© The State of Queensland (Queensland Health), 2011

Permission to reproduce should be sought from ip_officer@health.qld.gov.au

(Affix identification label here)

URN:

Family name:

Endoscopic Ultrasound (EUS) & Given name(s):

Fine Needle Biopsy Address:

Date of birth: Sex: M F I

Facility:

A. Interpreter / cultural needs Uncommon risks and complications include:

An Interpreter Service is required? Yes No  About 2 people in every 100 will get an infection
from a fine needle biopsy of a cyst. Antibiotics are
If Yes, is a qualified Interpreter present? Yes No given during and after the procedure to reduce
A Cultural Support Person is required? Yes No the risk of this complication.
If Yes, is a Cultural Support Person present? Yes No  About 1 person in every 100 will experience
pancreatitis. This usually settles without specific
B. Condition and treatment treatment but extremely rarely can cause death.
The doctor has explained that you have the following  About 2 people in every 1,000 will have minor
condition: (Doctor to document in patient’s own words) bleeding from the gut where the fine needle
biopsy was taken. This can usually be stopped
........................................................................................................................................................................... through the endoscope. Rarely, surgery is
needed to stop the bleeding.
...........................................................................................................................................................................
 About 1 person in every 1,000 will accidentally
This condition requires the following procedure.
(Doctor to document - include site and/or side where get a tear or hole (perforation) through the wall of
relevant to the procedure) the gut. This can cause a leak of stomach
DO NOT WRITE IN THIS BINDING MARGIN

contents into the abdomen. Surgery may be

........................................................................................................................................................................... needed to repair the tear or hole.
 Missed growths in and around the gastrointestinal
...........................................................................................................................................................................
tract.
The following will be performed:
 Your procedure may not be able to be completed.
An endoscopic ultrasound (EUS) is where the doctor
 Heart and lung problems such as heart attack or
uses an instrument called an endoscope, which has
vomit in the lungs causing pneumonia.
an ultrasound probe at its tip to examine the wall
Emergency treatment may be necessary.
layers (inside and outside) of the upper and lower
 Damage to your teeth or jaw due to the presence

PROCEDURAL CONSENT FORM

gastrointestinal tract. It also provides excellent
pictures of your pancreas, bile ducts and organs in of instruments in your mouth.
your chest.  ‘Dead arm’ type feeling in any nerve, due to
An endoscope is a long, thin, flexible tube with a small positioning with the procedure – usually
camera and light attached which allows the doctor to temporary.
see the pictures of the inside and outside of your gut  An existing medical condition that you may have
on a video screen. getting worse.
The EUS allows a fine needle biopsy (sample) of Rare risks and complications include:
tissue to be taken inside or outside the wall of the gut.
 Bacteraemia (infection in the blood). This will
This procedure may or may not require a sedation need antibiotics.
anaesthetic.
 Stroke resulting in brain damage.
C. Risks of an endoscopic ultrasound (EUS)  Anaphylaxis (severe allergy) to medication given
& fine needle biopsy at the time of procedure.
 Death as a result of complications to this
There are risks and complications with this procedure.
They include but are not limited to the following. procedure is rare.
v2.00 - 02/2011

Common risks and complications include: D. Significant risks and procedure options
 Nausea and vomiting. Faintness or dizziness, (Doctor to document in space provided. Continue in
especially when you start to move around. Medical Record if necessary.)
 Headache.
...........................................................................................................................................................................
 Pain, redness or bruising at the sedation injection
site (usually in the hand or arm). ...........................................................................................................................................................................

 Muscle aches and pains.

E. Risks of not having this procedure
SW9158

 Allergy to medications given at time of the

procedure. (Doctor to document in space provided. Continue in
Medical Record if necessary.)
...........................................................................................................................................................................

Page 1 of 2 Continues over page ►►►

 (Affix identification label here)

URN:

Family name:

Endoscopic Ultrasound (EUS) & Given name(s):

Fine Needle Biopsy Address:

Date of birth: Sex: M F I

Facility:

F. Patient consent I request to have the procedure

I acknowledge that the doctor has explained; Name of Patient: ..........................................................................................................................

 my medical condition and the proposed Signature: ..........................................................................................................................................

procedure, including additional treatment if the Date: ......................................................................................................................................................
doctor finds something unexpected. I understand
the risks, including the risks that are specific to Patients who lack capacity to provide consent
me. Consent must be obtained from a substitute decision
maker/s in the order below.
 The anaesthetic/sedation required for this
Does the patient have an Advance Health Directive
procedure. I understand the risks, including the
(AHD)?
risks that are specific to me.
 other relevant procedure/treatment options and Yes Location of the original or certified copy of the AHD:
their associated risks. ................................................................................................................................................................

 my prognosis and the risks of not having the

procedure. No Name of Substitute
 that no guarantee has been made that the Decision Maker/s: ...............................................................................................................

