Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Chest Tube Insertion
We have determined that you have a problem in your chest requiring placement of a chest tube. Chest tubes
may be required if the lung is collapsed (pneumothorax), or if the chest cavity is filled with liquid.
Description of the Procedure
The area of the chest tube is first numbed up (if you are awake for the procedure). A small incision is made in
the front or side of your chest where the chest tube is going to be placed. A tract for the tube is formed, and
the tube is inserted in proper position in the chest space. It is sutured into place, and secured to a suction
apparatus.
Alternatives for Treatment
Alternative treatments will depend on the nature of the disease undergoing treatment. This is often
performed for life-threatening problems for which there are few alternatives.
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:
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Bleeding – this is a problem that could happen any time the skin is cut. The need for a blood
transfusion is rare.
Infection – we take special care to prevent an infection, but it is always a possibility. An
infection of the tube may require prolonged hospitalization and treatment to resolve.
Reactions to medications – this could be many things, from a minor rash to possible death.
Reactions to anesthesia and surgery – this could show up as a heart attack, blood clots,
pneumonia, sore throat, or potential death, in rare cases.
Poor wound healing – breakdown of the incision.
Lung injury – the lung is very close and may be attached to the chest wall where the tube is going
to be placed, leading to a lung injury. This may necessitate an operation to fix.
Injury to the liver or spleen – these organs may occasionally be injured in the process of
placing a chest tube and may require major surgery to repair.
Recurrence of the original problem – the original problem may recur after removal of the
chest tube.
Pneumothorax on removal of chest tube – this may require another chest tube to be placed.
Failure of the tube to resolve the problem for which it was placed – this may require the
placement of more chest tubes, or consideration for alternative treatments.
(see other side)
Anticipated Recovery/Expected Rehabilitation
Recovery is variable, depending on the individual and the disease being treated. Activity will be severely
restricted while the chest tube is in place, with need for hospitalization. Most people will be able to resume
usual activities soon after removal of the chest tube.
Consent for Treatment
I understand my need for a chest tube. 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 the
chest tube placement.
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 a chest tube 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