Robert C Wright, MD, PS– Puyallup, Washington
Informed Consent – Removal of a Foreign Body
A foreign body consists of any device or material contained within the body that is not naturally there.
Often the foreign body is a surgically placed device such as a vascular access catheter. Sometimes it may
be an object that was acquired accidentally. Frequently, the reason for removal of the foreign body is
because the object is bothersome or irritating. Other times, the device is no longer needed because
treatments are completed.
Description of the Procedure
This procedure is almost always performed under local anesthesia, unless the foreign body is deep in the
body. The skin is incised over the object, and the object is located and removed. The skin is then closed
unless the object was infected, in which case the surgeon may decide to leave the skin open.
Risks/Complications of Treatment
In any medical treatment, it is impossible to predict all the things that could go wrong. Fortunately
complications are the exception rather than the rule. Every reasonable effort is made to avoid
complications. The most common possible complications are as follows:
Possible complications following any operation
1.
Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion during or after this operation is rare.
2.
Infection – we take special care to prevent an infection, but it is always a possibility with a
foreign body. An infection may require prolonged wound care and treatment to resolve.
3.
Reactions to medications – this could be many things, from a minor rash to possible death.
4.
Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots,
pneumonia, sore throat, or potential death, in rare cases.
5.
Poor wound healing – breakdown of the incision.
Possible complications following removal of a foreign body
1.
2.
Inability to locate the foreign body – this may occur if the object was received
accidentally.
Inability to remove the entire device – often, the “break-away” cuff of a Hickmann
catheter may be left intact beneath the skin. Occasionally, the end of a vascular
catheter may break off and require additional emergent procedures to retrieve.
Anticipated Recovery/Expected Rehabilitation
Recovery from surgery is usually quite rapid, with the ability to return to work within one to two days. If
there are sutures, they would be removed in one to two weeks.
(see other side)
Consent for Treatment
I understand my decision to have a foreign body removed from me. I have read and understand
the above explanation of the procedure being proposed. My surgeon has answered my questions,
and I choose to proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon permission to
act on his best judgment in deciding to remove or biopsy tissues that appear to be diseased,
understanding that complications may arise from that action.
I understand that while most people receiving removal of a foreign body benefit from the operation,
I may not. My condition may not improve, and it may worsen. No absolute guarantee can be
made.
HIPAA: Before and after surgery, unless otherwise requested in writing by you, visitors whom you
invite to attend the surgery will be informed of the surgical finding, your surgical status, and
anticipated recovery issues for effectiveness of communications. Because of the anesthetic, you may
or may not remember these important details.
PRINT NAME OF PATIENT ________________________________________________________________
SIGNATURE ______________________________________________ DATE _________________
WITNESS ________________________________________________ DATE _________________
SURGEON ________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ________________________________
I waive the right to read this form, and do not want to be educated and informed of treatment
risks; nonetheless I understand the need for this surgery and grant permission to the surgeon to
proceed on my behalf.
SIGNATURE __________________________________________________ DATE _________________
rev 6-30/kab