{"type":"doc","content":[{"type":"extension","attrs":{"layout":"default","extensionType":"com.atlassian.confluence.macro.core","extensionKey":"toc","parameters":{"macroParams":{"minLevel":{"value":"1"},"maxLevel":{"value":"6"},"outline":{"value":"false"},"style":{"value":"none"},"type":{"value":"list"},"printable":{"value":"true"}},"macroMetadata":{"macroId":{"value":"a24f0c01-ccca-4e34-a843-d92c93ff0f19"},"schemaVersion":{"value":"1"},"title":"Table of Contents"}},"localId":"45d1b1a3-02dd-408f-a158-7d9f748b5cc5"}},{"type":"heading","attrs":{"level":1},"content":[{"text":"Key objectives","type":"text"}]},{"type":"paragraph","content":[{"text":"Provide patients with information about their treatment and collect information from the patient before their course of treatment starts, helping to reduce clinic time and to support patient empowerment.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Outcome measures","type":"text"}]},{"type":"paragraph","content":[{"text":"Equip patients with the information they need before their treatment starts, also providing the tools they need to interact digitally rather than relying on face to face consultations.","type":"text"}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Current Baselines","type":"text"}]},{"type":"paragraph","content":[{"text":"The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a checklist/consent form with the patient, appointments aren’t being efficient and patients are having long waiting times.","type":"text"}]},{"type":"heading","attrs":{"level":1},"content":[{"text":"Workflow","type":"text"}]},{"type":"mediaSingle","attrs":{"layout":"center"},"content":[{"type":"media","attrs":{"width":1280,"id":"cb582db8-d866-4fcb-8317-81f76bf6e14e","collection":"contentId-3572990098","type":"file","height":725}}]},{"type":"heading","attrs":{"level":2},"content":[{"text":"Consent short video","type":"text"}]},{"type":"extension","attrs":{"layout":"default","extensionType":"com.atlassian.confluence.macro.core","extensionKey":"iframe","parameters":{"macroParams":{"src":{"value":"https://player.vimeo.com/video/566653281?h=514e39cf44&color=058CAD&byline=0"},"width":{"value":"100%"},"frameborder":{"value":"hide"},"height":{"value":"360"}},"macroMetadata":{"macroId":{"value":"1bdddd782ee90c1fd742c5bc6e70aab2"},"schemaVersion":{"value":"1"},"title":"Iframe"}},"localId":"38a29b78-d23f-431c-8f35-e65983de4962"}},{"type":"heading","attrs":{"level":1},"content":[{"text":"Advantages of using PKB","type":"text"}]},{"type":"paragraph","content":[{"text":"Cancer Research UK (CRUK) has identified several advantages of using the PKB consent process and found no disadvantages.","type":"text"}]},{"type":"bulletList","content":[{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Patients, carers, and professionals can access the PKB portal anytime, from any device.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Blank forms can be uploaded to PKB without altering content, either by PKB or the trust.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Forms can be customised to meet specific needs.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Consent can be obtained remotely or in person.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Accessible via a web browser at any time.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Already in use within NWL STP.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Trusts can choose to use only the consent form functionality without adopting other PKB features.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"No additional costs—whether uploaded by PKB or the trust, all charges are covered under the software licence.","type":"text"}]}]},{"type":"listItem","content":[{"type":"paragraph","content":[{"text":"Templates can be uploaded before go-live and updated as needed.","type":"text"}]}]}]},{"type":"heading","attrs":{"level":1},"content":[{"text":"Patient Agreement to Immunotherapy Care Plan Template","type":"text"}]},{"type":"mediaSingle","attrs":{"layout":"center","width":616,"widthType":"pixel"},"content":[{"type":"media","attrs":{"width":1280,"id":"9dd8139c-6e74-467b-b849-2a6467e986ae","collection":"contentId-3572990098","type":"file","height":14270}}]},{"type":"expand","attrs":{"title":"Example template code for Patient Agreement to Immunotherapy Care Plan"},"content":[{"type":"paragraph","content":[{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Special requirements:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

(e.g. other language/other communication method)

","type":"text"},{"type":"hardBreak"},{"text":"

Responsible consultant:

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Name of proposed course of treatment

","type":"text"},{"type":"hardBreak"},{"text":"

(include brief explanation if medical term not clear. Include regimen/protocol name and list drug names in full. Specify the indication, route, schedule of administration, and location of treatment.)

