CONSENT:PATIENTS + DOCTORS MAKING DECISIONS TOGETHER.

GMC. June 2008.

CONSENT FOR ENDOSCOPIC PROCEDURES.

UHCW JULY 2012.

CONSENT FOR ENDOSCOPY.

• PRINCIPLES OF CONSENT.

• PATIENTS LACK CAPACITY.

• OGD

• COLON

• FOS

• ERCP

• DIABETES

• CJD.

PRINCIPLES OF CONSENT .FROM MINOR INTERVENTIONS TO MAJOR DECISIONS +

SCREENING.

• 1. LISTEN TO THE PATIENT-THEIR FEARS /CONCERNS.• 2. DISCUSS SYMPTOMS – WHAT IS DIFF . DIAGNOSIS, WHAT

ARE THE LIKELY INVESTIGATIONS / TREATMENTS.• 3. SHARE INFORMATION – BENEFITS + RISKS OF

INVESTIGATIONS/ EXPLAIN MEDICAL JARGON .• 4. MAXIMISE PATIENTS OPPORTUNITIES TO MAKE DECISION

THEMSELVES.• 5. RESPECT THEIR DECISION.• 6. IF PATIENT HAS CAPACITY – ONLY THEY CAN MAKE

DECISION.• 7. IF PATIENT ALLOWS DR TO MAKE DECISION – THEY MUST

STILL BE TOLD BENEFITS / RISKS- DOCUMENT• 8. 2nd opinion

CONSENT- PATIENTS WHO LACK CAPACITY.Exclude deafness/ acute confusion/ depression/ medication.

• 1. WHAT IS IN PATIENTS BEST INTERESTS?• 2. INVOLVE FAMILY MEMBERS/ CARERS.• 3. PATIENT NEED ADVOCATE ?• 4. TAKE INTO ACCOUNT PATIENTS VIEWS BEFORE LOSS OF

CAPACITY.• 5. FOLLOW LAW .• 6. NEEDS AT LEAST 2 DOCTORS TO CONSENT FOR

PROCEDURE – CONSULTANT .• 7. CEILING OF TREATMENT .

OESOPHAGO-GASTRO-DUODENOSCOPYOGD.

• DIAGNOSTIC/ THEUAPEUTIC.• Preparation-EMPTY STOMACH- DO NOT EAT 6 HOURS BEFORE.

• MEDICATION TAKEN+ tell nurse allergies.

• Aspirin – stop 10 /7 , clopidogrel- stents/ cardiology.

• WARFARIN – STOP 5/7 BEFOR + CHECK DAY PROCEDURE.

• SEDATION –

• 1. THROAT SPRAY –cannot eat 1 hour post .

• 2. ivi sedation – need O2 SAT MONITOR, HR+ BP.

• Can not drive/ operate machinery / sign legal documents.

• REMOVE DENTURES.

OGD 2.RISKS TO DISCUSS –PRE CONSENT.

• DAMAGE TEETH.

• PERFORATION- 1 IN 1500. OGD. RARE BUT SERIOUS.

• BLEEDING.1 IN 150.

• COMPLICATION OF SEDATION – HYPOTENSION/ RESPIR ↓-transient.

• THEUAPEUTIC OGD .

• 1. DILATION – PERFORATION RATE= 10%

• Life threatening- hospital admission/ surgery.

• 2. SEMS/ STENT INSERTION.

• 10% complication rate – bleeding, migration+ pain.

• RECOVERY

• Explain findings, eat / drink, given report+ telephone nos.

COLONOSCOPY.DIAGNOSIS+ THERAPEUTIC .

• WHY COLONOSCOPY – CT blind since collapsed bowel/ no bx.

• MEDICATION- STOP IRON 1 WEEK BEFOR COLON.

• STOP OPIOIDS, CODEINE, LOPERAMIDE 3/7 BEFOR.

• WARFARIN STOP 5/7 BEFOR.

• DIABETES – LATER SLIDE.

• ALLERGIES.

• DIET- MUST BE LOW RESIDUE DIET 2/7 BEFOR COLON.

• NO FIBRE- no vegetables/ fruit/ cereals / brown bread.

• PROTEIN- meat/ fish with pasta + white rice.

• ↑ fluids .

• BOWEL PREP ~RENAL FUNCTION/ GFR.

• HAEMODIALYSIS / CRF gfr< 50-25 –alternative bowel prep.

COLONOSCOPY BOWEL PREP.MUST KNOW GFR/ RENAL FUNCTION.

