part of your GI tract scanned. DESATURATION TEST A desaturation test monitors the oxygen concentration in your bood. It is performed in the Pumonary Function Lab by pacing a sma device caed an oximeter on your finger. DOPPLERS CAROTID ARTERIAL Dopper utrasound is a specia utrasound technique that evauates bood as it fows through the carotid arteries. Your carotid arteries are ocated on each side of your neck and carry bood from your heart to your brain. 33

36 CIMS Heart Transpant Cinic EKG (ELECTROCARDIOGRAM) An EKG is used hep diagnose specific cardiac probems, such as arrhythmia. The procedure invoves attaching eectrodes to your wrists, ankes, and chest to send signas to an EKG machine to show your heart rate. HEART CATHETERIZATION (HEART CATH) A heart cath procedure heps to provide a diagnosis for heart disease through a fu exam of the heart and its bood fow. The test usuay asts 2 to 3 hours and is done whie you ie fat on a padded, tited tabe. You wi aso be instructed not to eat or drink for 6 hours before the test. MAMMOGRAM (WOMEN ONLY) A mammogram is used to detect breast cancer. There are two types of mammograms a reguar screenings mammogram and a diagnostic mammogram to foow-up on past treatments. MRI (MAGNETIC RESONANCE IMAGING) Your doctor may order an MRI procedure to ook more cosey at your brain, spine, pevic area, joints, abdomina area, heart, or bood vesses. The procedure takes between 2 and 15 minutes. You have to ie on a siding tabe in a arge cyindershaped structure. Make sure your doctor knows about any impanted medica devices, patches, or pacemakers. MYOCARDIAL VOLUME OXYGEN STRESS TEST (Mv02) An MV02 is a test that indirecty shows arteria bood fow to the heart during physica exercise. When compared to bood fow during rest, the test shows imbaances of bood fow to the heart's eft ventricuar musce tissue the part of the heart that performs the greatest amount of work pumping bood. PAP SMEAR (WOMEN ONLY) A pap smear is performed as a screening test for cervica cancer or any other abnormaity of the reproductive system. Tissue sampes are extracted from the cervix by your doctor. PULMONARY FUNCTION TESTING (PFT) PFT is a group of tests that measure the function of the ungs and show probems in the way a patient breathes. They aso measure ung disease progression, or: response to different treatments. The procedure invoves breathing through your mouth into a tube connected to a machine known as 'a spirometer. QUANTITATIVE VENTILATION PERFUSION SCAN (VQ SCAN) A VQ scan measures which ung is getting the most bood fow and which: ung receives the most air during inspiration. This radioogy study is conducted in two phases. During the first process, contrast materia is injected into your vein which wi ight up the ung arteries and veins. In the second process, you wi be required to inhae contrast materia. 6-MINUTE WALK DISTANCE (SMW) An SMW is an exercise test where you wi be asked to wak as fast, as far, and as ong as you can toerate for up to a tota. of 6 minutes. You wi be accompanied by a cardiopumonary rehabiitation exercise physioogist or nurse and given oxygen as needed, and a puse oximeter wi continuousy caibrate your puse rate and oxygen concentration. If you experience chest pain, eg pain, shortness of breath, or fatigue, you may stop the test. TEE (TRANSESOPHAGEAL ECHOCARDIOGRAM) A TEE is a different way of producing echocardiograms of the heart. The procedure invoves swaowing a very sma instrument that: uses sound waves to produce an eectronic image. You wi be asked not to eat or drink for severa hours before the test. 34

37 CIMS Heart Transpant Cinic TTE (TRANSTHORACIC ECHOCARDIOGRAM) A TTE is a noninvasive imaging technique used for screening bood fow through the chambers of the heart. The test invoves an instrument being paced on your ribs near the breast bone. The instrument is directed toward your heart and monitors the high frequency sound waves of your heart beat, converting them into a readabe eectrica impuse report. ULTRASOUND An utrasound test is used for diagnostic or therapeutic purposes. It usuay takes no more. than 20 to 45 minutes and invoves giding a ge-covered stick over your skin. You wi be tod how to prepare, depending on the reason your doctor has requested the utrasound. For exampe, you may be asked to fast for at east 8 hours before your test. 35

38 CIMS Heart Transpant Cinic EVALUATION TESTING FOR YOUR HEART TRANSPLANT - PATIENT INSTRUCTIONS MYOCARDIAL VOLUME OXYGEN STRESS TEST (MVO ) 2 Two hours, before the test, foow the instructions beow: Ø Ø Ø Do not drink beverages that have caffeine. Do not eat any food. Do not use any tobacco products. On the day of your exercise test, you can take your medicines as you usuay do. If you are a diabetic on insuin or ora diabetic medicines, pease ca your nurse coordinator who wi te you how to adjust your medicine for the period of time during which we have asked you not to eat. It is important that you wear comfortabe waking shoes, such as tennis shoes, if you have them. Loose-fitting cothing is best for exercise testing (such as gym shorts, oose bouses or shirts that: button or zipper in the front, and oose sweat pants or sacks). If you have a defibriator, pease know your device settings. 36