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Regimen","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Indication for treatment (i.e. tumour site):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Route(s) of administration:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Intravenous","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Subcutaneous","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Oral","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" If Other","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Frequency (treatment days and length of cycle):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Duration of treatment (number of cycles):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" A separate consent form must be completed for radiotherapy","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Participation in a clinical trial","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" (trial name)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Where the treatment will be given:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Outpatient","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Day unit/case","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inpatient","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" If other, please define","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Statement of health professional

","type":"text"},{"type":"hardBreak"},{"text":"

(to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in the hospital /Trust/NHS board's consent policy)

","type":"text"},{"type":"hardBreak"},{"text":"

Tick all relevant boxes

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I confirm the patient has capacity to give consent.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

I have explained the course of treatment and intended benefit to the patient.

","type":"text"},{"type":"hardBreak"},{"text":"

The intended benefits

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Curative - to give you the best possible chance of being cured.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Disease control/palliative - the aim is not to cure but to control or shrink the disease.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

The aim is to improve both quality of life and survival.

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Adjuvant - therapy given after surgery to reduce the risk of the cancer coming back.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Neo-adjuvant - therapy given before surgery/radiotherapy to shrink the cancer, allow radical treatment and reduce the risk of the cancer coming back.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Significant, unavoidable or frequently occurring risks (indicate all that apply):

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" This medicine acts on your immune system and may cause inflammation in parts of the body. This can sometimes cause severe side effects which may be life-threatening. It is important that any side effects are treated when they occur to stop them from getting worse. Some side effects begin during treatment but they can sometimes happen months after the last treatment. ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Tiredness and feeling weak (fatigue). ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Diarrhoea. ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Feeling sick (nausea) and being sick (vomiting). ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Loss of appetite. Skin reactions and rashes (which can be severe). ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Hair loss or thining of the hair. ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Flu-like symptoms. ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" High temperature (fever).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Infusion-related reactions include allergic reactions (causing a high temperature, chills, shivering (rigors), a headache, and feeling sick (nausea), and pain at the site of the infusion.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation in the stomach or intestines (causing stomach pain, diarrhoea, and mucus or blood in the stools). ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the liver. ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the nervous system (causing muscle weakness, and numbness and tingling in the hands and feet).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the lungs (causing breathlessness and cough).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the pancreas. Inflammation of the kidneys.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the eyes (causing blurred vision and eye pain).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of hormone producing glands (causing underactive function of the thyroid, adrenal and/or pituitary gland).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Some side effects are permanent and require long term or life time hormone replacement.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the joints (arthritis).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the heart muscle (causing increase in heart beat and abnormal heart rhythms).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Impaired kidney function. Impaired liver function.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Problems with sleep. Unstable blood sugars.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Blood pressure changes.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Some side effects may need to be treated with high dose steroids or other immunosuppressive drugs.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Cancer can increase your risk of developing a blood clot (thrombosis).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" A blood clot may cause pain, redness and swelling in a leg, or breathlessness and chest pain - you must tell your doctor straight away if you have any of these symptoms.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Some anti-cancer medicines possibly can damage women's ovaries and men's sperm. This may lead to infertility in men and women and/or early menopause in women. Early menopause can cause symptoms such as hot flushes, vaginal dryness.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Some anti-cancer medicines may damage the development of a baby in the womb. It is important not to become pregnant or father a child while you are having treatment and for a few months afterwards. It is important to use effective contraception during and for several months after chemotherapy. You can talk to your doctor or nurse about this.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Complications of treatment can very occasionally be life threatening and may result in death. The risks are different for every individual. Potentially life threatening complications include those listed on this form, but, other exceedingly rare side effects may also be life threatening.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other risks and information:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have discussed the intended benefits of the treatment advised and risks of any available alternative treatments (including no treatment).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have discussed the side effects of the treatment advised, which could affect the patient straight away or in the future, and that there may be some side effects not listed because they are rare or have not yet been reported. Each patient may experience side effects differently.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have discussed what the treatment is likely to involve (including inpatient / outpatient treatment, timing of the treatment, blood and any additional tests, follow-up appointments etc) and location.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have explained to the patient, that he/she has the right to stop this treatment at any time and should contact the responsible consultant or team if they wish to do so.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have discussed concerns of particular importance to the patient in regard to treatment","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" (please write details here):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Clinical management guideline/Protocol compliant (please select):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Yes","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" No","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Not available","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" If No please document reason here:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" The following leaflet has been provided:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Information leaflets for:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Unlicensed medicine use information (when relevant)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" 24 hour chemotherapy service contact details","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" SACT treatment record (","type":"text"},{"type":"inlineCard","attrs":{"url":"http://cruk.org/treatment-record"}},{"text":" )","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" please state:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Healthcare professional details:

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Statement of interpreter

","type":"text"},{"type":"hardBreak"},{"text":"

(where appropriate)

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Interpreter booking reference (if applicable):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

I have interpreted the information above to the patient to the best of my ability and in a way in which I believe they can understand.

