Informed Consent para sa Pasyente
Ako, si _____________________________ (pangalan), _____ (edad) taong gulang, ay malayang
makikibahagi sa pananaliksik na pinamagatang “A Comparison of Patient Preferences and
Resident Physician Attitudes and Practice on Disclosure of Poor Prognosis” na nasa
pangunahing pamamahala ni Dr. Barbara Amity N. Flores. Naipaliwanag sa akin at naunawaan
ko ang mga sumusunod:
Ang layunin ng pagsusuri na ito ay malaman ang mga saloobin at kagustuhan ng mga
pasyenteng katulad ko sa pagtanggap ng balita ukol sa maselan na paksa ng kamatayan.
Inaasahan na ang kalalabasan ng pagsusuri na ito ay makakatulong sa mga doctor upang mas
mapabuti ang pangngalaga ng mga pasyente, lalo na sa mga malubha ang sakit o nalalapit na sa
kamatayan.
Ako ay isa sa 156 na napiling pasyente na sasagot ng isang survey questionnaire ukol sa
nabanggit na paksa.
Hindi kinakailangan mag follow-up matapos masagutan ang questionnaire.
Walang anumang gamot ang ibibigay o ipapainom sa akin sa pananaliksik na ito.
Wala akong matatanggap na kabayaran sa aking pagsali.
Lahat ng impormasyon patungkol sa akin ay mananatiling lihim sa kaalaman ng ibang
tao. Ang mga resulta ng pananaliksik na ito ay maaaring ilahad sa mga talakayan o pahayagan
liban sa personal na impormasyon ukol sa akin.
Kusang-loob akong nakikibahagi sa pananaliksik na ito at maaari kong itigil ang aking
pakikipagbahagi sa kahit na anong oras o sa kahit na anong kadahilanan.
Para sa karagdagang kaalaman, maaari akong makipag-ugnayan kay Dra. Flores sa
numerong ito 554-8400 local 5300 o local 2521. Maari rin akong makipag-ugnayan sa Expanded
Hospital Research Office (EHRO) sa numerong 554-8400 local 2065, Lunes hanggang Biyernes
mula 8:00 ng umaga hanggang 4:00 ng hapon.
Walang mali o tamang sagot sa survey questionnaire na papasagutan sa akin, ang
kinakailangan lamang dito ay tapat na opinyon sa mga paksang bahagi ng pag-aaral.
Lagda:
________________________
Pangalan: ________________________
Petsa:
________________________
Pangalan at lagda ng tumanggap ng pahintulot na ito:
_____________________________________
Survey Questionnaire for PATIENTS
PATIENT FORM #:
EDAD:
TIRAHAN:
KASARIAN: ( ) LALAKI
Status Sibil: ( ) Single
( ) BABAE
( ) May asawa
RELIHIYON: ( ) KATOLIKO
( ) HINDI KATOLIKO (isulat ang Relihiyon):_____________________
NAKAPAGTAPOS HANGGANG:
( ) ELEMENTARY ( ) HIGH SCHOOL ( ) KOLEHIYO ( ) VOCATIONAL
( ) HINDI NAKAPAG-ARAL
ANO ANG IYONG SAKIT?
Gaano katagal mo na alam ang tungkol sa iyong sakit?:
( ) Bagong alam lang
( ) Ilan BUWAN pa lamang ( _____ bilang ng buwan)
( ) TAON na
( _____ bilang ng taon)
1. Komportable akong pag-usapan ang tungkol sa kamatayan.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
2. Napag-uusapan ang kamatayan sa aming pamilya.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
3. Tinatanggap ko na ang kamatayan ay natural na bahagi ng buhay ng isang tao.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
4. Mas gusto ko na hindi malaman kung ako ay mamamatay o malapit ng mamatay.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
5. Mas gusto ko na ang aking doctor ang magsabi sa akin na ako ay malubha na o malapit ng
mamamatay.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
6. Mas gusto ko na ang aking kamag-anak o mahal sa buhay ang magbabalita sa akin na ako
ay malubha na o mamamatay.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
7. Ayaw kong malaman ng aking kamag-anak/mahal sa buhay na ako ay may malubhang sakit at
mamamatay na.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
8. Importante sa akin ang malaman ng maaga na ako ay malubha na ang sakit at malapit ng
mamatay upang mapaghandaan ko ito.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
9. Hindi ako mawawalan ng pag-asa na magkaroon ng matiwasay na buhay kahit na malaman ko
na ako’y malubha na ang kalagayan at malapit ng mamatay.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
10. Mas gusto kong ipagpaliban ang usapan at pagdesisyun sa mga detalye ng aking kamatayan
hanggat maari.
