Consent form

[organization name]

Conservative Sharp Wound Debridement Patient Consent Form

Patient agreement to treatment

Patient Name __________________________________________________________

Physician ______________________________________________________________

DEFINITION:

Conservative sharp wound debridement is the removal of loose, avascular (non-viable) tissue using surgical instruments (e.g., scissors, scalpel, forceps) without inflicting pain or precipitating bleeding.

SUPPORTIVE DATA:

1. 
   Debridement
   

• 
  Facilitates visualization of the wound wall and base for accurate and thorough assessment and treatment.
  
• 
  Reduces the bioburden (volume of pathogenic microbes) of the wound by removing necrotic tissue and foreign matter. Devitalized tissue supports bacterial growth with increased risk for wound infection.
  
• 
  Controls and potentially prevents infections.
  
• 
  Interrupts at the molecular level the cycle of the chronic wound so that protease and cytokine levels more closely approximate those of the acute wound.
  
• 
  Essential to optimal wound management
  
• 
  Indicated for any wound, acute or chronic, when necrotic tissue or foreign bodies are present or when infected. (contraindications to debridement include arterial insufficiency, pressure ulcers on the heel/toes, ischemic wounds, or those with dry gangrene.
  

2. 
   Various forms of necrotic tissue
   

• 
  Eschar is firm, dry, leathery appearance of desiccated and compressed tissue layers.
  
• 
  Slough contains fibrin, bacteria, intact leukocytes, cell debris, serous exudate, and quanties of DNA. May be adherent to the wound bed and edges or loosely adherent and stringy. May appear brown, yellow, or gray. Slough, when dries and hardens, becomes eschar.
  

3. 
   Various methods of debridement include:’
   

• 
  Selective Conservative (only necrotic tissue removed-no bleeding results)
  
• 
  Non selective (viable as well as nonviable tissue is removed)
  

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 as defined above.



The possible risks including but not limited to bleeding and/or infection.

Extra procedures which may become necessary during the procedure

 silver nitrate cauterization

 other procedure (please specify) _________________________________________________.

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.

This procedure may involve:  local anaesthesia  sedation

Signed:…….…………………………………… Date .. …………………….……….

Name (PRINT) ………………………. ……… Job title …….. ………………….…

Contact details (if patient wishes to discuss options later) …..……………….……………

Statement of patient Patient identifier/label

Please read this form carefully. 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 or 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 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.

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:…….…………………………………… Date .. …………………….……….

Name (PRINT) ………………………. ……… Job title …….. ………………….…

Important notes:

 See also advance directive/living will (eg Jehovah’s Witness form)

 Patient has withdrawn consent (ask patient to sign /date here) ……………...……….