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Statement of patient

","type":"text"},{"type":"hardBreak"},{"text":"

Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of the form which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask - we are here to help you. You have the right to change your mind at any time, including after you have signed this form.

","type":"text"},{"type":"hardBreak"},{"text":"

I agree to the procedure and course of treatment described on this form.

","type":"text"},{"type":"hardBreak"},{"text":"

I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate training and experience.

","type":"text"},{"type":"hardBreak"},{"text":"

I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.

","type":"text"},{"type":"hardBreak"},{"text":"

I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion:

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

A witness should sign below if the patient is unable to sign but has indicated their consent. Young people/children may also like a parent to sign here (see notes).

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Copy accepted by patient:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Yes","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" No","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Confirmation of consent

","type":"text"},{"type":"hardBreak"},{"text":"

(health professional to complete when the patient attends for treatment, if the patient has signed the form in advance)

","type":"text"},{"type":"hardBreak"},{"text":"

On behalf of the team treating the patient, I have confirmed that the patient has no further questions and wishes the course of treatment/procedures to go ahead.

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Important notes: (select if applicable)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" See also advance decision to refuse treatment","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Patient has withdrawn consent","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" (ask patient to sign /date here)","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Further information for patients

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Contact details (if patient wishes to discuss options later):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Contact your hospital team if you have any questions about cancer and its treatment.

","type":"text"},{"type":"hardBreak"},{"text":"

Cancer Research UK can also help answer your questions about cancer and treatment. If you want to talk in confidence, call our information nurses on freephone 0808 800 4040, Monday to Friday, 9am to 5pm. Alternatively visit ","type":"text"},{"type":"inlineCard","attrs":{"url":"http://www.cruk.org"}},{"text":" for more information.

","type":"text"},{"type":"hardBreak"},{"text":"

These forms have been produced by Guy's and St. Thomas' NHS Foundation Trust as part of a national project to support clinicians in ensuring all patients are fully informed when consenting to SACT. The project is supported by Cancer Research UK. This does not mean you are taking part in a clinical trial.

","type":"text"},{"type":"hardBreak"},{"text":"

What a consent form is for

","type":"text"},{"type":"hardBreak"},{"text":"

This form documents the patient's agreement to go ahead with the treatment you have proposed. It is not a legal waiver - if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoir to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient.

","type":"text"},{"type":"hardBreak"},{"text":"

The law on consent

","type":"text"},{"type":"hardBreak"},{"text":"

See the following publications for a comprehensive summary of the law on consent. Consent: Patients and doctors making decisions together, GMC 2008 (available at ","type":"text"},{"type":"inlineCard","attrs":{"url":"http://www.gmc-uk.org/guidance"}},{"text":" ), and Reference guide to consent for examination or treatment, Department of Health, 2nd edition 2009 (available at ","type":"text"},{"text":"www.doh.gov.uk","type":"text","marks":[{"type":"link","attrs":{"href":"http://www.doh.gov.uk"}}]},{"text":").

","type":"text"},{"type":"hardBreak"},{"text":"

Who can give consent

","type":"text"},{"type":"hardBreak"},{"text":"

Everyone aged 16 or over is presumed to have the capacity to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has \"sufficient understanding and intelligence to enable him or her to understand fully what is proposed\", then the child will have capacity to give consent for himself or herself.

","type":"text"},{"type":"hardBreak"},{"text":"

Young people aged 16 and 17, and younger children with capacity, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent, someone with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where children are able to give consent for themselves, you should always involve those with parental responsibility in the child's care, unless the child specifically asks you not to do so. If a patient has the capacity to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally.

","type":"text"},{"type":"hardBreak"},{"text":"

When NOT to use this form

","type":"text"},{"type":"hardBreak"},{"text":"

If the patient is 18 or over and lacks the capacity to give consent, you should use an alternative form (form for adults who lack the capacity to consent to investigation or treatment). A patient lacks capacity if they have an impairment or disturbance of the brain, affecting the way their mind works. For example, if they cannot do one of the following:

","type":"text"},{"type":"hardBreak"},{"text":"

understand information about the decision to be made
retain that information in their mind
use or weigh this information as a part of their decision making process, or
communicate their decision (by talking, using sign language or any other means)

","type":"text"},{"type":"hardBreak"},{"text":"

You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so.