( ) HIGIT na sumasang-ayon
( ) HINDI sumasang-ayon
( ) Sumasang-ayon
( ) MARIING HINDI sumasang-ayon
MARAMING SALAMAT PO
Informed Consent Form for Resident Physicians
I, __________________________ (Name/Initials),_______ (Age) ________(Gender), of
(Department) ________________________ give my consent to participate in the study entitled
A Comparison of Patient Preferences and Resident Physician Attitudes and Practice on
Disclosure of Poor Prognosis; under the supervision of Barbara Amity N. Flores, MD. I fully
understand my contribution and what is expected from me in this study. The following have been
explained well to me prior to my signing this consent:
The objective of the study is to determine patient and Resident Physicians perspectives
on death and disclosure of poor prognosis. This is a cross-sectional study. The target populations
are PGH patients seen at the Family Medicine Clinic and Resident Physicians from the Medical
and Surgical departments, particularly from Family Medicine, Internal Medicine, Pediatrics,
Surgery, Ophthalmology, Otorhinolaryngology and Obstetrics and Gynecology, currently
rotating/holding clinics at the Outpatient Department during the duration of the month of August.
I am one of the 52 Physician Residents selected to answer the survey questionnaire to be,
answered as honestly and judiciously as possible.
There will be no clinic visits or follow-ups required in this study. I am to submit my
accomplished survey questionnaire as soon as I finish answering it.
There will be no diagnostic tests or any medications involved in this study.
There will be no compensation for participating in this study.
All records or information revealed in this study will be kept strictly confidential.
However, the results may be published in journals or used as future reference if needed.
Results of the study may be shared with the respondents upon request.
My participation is voluntary and I can withdraw any time for any reason without any
repercussions to my training.
I can call or ask questions anytime regarding this study. The contact person should I need
more information about the study is Dr. Barbara Amity N. Flores at mobile number 09228483451 or via email thru amityflores@yahoo.com. I may also contact the Expanded Hospital
Research Office (EHRO) for other concerns regarding the study, during office hours, Monday to
Friday, 8:00am to 4:00 pm, at telephone number 554-8400 local 2506.
Signature of Respondent: ________________________________________
:
Informed Consent obtained by:____________________________________
Name and Signature / Date
Survey Questionnaire for Resident Physicians
Survey Form Number:
Gender: □ Male
Age:
Civil Status: □ Single
□ Female
□ Married
Religion : □ Catholic
□ Non-Catholic: (pls. Specify) ____________________
Specialty:
□ FM □ IM □ OB-Gyne □ ORL/ENT □ Ortho □ Ophthalmology □ Pediatrics □ Surgery
Year Level:
□ 1st yr Resident
□ 2nd yr Resident □ 3rd yr Resident □ 4th -5th yr Resident
Have you had clinical experience in the care of dying patients:
□ Yes □ No
Have you ever encountered difficulties/problems with disclosure of a terminal illness/bad
prognosis/death to a patient in the past?
□ Yes □ No
If you answered yes, is it still a problem for you now? □ Yes
□ No
Have you ever referred a patient to Supportive Palliative and Hospice Care for the purpose of
Disclosure in the past?
□ Yes □ No
If your answer is yes, do you still refer patients to SPHC for the purpose of Disclosure of terminal
illness/death? □ Yes □ No
Instructions: Please put a check mark under the column that corresponds to what you consider
as most appropriate for each phrase. There are no right or wrong answers.
4- Strongly Agree; 3- Agree; 2- Disagree; and 1- Strongly Disagree
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I believe Death is a natural process and part of the circle of life.
I consider a patient’s death as a failure of medicine.
I feel that a patient’s death represents a personal failure.
I prefer to avoid contact with dying patients.
I have difficulty in telling my patients directly they are going
to die.
I feel competent communicating with dying patients.
I consider taking care of dying patients an unpleasant aspect of my
profession.
I struggle to be honest and forth-coming with patients who
are dying.
I have personal discomfort in telling patients they are dying.
I believe that patients have the right to know that they are dying
Majority of patients do not want to know that they are dying
Majority of patients prefer to receive bad prognosis/ disclosure of
terminal illness/death from their doctor
Majority of patients prefer to receive bad prognosis/disclosure of
terminal illness/death from a relative or loved one
It is important that patients know at the earliest possible time that
they are dying.
Telling a patient that he/she is dying will destroy hope.
Majority of patients prefer only to discuss death and end-of-life care
when they are closer to death.
I prefer telling the family about my patient’s poor prognosis without
his/her knowledge
I believe that there is no need for me to have further
training/education on disclosing terminal illness and other end-of-life
care issues.
I only disclose serious illness/dying to patients when they ask about
it.
I withhold information about poor prognosis/death from patients
when requested by the family
THANK YOU VERY MUCH
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