DO NOT WRITE IN THIS BINDING MARGIN

procedure will improve my condition even though Signature: .....................................................................................................................................
it has been carried out with due professional care.
Relationship to patient: .................................................................................................
 the procedure may include a blood transfusion.
 tissues and blood may be removed and could be Date: ....................................................... PH No: ..................................................................
used for diagnosis or management of my Source of decision making authority (tick one):
condition, stored and disposed of sensitively by Tribunal-appointed Guardian
the hospital. Attorney/s for health matters under Enduring Power
 if immediate life-threatening events happen of Attorney or AHD
during the procedure, they will be treated based Statutory Health Attorney
on my discussions with the doctor or my Acute If none of these, the Adult Guardian has provided
Resuscitation Plan. consent. Ph 1300 QLD OAG (753 624)
 a doctor other than the Consultant may conduct
the procedure. I understand this could be a doctor
G. Doctor/delegate statement
undergoing further training.
I have been given the following Patient I have explained to the patient all the above points
Information Sheet/s: under the Patient Consent section (G) and I am of
the opinion that the patient/substitute decision-
Endoscopic Ultrasound (EUS) & Fine maker has understood the information.
Needle Biopsy
Name of
 I was able to ask questions and raise concerns Doctor/delegate: ..........................................................................................................................
with the doctor about my condition, the proposed
Designation:.....................................................................................................................................
procedure and its risks, and my treatment
options. My questions and concerns have been Signature: ..........................................................................................................................................
discussed and answered to my satisfaction.
Date: .......................................................................................................................................................
 I understand I have the right to change my mind
at any time, including after I have signed this form H. Interpreter’s statement
but, preferably following a discussion with my
doctor. I have given a sight translation in
 I understand that image/s or video footage may .....................................................................................................................................................................
be recorded as part of and during my procedure (state the patient’s language here) of the consent
and that these image/s or video/s will assist the form and assisted in the provision of any verbal and
doctor to provide appropriate treatment. written information given to the patient/parent or
On the basis of the above statements, guardian/substitute decision-maker by the doctor.
Name of
Interpreter: ........................................................................................................................................
02/2011 - v2.00

Signature: ..........................................................................................................................................

Date: .......................................................................................................................................................

Page 2 of 2
 © The State of Queensland (Queensland Health), 2011
Permission to reproduce should be sought from ip_officer@health.qld.gov.au
Consent Information - Patient Copy
Endoscopic Ultrasound (EUS) & Fine Needle Biopsy

1. What is an endoscopic ultrasound (EUS) You may remember some or little about what has
and fine needle biopsy? occurred during the procedure.
An endoscopic ultrasound (EUS) is where the doctor Anaesthesia is generally very safe but every
uses an instrument called an endoscope, which has anaesthetic has a risk of side effects and
an ultrasound probe at its tip to examine the wall complications. Whilst these are usually temporary,
layers (inside and outside) of the upper and lower some of them may cause long-term problems.
gastrointestinal tract. It also provides excellent pictures The risk to you will depend on:
of your pancreas, bile ducts and organs in your chest.
 personal factors, such as whether you smoke or
An endoscope is a long, thin, flexible tube with a small
camera and light attached which allows the doctor to are overweight.
see the pictures of the inside and outside of your gut  whether you have any other illness such as
on a video screen. The scope bends, so that the asthma, diabetes, heart disease, kidney disease,
doctor can move it around the curves of your gut. The high blood pressure or other serious medical
scope also blows air and this expands the folds of conditions.
tissues so that the doctor can see the linings better.
As a result, you might feel some pressure, bloating or
cramping during the procedure. 4. What are the risks of this specific
The EUS allows a fine needle biopsy (sample) of
procedure?
tissue to be taken inside or outside the wall of the gut. There are risks and complications with this procedure.
This needle is passed through the scope, and using They include but are not limited to the following.
the ultrasound as a guide, it is passed into the tissue Common risks and complications include:
of concern.
 Nausea and vomiting. Faintness or dizziness,
The EUS procedure is mostly used to: especially when you start to move around.
 diagnose tumours of the oesophagus, stomach,  Headache.
duodenum, pancreas and bile ducts.
 Pain, redness or bruising at the sedation injection
 diagnose some tumours of the lung. site (usually in the hand or arm).
 diagnoses diseases of internal organs including,
Pancreatitis or cysts of the pancreas.  Muscle aches and pains.
 Allergy to medications given at time of the
 detect bile duct stones, including gall stones.
procedure.
 asses abnormalities of the walls (inside and
outside) of the gut. Uncommon risks and complications include:
 About 2 people in every 100 will get an infection
 collect fluid samples from the lungs or abdominal
cavity. from a fine needle biopsy of a cyst. Antibiotics are
given during and after the procedure to reduce the
This procedure has 2 possible points of body entry, risk of this complication.
through a patient’s mouth or anus, depending on the
disease under investigation.  About 1 person in every 100 will experience
pancreatitis. This usually settles without specific
You should plan on 2 to 3 hours for waiting, treatment but extremely rarely can cause death.
preparation and recovery. The procedure itself usually
takes anywhere from 30 to 60 minutes.  About 2 people in every 1,000 will have minor
bleeding from the gut where the fine needle
This procedure may or may not require a sedation biopsy was taken. This can usually be stopped
anaesthetic. through the endoscope. Rarely, surgery is needed
to stop the bleeding.
2. Will there be any discomfort? Is any  About 1 person in every 1,000 will accidentally get
anaesthetic needed? a tear or hole (perforation) through the wall of the
The procedure can be uncomfortable and to make the gut. This can cause a leak of stomach contents
procedure more comfortable a sedative injection or a into the abdomen. Surgery may be needed to
light anaesthetic will be given. repair the tear or hole.
Before the procedure begins, the doctor will put a drip  Missed growths in and around the gastrointestinal
into a vein in your hand or forearm. This is where the tract.
sedation or anaesthetic is injected.  Your procedure may not be able to be completed.
 Heart and lung problems such as heart attack or
vomit in the lungs causing pneumonia.
3. What is sedation?
Emergency treatment may be necessary.
Sedation is the use of drugs that give you a ‘sleepy-
02/2011 - v2.00