","type":"text"},{"type":"hardBreak"},{"text":"

Relatives cannot be asked to sign a form on behalf of an adult who lacks capacity to consent for themselves, unless they have been given the authority to do so under a Lasting Power of Attorney or as a court deputy.

","type":"text"},{"type":"hardBreak"},{"text":"

Information

","type":"text"},{"type":"hardBreak"},{"text":"

Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about 'significant risks which would affect the judgement of a reasonable patient'. 'Significant' has not been legally defined, but the GMC requires doctors to tell patients about 'significant, unavoidable or frequently occurring' risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on the consent form or in the patient's notes.

","type":"text"},{"type":"hardBreak"},{"text":"

References

","type":"text"},{"type":"hardBreak"},{"text":"

Summary of Product Characteristics (SPCs) for individual drugs: <","type":"text"},{"text":"https://www.medicines.org.uk/emc>
Cancer Research UK: <","type":"text"},{"text":"https://www.cancerresearchuk.org/aboutcancer/cancer-in-general/treatment/cancer-drugs>
Macmillan Cancer Support: <","type":"text"},{"text":"https://www.macmillan.org.uk/information-and-support/treating/chemotherapy/drugs-andcombination-regimens>
Guy's and St. Thomas' NHS Foundation Trust, Chemotherapy consent forms.

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"}]}]},{"type":"heading","attrs":{"level":1},"content":[{"text":"Patient agreement to systemic anti-cancer therapy (SACT) Care Plan Template","type":"text"}]},{"type":"mediaSingle","attrs":{"layout":"center","width":564,"widthType":"pixel"},"content":[{"type":"media","attrs":{"width":1280,"id":"21705c67-64dd-4c4c-bbca-50eca2e732a8","collection":"contentId-3572990098","type":"file","height":6592}}]},{"type":"expand","attrs":{"title":"Example template code for Patient agreement to systemic anti-cancer therapy (SACT) Care Plan"},"content":[{"type":"paragraph","content":[{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Special requirements:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

(e.g. other language/other communication method)

","type":"text"},{"type":"hardBreak"},{"text":"

Responsible consultant:

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Name of proposed course of treatment

","type":"text"},{"type":"hardBreak"},{"text":"

(include brief explanation if medical term not clear. Include regimen/protocol name and list drug names in full. Specify the indication, route, schedule of administration, and location of treatment.)

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Regimen","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Indication for treatment (i.e. tumour site):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Route(s) of administration:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Intravenous","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Subcutaneous","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Oral","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" If Other","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Frequency (treatment days and length of cycle):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Duration of treatment (number of cycles):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" A separate consent form must be completed for radiotherapy","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Participation in a clinical trial","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" (trial name)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Where the treatment will be given:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Outpatient","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Day unit/case","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inpatient","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" If other, please define","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Statement of health professional

","type":"text"},{"type":"hardBreak"},{"text":"

(to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in the hospital /Trust/NHS board's consent policy)

","type":"text"},{"type":"hardBreak"},{"text":"

Tick all relevant boxes

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I confirm the patient has capacity to give consent.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

I have explained the course of treatment and intended benefit to the patient.

","type":"text"},{"type":"hardBreak"},{"text":"

The intended benefits

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Curative - to give you the best possible chance of being cured.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Disease control/palliative - the aim is not to cure but to control or shrink the disease.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

The aim is to improve both quality of life and survival.

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Adjuvant - therapy given after surgery to reduce the risk of the cancer coming back.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Significant, unavoidable or frequently occurring risks (indicate all that apply):

