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Consent to Perform Echocardiography

VetBooks.ir Patient name:_________________________________
Pet owner’s name:_____________________________ Med rec #____________
Best contact during/after procedure (e.g., cell phone number):____________________

INTRODUCTION Sedation will involve the administration of medications that cause
We want to make sure that you understand the planned medical your pet to become drowsy and relaxed, but to remain conscious.
procedure to be performed on your pet. You should know why the Your pet will remain in control of vital functions such as breathing.
procedure has been suggested, what the potential benefits are for In general, there are fewer risks associated with sedation than
your pet, and the most common/important risks of the procedure. with general anesthesia, but adverse events occur very rarely.
Alternatives to this procedure, when applicable, will be discussed Some medications used to induce sedation can be “reversed” by
with you. It is also important that you recognize that medicine is giving other medications to counter the sedative effect, allowing
not an exact science, and that the outcome cannot be guaranteed. your pet to “wake up” more quickly after the procedure has been
We encourage you to ask us as many questions as required for completed.
you to make a well-informed decision.
FORESEEABLE RISKS TO THE PROCEDURE
BENEFITS/OPTIMAL OUTCOME OF THE PROCEDURE An echocardiogram is considered very safe. The ultrasound waves
An echocardiogram is used to diagnose and evaluate the severity of used to generate images are painless and do not cause discomfort.
heart disease by assessing the structure and function of the heart. Unlike x-rays, no radiation is involved. There is a risk that we will
Specifically, an echocardiogram provides information regarding: the not identify a specific cause of your pet’s illness despite performing
heart’s size, pump function, and valve structure; presence of heart the echocardiogram.
defects and tumors; and can estimate blood pressure in the lungs.
Information from this procedure can be used to determine whether Other anticipated risks specific to your pet:___________________
heart medications should be prescribed and to determine risks for
other procedures such as general anesthesia or administration of _________________________________________________________
certain chemotherapy drugs. This procedure is not a treatment
for disease, but we aim to find a diagnosis for a treatable disease.
ALTERNATIVES TO THE PROCEDURE
EXPLANATION OF THE PROCEDURE Chest x-rays may be performed as an alternative to the echocardio-
During an echocardiogram, your pet is gently restrained on its gram, but chest x-rays only provide a general picture of heart size
side, typically for 15-30 minutes in a dark and quiet room. Rubbing and cannot evaluate heart function. Additionally, x-rays cannot tell us
alcohol and ultrasound gel is applied to your pet’s chest over the why an enlarged heart is large while echocardiography usually can.
heart. An ultrasound probe is placed against your pet’s chest, An electrocardiogram (ECG or EKG) evaluates the heart rhythm but
which uses high-frequency sound waves to provide an image is poor at evaluating heart size and cannot evaluate heart function,
of the heart. This is similar to the ultrasound many people are and it is not recommended as an alternative procedure. Without the
familiar with that is used to examine a pregnant woman to “see” additional information provided by an echocardiogram, we would
the baby, only in the case of an echocardiogram we are “seeing” need to develop a treatment plan without a confirmed diagnosis,
your pet’s heart. Occasionally, small patches of hair may need to which might lead to a suboptimal outcome.
be shaved to improve image quality. Electrodes are attached to
your pet’s feet to keep track of your pet’s heart rhythm during the AUTHORIZATION
procedure. By signing this form below, you agree that:
Additional procedures planned for your pet at the same time • You understand how/why the procedure is likely to help your
as the echocardiogram: pet
• You understand what will be done to your pet during the
____________________________________________________________ procedure
• You understand the known risks that accompany the procedure,
USE OF SEDATIVES OR ANESTHESIA and also understand that unforeseen complications may occur
An echocardiogram requires your pet to lay on its side for 15-20 • You understand that the procedure may not produce the results
minutes with minimal movement. Most animals tolerate this procedure we hope to achieve
without the use of sedation, but some animals feel stressed and • You understand the alternatives to this procedure for your pet
move excessively when restrained for an extended period. For such • You agree that you have been given time to ask questions regard-
animals, light sedation is required for the animal’s comfort and ing the procedure, that these have been answered satisfactorily,
safety, and to allow the procedure to be performed satisfactorily. and that you are free to decline the procedure.

From Cohn and Côté: Clinical Veterinary Advisor, 4th edition. Copyright © 2020 by Elsevier Inc. All rights reserved.