• 1. 5 SENNAKOT TABLETS

• 2. MOVIPREP SACHET IN 2 PINTS WATER.

• 3. 4 HOURS LATER –ANOTHER MOVIPREP 1-2 PINTS.

• SEDATION -can not drive home/machinery 24 hrs.

• RISKS-

• 1.PERFORATION- 1 IN 1000 COLONS.

• 2. BLEEDING. RISK 1 IN 100-200.

• 3. SEDATION – TRANSIENT .

• RECOVERY – see copy report / explanation

HOME ALONE – admission 24 hours.

• Telephone nos if emergency.

FOS- FLEXIBLE SIGMOIDOSCOPY.

• LOW RESIDUE DIET -2/7 PRIOR .

• No vegetables/ fruit / cereals.

• Same medication to be avoided-

• WARFARIN STOP 5/7.

• GIVEN ENEMA PR BEFOR PROCEDURE.

• RISKS OF FOS-

• VERY LOW IF DIAGNOSTIC.

• 1 IN 15,000 SUFFER PERFORATION.

• 1 IN 200 – BLEEDING ( POLYPS REMOVAL)

• Needs injection tx adrenaline/ clips / thermal.

• RECOVERY

• Explain report, eat + drink.

ERCPENDOSCOPIC RETROGRADE CHOLANGIO-

PANCREATOGRAPHY.

• Side viewing endoscope advanced into prox. Small bowel to cannulate ampulla + visualize biliary tree under XR imaging.

• Remove stones, sphinctomy+ insert stents.

• PREPARATION –no eating 6 hr prior.

• Check – warfarin, aspirin + clopidogrel.

• SEDATION.

• RISKS-

• 1. PANCREATITIS 1-2% , 1 IN 50 CASES.

• 2. BLEEDING –SPHINCTOMY 2%.

• 3. PERFORATION .

• 4. REACTION TO SEDATION .

• RECOVERY – findings explained/ report / telephone nos.

DIABETES + ENDOSCOPY PREPARATION + DIET FOR COLON/ FOS

• 1. IDDM.

• 2 DAYS PRIOR TO ENDOSCOPY- follow low residue diet.

• Bed time insulin reduce by 50%

• 1 DAY BEFORE PROCEDURE- low residue diet .

• Take am insulin as normal.

• Commence bowel prep / fluids +reduce insulin by 50%

• MONITOR BM, take glucose if necessary.

• DAY OF PROCEDURE.

• DO NOT TAKE INSULIN AM.

• CHECK BM,

• Bring insulin with you – post procedure dose/ eating.

DIABETES + ENDOSCOPY PREPARATION FOR COLON. 2

• 2. NIDDM / DIET

• 2 DAYS PRIOR –

• Low residue diet .

• 1 DAY BEFORE PROCEDURE-

• Once on bowel prep / fluids DO NOT METFORMIN.

• If on GLICLAZIDE –DO NOT TAKE PM DOSE.

• MONITOR BM- take glucose if low.

• DAY OF PROCEDURE-

• DO NOT TAKE DIABETIC MEDICATION.

• Bring medication so post procedure .

ENDOSCOPY +CREUTZFELDT-JAKOB DISEASECJD.

• CJD RARE+ FATAL NEURO DEGENERATIVE BRAIN DISEASE.

• GROUP DISEASES-CALLED TSE (TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES ) – affect humans + domestic animals.

• Mechanism of TSE- ↑ in naturally occurring prion protein.

• CJD –sporadic =no cause (80% , rare)

• --inherited types (15%)

• --variantCJD = strongly linked to ingestion of food containing a TSE called BOVINE SPONGIFORM ENCEPHALITIS .

• IATROGENIC CJD very rare. 4 cases via blood transfusion.

• CJD can be accidentally transmitted during medical ( endoscopy ) or surgical procedures- no cases so far.

• Identify patients who may be risk gp for CJD – since endoscopy might pass infective agent on.

RISK ASSESSMENT FOR IDENTIFICATION OF PATIENT WHO MIGHT CARRY TSE DISORDER.

• 1. HAS PATIENT RECEIVED NATURAL GH?

• 2. PATIENT RECEIVED NATURAL PITUITARY HORMONE?

• 3. FH OF CJD / TSE

• 4. ANY NEUROSURGICAL / ENT IMPLANT BEFOR 1993- implantation of human dura mater graft.

• 5. is CJD PART OF DIFF DIAGNOSIS ?

• IF YES TO ANY OF THESE-

• ALL INVASIVE PROCEDURES STOP.

• INFORM INFECTION CONTROL.