39 CIMS Heart Transpant Cinic EVALUATION TESTING FOR YOUR HEART TRANSPLANT - PATIENT INSTRUCTIONS 24 HOUR URINE COLLECTION FOR CREATININE CLEARANCE Pease foow these instructions carefuy: Take the prescription to your oca ab to get a sampe coection container. Drink the same amount of iquid during the 24-hour coection period that you woud usuay drink, uness otherwise instructed by your doctor. Do not drink acohoic beverages during the 24-hour coection period. Coection instructions: 1. Empty your badder when you get up in the morning and throw away the urine. Write down the time that you do this. 2. For the next 24 hours, coect a of your urine into the sampe container from your oca ab. 1. The fina urine coection is to be made at the same time as your first discarded urine the day before. 2. The coected urine must be kept chied in the refrigerator or in a cooer with ice). 3. Write your name, date, and start and end times on the container abe when the 24-hour urine coection is finished. 4. Take your sampes and your prescription to the ab ASAP after the 24-hour coection period is finished. 37

40 CIMS Heart Transpant Cinic Transpant Medicine Frequenty Asked Questions (FAQ) Transpant pharmacists: One of the most important factors infuencing the outcome of a transpant procedure is your reationship with your pharmacist. Organ avaiabiity and other practica aspects of transpant surgery sometimes seem to dominate the conversation, but making a strong connection with your pharmacist is vita to maintaining and regaining your heath throughout every stage of the process. And now that many patients are facing uncertainty regarding the avaiabiity and affordabiity of their medications, it's more important than ever to understand how we can a work together to make heaing possibe. Every patient is different, but there are certain questions we hear quite often. If you have questions about the pharmaceutica aspects of transpant surgery, you may find an answer beow - and you may think of more questions as we! Make notes and bring your ist aong with you the next time you visit with your transpant pharmacist. The vaue of an open honest reationship with your transpant cannot be overstated. Wi I have to take this medication for the rest of my ife? Yes. Amost everybody who receives a transpanted organ wi need ifeong immunosuppressive therapy. Some patients may be abe to reduce their dosage as time goes by in some cases, you may need additiona medications to counteract undesirabe effects of your main medications. Your doctor wi coaborate to fine tune your medication regiment to your specific and changing needs. What kinds of drugs wi I get, and how do I take them? This depends upon the type of transpant you receive, but when you eave the hospita, you' probaby be taking 12 to 15 new medicines at east three or four times a day. That may sound ike a ot but the transpant team can teach you how to arrange your pi box so that you take the right medications at the right times. After a whie, your transpant medications needs may decrease. We generay sette on a core group of six medications to be taken three or four times a day. We recommend that you fi your initia prescriptions before eaving the hospita. Be sure to pan ahead if you' re going out of town or won't be abe to get to your ong term pharmacy in time to refi your prescriptions. It is vita that you continue to take your medications exacty as prescribed, without interruption. But if you find yoursef stranded without your medication, you can ca your transpant coordinator at any time of the day or night. The transpant team is aways here for you, and we wi hep you get the medicine you need. What about the medicines I aready take, ike bood pressure medication or my inhaer? Depending on the organ you received, you may be abe to discontinue some medicines unreated to anti-rejection medication for instance, if you received a new kidney, your high bood pressure may be better controed, reducing the need for bood pressure medication. If your chronic condition contributed to your need for a transpant, the transpant surgery may correct the source of the underying disease. It's something to discuss with your physician and your pharmacist. Never discontinue a drug without consuting your transpant team. 38

41 CIMS Heart Transpant Cinic How can I earn more about managing my medications? As an integra part of the transpant process, CIMS provides speciaized patient education. During these sessions, dedicated transpant team nurse coordinators and pharmacists wi teach you about your specific medications the side effects you can expect, and how taking them wi affect your everyday ife. We aso expain how food and other medications figure into your schedue. We hep you deveop a strategy for ensuring that you re aways prepared to take your medications at the right time. Are there any natura remedies that can hep? No. The immune system is compex, and so is transpant surgery. Your drug regimen is taiored to your situation and every drug we prescribe has a specific job to do. Natura remedies may interfere with the action or interaction of your medications. Never take any over-the-counter or herba remedy without checking with your pharmacist or transpant nurse coordinator. There are natura actions you can take to hep in recovery. Eat a heathfu, baanced diet, and get the rest you need. Try to find ways to reduce stress in your ife. If your doctor gives you the go-ahead, get an appropriate amount of exercise. Your new organ wi adapt more quicky in a heathy environment, so do your best to keep your body in good working order. 39

42 CIMS R Care Institute of Medica Sciences Earning Trust with Word-Cass Practices CIMS Hospita, Nr. Shukan Ma, Off Science City Road, Soa, Ahmedabad , Gujarat, INDIA. Ph. : (5 ines) Fax : Mobie : , For appointment ca : , Mobie : or Emai : opd.rec@cimshospita.org 40