En肝脏肿瘤射频消融术知情同意书

En肝脏肿瘤射频消融术知情同意书Modern Hospital GuangzhouInformed Consent of Percutaneous radiofrequency ablation for Liver TumorPatient name：Sex：Age：Case No：Brief description of disease and treatment recommendationsI am aware that I have been diagnosed with and recommended to undergo percutaneous radiofrequency ablation for liver tumor underanesthesia.Hepatic tumor means tumor located in liver, which consists of benign tumor and malignant tumor. Malignant hepatic tumor mainly includes primary hepatic carcinoma and secondary hepatic carcinoma. Main clinical symptoms are: hepatic region discomfort in right upper quadrant, pain, weakness of whole body, loss of appetite and emaciation. When cancer develops into mid-term and advanced stage, the patient will have enclosed mass in the upper abdomen, abdominal distension, fever and diarrhea etc. In severe cases, patient might have upper gastrointestinal hemorrhage, ascites, jaundice, hepatic encephalopathy and rupture and bleeding of liver cancer etc.Percutaneous radiofrequency ablation for liver tumor is a frequently applied method to treat hepatic tumor in recent years. The advantages of this method are easy operation, short operative time, slight damage to liver and slight effect to liver function and other organ’s function. Therapeutic effect for tumor is relatively better. Tumor whose diameter is not so big can maintain long term remission after several treatments. According to documentary report, long term effect of treating smallhepatocellular carcinoma by radiofrequency ablation is similar to surgery; however, the damage to liver is very slight. So this method is appropriate for those patients with both liver cancer and liver cirrhosis or those patients with bad liver function and liver cancer.OthersPotential risks and handling:I have been informed of the following possible risks of percutaneous radiofrequency ablation for liver tumor. However, certain uncommon risks are not included hereinto. The method of surgery should be individualized based on medical condition.I have been informed that I am entitled to discuss with my physician regarding the surgery and any associated special questions.1．I understand that all anesthetic procedures carry potential risks.2．I understand that all drugs might cause unwanted side effects, including mild symptoms such as nausea and rashes, serious anaphylactic shock, and even life-threatening events.3．I understand the risks associated with this procedure and doctor’s measures:1)Anesthetic accidents.2)Bleeding or hematoma in puncture area; massive hemorrhage in abdominal or thoraciccavity; .peritonitis/pleuritis.3)Cardiovascular and cerebrovascular accidents during procedure, for example vagal reflexleads to low blood pressure, heartbeat slowdown or even cardiac arrest.4)Pain or intractable intercostal neuralgia after procedure;skin burning is possible and skingrafting might be needed in case of severe situation.5)Failure of puncture and procedure; incomplete necrosis of tumor; excessive ablation;ablation of normal tissues by mistake; recurrence and metastases of tumor; needle tract implantation metastases; lesion bleeding causing extensive metastases of tumor etc.6)Burning organs adjoining lesion or even perforation, for example perforation of pleuracauses hemopneumothorax, thoracic infection, hemoptysis choke or even respiratory failure in severe case; perforation of gallbladder causing bile peritonitis; bile duct injury leading to obstructive jaundice; stomach and intestinal injury or even perforation causing peritonitis; puncture of large blood vessels by mistake leading to massive bleeding, shock, etc. Above-mentioned situations might need surgery or even threaten patient’s life.7)Fever, pain, nausea and vomiting etc after procedure.8)Infection, local abscess, bacteremia or even septicopyemia.9)Liver and kidney function failure, jaundice, ascites, hypoalbuminemia, hemoglobinuriaand anuria etc.10)Other unexpected or unprevented complications.4. I understand that patients with hypertension, heart disease, diabetes, renal insufficiency, venous thrombosis, etc or with a smoking history might have increased risks described above, or experience worsening of associated medical condition or episodes of cerebro-cardiovascular accident, even death during surgery or postoperatively.Special risks or major high-risk factorsI understand that the following special complications or risks may occur under current medical condition:Appropriate measures will be taken in the case of the risks and accidents as described above. Choices of the patient’s informed consent●I have been informed of the method of surgery, complications and risks that mayoccur during surgery and postoperatively, and other possible treatment options.All questions regarding this procedure have been properly answered.●I agree that adjustments to scheduled method of surgery are allowed duringsurgery based on the medical condition.●I understand that this procedure requires the collabo rative efforts by severalphysicians.●I am not ensured a 100% success of this procedure.●I authorize affected organs, tissues and specimens as well as imaging data thatare involved in this procedure can be handled by the physician, which includepathological and cytological examinations, scientific studies, medical wastedisposal, etc.●For the best of knowledge, I have disclosed my medical condition to thephysician in a truthful and thorough manner. I shall bear all the consequences asa result of hidden truth.Signature of patient Date of signature DD MM YY Hr MinID No. TelMailing addressSignature of authorized family member should be obtained in the event that the patient was unable to sign informed consent: Signature of authorized family member Date of signature DD MM YY Hr MinRelationship with the patientID No. TelMailing addressStatement of physicianI have informed the patient of the method of surgery, complications and risks that may occur during surgery and postoperatively, and other possible treatment options, and answered all questions regarding this procedure.Signature of physician Date of signature DD MM YY Hr Min。