 Damage to your teeth or jaw due to the presence

like’ feeling. It makes you feel very relaxed during a
of instruments in your mouth.
procedure that may be otherwise unpleasant or
painful.

Page 1 of 2 Continues over page ►►►

 Consent Information - Patient Copy
Endoscopic Ultrasound (EUS) & Fine Needle Biopsy

 ‘Dead arm’ type feeling in any nerve, due to 9. Are there other tests I can have instead?
positioning with the procedure – usually Yes. A computer tomography scan (CT) and magnetic
temporary. resonance imaging (MRI’s). Your doctor will discuss
 An existing medical condition that you may have these options with you.
getting worse.
Rare risks and complications include: 10. What can I expect after the endoscopic
 Bacteraemia (infection in the blood). This will ultrasound?
need antibiotics. You will be in the recovery area for about 2 hours until
 Stroke resulting in brain damage. the effect of the sedation wears off.
 Anaphylaxis (severe allergy) to medication given Your doctor will tell you when you can eat and drink.
at the time of procedure. Most times this is straight after the procedure.
 Death as a result of complications to this You might have some cramping pain or bloating
procedure is rare. because of the air entering the bowel during the
procedure. This should go away when you pass wind.
Moving around helps this.
5. What are you responsibilities before
having this procedure? You will be told what was found during the
examination or you may need to come back to discuss
You are less at risk of problems if you do the following: the results, and to find out the results of any biopsies
 Bring all your prescribed drugs, those drugs you that may have been taken.
buy over the counter, herbal remedies and
supplements and show your doctor what you are
taking. Tell your doctor about any allergies or side 11. What are the safety issues?
effects you may have. Sedation will affect your judgment for about 24 hours.
 Do not drink any alcohol and stop recreational For your own safety and in some cases legally;
drugs 24 hours before the procedure. If you have  Do NOT drive any type of car, bike or other
a drug habit please tell your doctor. vehicle. You must be taken home by a
 If you take Warfarin, Persantin, Clopidogrel responsible adult person.
(Plavix or Iscover), Asasantin or any other drug  Do NOT operate machinery including cooking
that is used to thin your blood ask your doctor if implements.
you should stop taking it before the procedure as
 Do NOT make important decisions or sign a legal
it may affect your blood clotting. Do not stop
document.
taking them without asking your doctor.
 Do NOT drink alcohol, take other mind-altering
 Tell your doctor if you have:
substances, or smoke. They may react with the
- had heart valve replacement surgery. sedation drugs.
- received previous advice about taking antibiotics  Have an adult with you on the first night after your
before a dental treatment or a surgical surgery.
procedure.

Notify the hospital Emergency Department straight

6. Preparation for the procedure away if you have;
Your stomach must be empty for the procedure to be  severe ongoing abdominal pain.
safe and thorough, so you will not be able to eat or
drink anything for at least six hours before the  trouble swallowing.
procedure.  a fever.
 sharp chest or throat pain.
7. What if the doctor finds something wrong?  have redness, tenderness or swelling for more
Your doctor may take a biopsy (a very small piece of than 48hours where you had the injection for
the stomach lining) to be examined at Pathology. sedation (either in the hand or arm).

Biopsies are used to identify many conditions even if
cancer is not thought to be the problem. Notes to talk to my doctor about:
............................................................................................................................................................................

8. What if I don’t have the procedure?

............................................................................................................................................................................
Your symptoms may become worse and the doctor will
02/2011 - v2.00

not be able to give you the correct treatment without ............................................................................................................................................................................

knowing the cause of your problems.
............................................................................................................................................................................

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