Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ZOLEDRONIC ACID. Patient s first names.
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1 Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ZOLEDRONIC ACID Patient s surname/family name Patient s first names Date of birth NHS number (or other identifier) Hospital Name: Male Female Special requirements (e.g. other language/other communication method) Prevention of bone-related events - Intravenous Zoledronic Acid Responsible health professional Job title Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) Zoledronic Acid intravenous infusion every 3 to 4 weeks
2 Patient identifier/label: Page 2 of 6 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 reduce, prevent or delay symptoms related to bony involvement from... cancer To reduce calcium levels in the blood Significant, unavoidable or frequently occurring risks: Common side effects include increased pain, flu-like symptoms which include a headache, high temperature, chills and muscle and joint pains. Less common side-effects include drop in calcium levels below normal, effects on the kidneys, red or sore eyes, anaemia (low number of red blood cells), headaches, feeling sick (nausea) and being sick (vomiting). There is also a rare but serious risk of developing jaw problems (osteonecrosis). It means healthy bone dies off in a way that is not normal. This tends to happen more commonly in people that have had teeth removed or other dental procedures while on zoledronic acid. It can result in poor healing of the gums or loosening of teeth. If possible, dental treatment should be avoided while on zoledronic acid. A further rare but serious side effect is atypical fracture of the femur. This means a break in the bone of the thigh. Report any thigh, hip or groin pain to a doctor. Zolendronic acid may need to be stopped if this happens. Any other risks:... Dental check is required prior to starting treatment with zoledronic acid: Dental check confirmed What the treatment is likely to involve (including inpatient / outpatient treatment, timing of the treatment, follow-up appointments etc) and location. 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.
3 Patient identifier/label: Page 3 of 6 The following leaflet/tape has been provided: Macmillan leaflet for Zoledronic Acid 24 hour chemotherapy service contact details.. Signed:. Name (PRINT). Date.... Job title... Contact details (if patient wishes to discuss options later)... Statement of interpreter (where appropriate) Language Line ref: 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).. Copy accepted by patient: yes/no (please ring)
4 Patient identifier/label: Page 4 of 6 Statement of patient 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. I agree to the procedure and 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 training and experience. I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health. 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:. Name (PRINT). Date.... Job title... Important notes: (tick if applicable) See also advance decision (eg Jehovah s Witness form) Patient has withdrawn consent (ask patient to sign /date here)....
5 Patient identifier/label: Page 5 of 6 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 Who can give consent Everyone aged 16 or more is presumed to have the capacity 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 have the capacity 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 has the mental capacity 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 lacks the capacity to give consent, you should use form 4 (form for adults who lack the capacity to consent to investigation or treatment) instead of this form. A patient lacks capacity if they have an impairment of the mind or brain or disturbance affecting the way their mind or brain works and they cannot: understand information about the decision to be made retain that information in their mind use or weigh that information as part of the decision-making process, or communicate their decision (by talking, using sign language or any other means). 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 a form on behalf of an adult who lacks capacity to consent for themselves, unless they have been given the authority to so under a Lasting Power of Attorney or as a court appointed deputy. 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.
6 Patient identifier/label: Page 6 of 6 References: 1- South East London Cancer Network, Agreed lists of Chemotherapy Regimens 2- Macmillan Cancer Support, Cancer Information 3- Royal Marsden NHS Foundation Trust, Consent Forms
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM BEVACIZUMAB. Patient s first names. Date of birth.
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Patient identifier/label: Page 1 of 7 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM EC-T: EPIRUBICIN / CYCLOPHOSPHAMIDE - DOCETAXEL
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Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CABOZANTINIB. Patient s first names.
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CABOZANTINIB Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number (or other
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CISPLATIN + ETOPOSIDE ORAL/INTRAVENOUS
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Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CYTARABINE (HIGH DOSE)
Patient identifier/label: Page 1 of 6 CYTARABINE Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital
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Page 1 of 6 FORM FERRERI / IELSG PROTOCOL Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ABVD. Patient s first names.
Patient identifier/label: Page 1 of 6 Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS number
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 +/- RITUXIMAB. Patient s first names.
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