DONOR NEPHRECTOMY
Informed Consent Information
The purpose of this document is to provide written information regarding the
risks, benefits and alternatives of the procedure named above. This material
serves as a supplement to the discussion you have with your physician. It is
important that you fully understand this information, so please read this
document thoroughly. If you have any questions regarding the procedure, ask
your physician prior to signing the consent form. We appreciate your selecting
UCLA Health System to meet your needs.
The Procedure: The kidneys filter the blood and remove by products of
metabolism by secreting them into the urine. The urine is then transported into
the bladder and then eliminated from the body. Most people have two kidneys.
If you are healthy, it is usually safe to remove one kidney and give it to someone
whose kidneys have failed. This is possible because each healthy kidney has
enough reserve filtering capacity to take care of all of the body’s needs.
Nearly all patients do very well after this surgery, however, having a kidney
removed (nephrectomy) is a major operation and the doctors cannot guarantee
that the operation will be perfect for you, or the recipient of your kidney.
Everyone has some pain after this surgery and we will do everything possible to
facilitate your recovery.
Benefits
If your kidney is successfully
transplanted (about 98% chance),
your gift will make a significant
difference in the health and quality of
life for the patient with kidney failure
that receives it. The doctors cannot
guarantee you will receive any of this
benefit.
UCLA Form #500200 Rev. (11/08)
Signed Chart Copy
The doctors also cannot guarantee
that the recipient of your kidney will
live longer than if you had not
donated. Only you can decide if the
potential benefits are worth the risks.
Patient Copy
Page 1 of 2
Risks
Before undergoing this procedure, prolonged hospitalization, and/or
understanding the risks is essential. extended outpatient therapy to permit
No procedure is completely risk-free. adequate treatment.
The following risks may occur, but
there may be unforeseen risks and
risks that are not included on this list.
Some of these risks, if they occur,
may necessitate additional surgery,
Alternatives
The alternatives to this procedure If you decide not to have this
include:
procedure, there may be associated
1. Not undergoing the procedure
risks to this decision. Please discuss it
with your doctor.
I discussed the above risks, benefits, and alternatives with the patient.
The patient had an opportunity to have all questions answered and was
given a copy of this information sheet.
Physician Signature
Date
Patient Signature
Date
Patient’s Representative or
Parent Signature
Date
U UCLA Form #500200 Rev. (11/08)
Signed Chart Copy
Patient Copy
Page 2 of 2
DONOR NEPHRECTOMY
Informed Consent Information
The purpose of this document is to provide written information regarding the
risks, benefits and alternatives of the procedure named above. This material
serves as a supplement to the discussion you have with your physician. It is
important that you fully understand this information, so please read this
document thoroughly. If you have any questions regarding the procedure, ask
your physician prior to signing the consent form. We appreciate your selecting
UCLA Health System to meet your needs.
The Procedure: The kidneys filter the blood and remove by products of
metabolism by secreting them into the urine. The urine is then transported into
the bladder and then eliminated from the body. Most people have two kidneys.
If you are healthy, it is usually safe to remove one kidney and give it to someone
whose kidneys have failed. This is possible because each healthy kidney has
enough reserve filtering capacity to take care of all of the body’s needs.
Nearly all patients do very well after this surgery, however, having a kidney
removed (nephrectomy) is a major operation and the doctors cannot guarantee
that the operation will be perfect for you, or the recipient of your kidney.
Everyone has some pain after this surgery and we will do everything possible to
facilitate your recovery.
Benefits
If your kidney is successfully
transplanted (about 98% chance),
your gift will make a significant
difference in the health and quality of
life for the patient with kidney failure
that receives it. The doctors cannot
guarantee you will receive any of this
benefit.
UCLA Form #500200 Rev. (11/08)
Signed Chart Copy
The doctors also cannot guarantee
that the recipient of your kidney will
live longer than if you had not
donated. Only you can decide if the
potential benefits are worth the risks.
Patient Copy
Page 1 of 2
Risks
Before undergoing this procedure, prolonged hospitalization, and/or
understanding the risks is essential. extended outpatient therapy to permit
No procedure is completely risk-free. adequate treatment.
The following risks may occur, but
there may be unforeseen risks and
risks that are not included on this list.
Some of these risks, if they occur,
may necessitate additional surgery,
Alternatives
The alternatives to this procedure If you decide not to have this
include:
procedure, there may be associated
1. Not undergoing the procedure
risks to this decision. Please discuss it
with your doctor.
I discussed the above risks, benefits, and alternatives with the patient.
The patient had an opportunity to have all questions answered and was
given a copy of this information sheet.
Physician Signature
Date
Patient Signature
Date
Patient’s Representative or
Parent Signature
Date
UCLA Form #500200 Rev. (11/08)
Signed Chart Copy
Patient Copy
Page 2 of 2