UNIVERSITY MEDICAL CENTER
Lubbock, Texas
DISCLOSURE AND CONSENT – Peripherally Inserted Central Venous Catheter (PICC) PLACEMENT
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.
1. I voluntarily request ______as my specially trained nurse, interventional radiologist, or physician(s), and such associates, technical assistants and other health care providers as they may deem necessary, to treat my conditions which has been explained to me as: The treatment ordered by your physician includes IV fluids and/or medications that may be irritating to smaller veins. Because the large vessel above your heart has a rapid blood flow, these products will be less likely to irritate the vein.
2. I understand that the following surgical, medical, and/or diagnostic procedures are planned for me and I voluntarily consent and authorize these procedures: Having a PICC (Peripherally Inserted Central Venous Catheter) inserted means that a soft flexible catheter will be placed in the vein and the catheter’s tip will rest in the large blood vessel above your heart. A chest x-ray will be taken to confirm that the tip is in the proper location, and the catheter may be repositioned if necessary.
3. I understand that no warranty or guarantee has been made to me as to the result.
4. Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for me. I realize that common to surgical, medical and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I also realize that the following hazards may occur in connection with this particular procedure:
Catheter infection: Great care is taken to prevent the infections. We follow strict, sterile methods whenever handling the catheter or changing the dressings.
Bleeding in the first 24 hours after placement. Some bleeding is common and generally stops on its own.
Hematoma (bruising): There may be some bruising near the catheter. This will go away in a few days without further treatment.
Irritation of the blood vessel: The catheter may cause some redness and tenderness along the vein during the first 2-3 days after its insertion. We treat this with warm moist heat and medication.
Thrombosis: Sometimes a blood clot may form in the vein, causing tenderness, redness, and swelling of the arm. We look at your site every day and will remove it if this occurs.
Plugged Line: This happens when blood backs up into the catheter. We flush the catheter and clamp after each use to prevent this from happening. If you are receiving IV fluids on a pump, let your nurse know when the pump alarms.
Catheter is dislodged: It is very important to prevent a catheter from being accidentally pulled out of the vein. The dressing over the insertion site holds the catheter in place. Please let your nurse know if it becomes wet or loose, we will change it for you.
Unexpected puncture of nearby arteries or nerves: We make every effort to prevent punctures, but the closeness of the vein to arteries and nerves creates a risk. If one occurs, the needle will be withdrawn immediately and another site will be chosen.
Cardiac dysrhythmia (irregular heartbeat): The location of the catheter’s tip may cause an irregular heartbeat. The patient will be on a heart monitor during placement. A chest x-ray will be used to check the tip location and the catheter will be repositioned if necessary.
Air embolus (air bubble): An air bubble may occur when the syringe or tubing is connected or disconnected. This is rare due to the small size of the catheter.
5. I understand that anesthesia involves additional risks and hazards but I request the use of anesthetics for the relief and protection from pain during the planned procedure. I realize the anesthesia may have to be changed possibly without explanation to me. I understand that certain complications may result from the use of any anesthetic including respiratory problems, drug reaction, paralysis, brain damage or even death. Monitored Anesthesia Care (MAC or conscious sedation) includes additional risks of permanent organ damage and memory dysfunction/memory loss and may be used in conjunction with a local anesthetic.
6. I have been given an opportunity to ask questions about my condition, alternative forms of anesthesia and treatment, risks of
non-treatment, the procedures to be used, and the risks and hazards involved, potential benefits, risks, or side effects, including potential problems related to recuperation and the likelihood of achieving care, treatment, and service goals. I believe that I have sufficient information to give this informed consent.
7. I certify this form has been fully explained to me by ______that I have read it or have had it read to me,
that the blank spaces have been filled in, and that I understand its contents.
DATE: ______TIME: ______
______
Patient/other legally responsible person to sign Relationship (if other than patient)
______
Witness Rev 07/08
Instructions for form completion:
Note: Enter “not applicable” or “none” in spaces as appropriate. Consent may not contain blanks.
Section 1: Enter name of physician(s) responsible for procedure and patient’s condition in lay terminology. Specific location of procedure must be indicated (e.g. right hand, left inguinal hernia) & may not be abbreviated.
Section 2: Enter name of procedure(s) to be done. Use lay terminology.
Section 3: The scope and complexity of conditions discovered in the operating room requiring additional surgical procedures should be specific to diagnosis.
Section 5: Enter risks as discussed with patient.
- Risks for procedures on List A must be included. Other risks may be added by the Physician.
- Procedures on List B or not addressed by the Texas Medical Disclosure panel do not require that specific risks be discussed with the patient. For these procedures, risks may be enumerated or the phrase: “As discussed with patient” entered.
Section 7: Enter any exceptions to disposal of tissue or state “none”.
Section 8: An additional permit with patient’s consent for release is required when a patient may be identified in photographs or on video.
Section 10: Enter name of physician explaining procedure (obtaining informed consent) to patient.
Date/Time: Enter date and time patient signed consent.
Witness: Enter name and address of competent adult who witnessed patient’s (authorized person’s) signature.
If the patient does not consent to a specific provision of the consent, the consent should be rewritten to reflect the procedure that the patient (authorized person) is consenting to have performed.
For additional information on informed consent policies, refer to policy SPP PC-17.