Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM VISMODEGIB. Patient s first names.
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1 Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM VISMODEGIB 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 (or other identifier) South London Healthcare NHS Trust: Princess Royal University Hospital Queen Elizabeth Hospital Queen Mary s Hospital Male Female Special requirements (e.g. other language/other communication method) Treatment for Basal Cell Carcinoma Oral Vismodegib Responsible health professional Job title Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) Oral vismodegib capsules taken once daily, continuously. Prescribed every 28 days - treatment continued at the discretion of the treating doctor 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:
2 Patient identifier/label: Page 2 of 6 The intended benefits Improved survival Control of symptoms Curative to give you the best possible chance of being cured Palliative the aim is not to cure but to control or shrink the disease. The aim is to improve both quality of life and survival Adjuvant therapy given after surgery to reduce the risk of recurrence of cancer Neo-adjuvant therapy given before surgery to shrink the cancer and reduce the risk of recurrence of cancer Significant, unavoidable or frequently occurring risks: The most common side-effects include muscle spasms, hair loss, taste disturbance or loss of taste, weight loss, tiredness (fatigue), feeling sick (nausea), being sick (vomiting), loss of appetite, diarrhoea, and constipation. Indigestion, abdominal pain, rash or dry itchy skin, muscle and joint pain have been reported. Some chemotherapy drugs can damage women s ovaries and men s sperm, with risk of infertility and early menopause in women. I have warned the patient about the likelihood of: early menopause in women infertility (in men and in women) Some anti-cancer drugs may damage the development of a baby in the womb (foetus), leading to the many risks associated with an abnormal pregnancy. Therefore, I have discussed the issues of protected sex and the use of double barrier method of contraception. This is an issue for both men and women. The patient has been advised not to get a partner pregnant during the period of treatment and for 2 months after the completion of treatment. Women of childbearing potential should not become pregnant during treatment and for 24 months after completion of treatment. Women of child bearing potential must have a negative pregnancy test conducted by the healthcare provider, within 7 days of starting vismodegib treatment, and a negative pregnancy test monthly during treatment. What the treatment is likely to involve (including inpatient / outpatient treatment, timing of the treatment, follow-up appointments etc) and location. Any other risks:...
3 Patient identifier/label: Page 3 of 6 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. The following leaflet/tape has been provided: Macmillan/Cancerbackup leaflet for Vismodegib South East London Cancer Network Vismodegib Patient Treatment Plan 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
6 Patient identifier/label: Page 6 of 6 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. 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 6. Patient s first names. Date of birth
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