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Tiredness and feeling weak (fatigue)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" An increased risk of getting an infection from a drop in white blood cells - it is harder to fight infections and you can become very ill. If you have a severe infection this can be life threatening. Contact your doctor or hospital straight away if: • your temperature goes over 37.5°C or over 38°C, depending on the advice given by your chemotherapy team • you suddenly feel unwell (even with a normal temperature)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Anaemia (low number of red blood cells).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Bruising or bleeding.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Feeling sick (nausea) or being sick (vomiting).","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Sore mouth and ulcers.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Diarrhoea.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Constipation.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Taste changes.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Loss of appetite.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Hair loss.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Skin rashes.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Nail changes.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Chemotherapy may leak outside of the vein while it is being given; this is called extravasation. If this happens when you're having chemotherapy it can damage the tissue around the vein. Tell the nurse straight away if you have any stinging, pain, redness or swelling around the vein. Extravasation is not common but if it happens it's important that it's dealt with quickly.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Inflammation of the hands and feet.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Numbness or tingling in hands or feet.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Impaired hearing or ringing in the ears.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Problems with the eyes.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Allergic reactions.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Impaired heart function.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Impaired lung function.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Impaired kidney function.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Impaired liver function.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Fluid retention.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Tumour lysis syndrome.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Problems with sleep.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Flu-like symptoms.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Unstable blood sugars.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Risk of a second cancer.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Potential side-effects with the anti-sickness medication may include: constipation, headaches, indigestion, difficulty sleeping and agitation.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Cancer can increase your risk of developing a blood clot (thrombosis), and having treatment with anti-cancer medicines may increase this risk further. A blood clot may cause pain, redness and swelling in a leg, or breathlessness and chest pain - you must tell your doctor straight away if you have any of these symptoms.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Some anti-cancer medicines can damage women's ovaries and men's sperm. This may lead to infertility in men and women and/or early menopause in women. Early menopause symptoms include hot flushes, vaginal dryness.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Some anti-cancer medicines may damage the development of a baby in the womb. It is important not to become pregnant or father a child while you are having treatment and for a few months afterwards. It is important to use effective contraception during and for several months after treatment. You can talk to your doctor or nurse about this.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other risks and information:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have discussed concerns of particular importance to the patient in regard to treatment","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" (please write details here):","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Clinical management guideline/Protocol compliant (please select):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Yes","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" No","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Not available","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" If No please document reason here:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" The following leaflet has been provided:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Information leaflets for:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" 24 hour alert card or SACT advice service contact details","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" SACT record booklet / diary","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Other","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" please state:","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Healthcare professional details:

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

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Statement of interpreter

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(where appropriate)

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","type":"text"},{"type":"hardBreak"},{"text":" Interpreter booking reference (if applicable):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

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I have interpreted the information above to the patient to the best of my ability and in a way in which I believe they can understand.

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Statement of patient

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I have had enough time to consider my options and make a decision about treatment.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" I agree to the course of treatment described on this form.","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

A witness should sign below if the patient is unable to sign but has indicated their consent. Young people/children may also like a parent to sign here (see notes).

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","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Copy accepted by patient:","type":"text"},{"type":"hardBreak"},{"text":"

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","type":"text"},{"type":"hardBreak"},{"text":" Yes","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" No","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Confirmation of consent

","type":"text"},{"type":"hardBreak"},{"text":"

(health professional to complete when the patient attends for treatment, if the patient has signed the form in advance)

","type":"text"},{"type":"hardBreak"},{"text":"

On behalf of the team treating the patient, I have confirmed that the patient has no further questions and wishes the course of treatment/procedures to go ahead.

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Signed:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Date:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Name (print):","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Job title:","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" ","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Important notes: (select if applicable)","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" See also advance decision to refuse treatment","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":" Patient has withdrawn consent","type":"text"},{"type":"hardBreak"},{"text":"

","type":"text"},{"type":"hardBreak"},{"text":"

Further information for patients

","type":"text"},{"type":"hardBreak"},{"text":"

Contact your hospital team if you have any questions about cancer and its treatment.

","type":"text"},{"type":"hardBreak"},{"text":"

What a consent form is for

","type":"text"},{"type":"hardBreak"},{"text":"

The law on consent

","type":"text"},{"type":"hardBreak"},{"text":"

Who can give consent

","type":"text"},{"type":"hardBreak"},{"text":"

When NOT to use this form

","type":"text"},{"type":"hardBreak"},{"text":"

understand information about the decision to be made
retain that information in their mind
use or weigh this information as a part of their decision making process, or
communicate their decision (by talking, using sign language or any other means)

","type":"text"},{"type":"hardBreak"},{"text":"

You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so.

","type":"text"},{"type":"hardBreak"},{"text":"

Information

","type":"text"},{"type":"hardBreak"},{"text":"

References

","type":"text"},{"type":"hardBreak"},{"text":"

Summary of Product Characteristics (SmPCs) for individual drugs: <","type":"text"},{"text":"https://www.medicines.org.uk/emc>
Cancer Research UK: <","type":"text"},{"text":"https://www.cancerresearchuk.org/aboutcancer/cancer-in-general/treatment/cancer-drugs>
Macmillan Cancer Support: <","type":"text"},{"text":"https://www.macmillan.org.uk/information-and-support/treating/chemotherapy/drugs-andcombination-regimens>
Guy's and St. Thomas' NHS Foundation Trust, Chemotherapy consent forms.

","type":"text"},{"type":"hardBreak"},{"text":"

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