ERCP consent

Question 1

A 63 year-old man presented with jaundice and is booked for an endoscopic retrograde cholangio-pancreatiogram (ERCP). Can you outline the consent fo ratios procedure.

Answer 1

I would need to ensure that the patient has capacity to consent to this procedure before proceeding with gaining informed consent for the procedure, and then properly documenting the patient interaction.

Goals
1 - assess capacity and competence to give informed consent to this procedure
2 - use I PRAC structure for gaining appropriate informed consent from the patient prior to performing the procedure

Question 2

Capacity assessment

Answer 2

4 components to capacity assessment;
1 - Patient can understand information (comprehension): hearing, education, use of lay terms, etc
2 - Retain the information (retention): must be able to repeat it back to you
3 - Weigh up pros/cons (logical decision making process)
4 - Communicate a decision (communicate all of that back to you in a way that they/you understand)

Capacity is a dynamic thing, and is also specific to medical decision, so may need to reassess at different times.

Legal considerations;

• primary carer
• Enduring guardian
• power of attorney
• Advanced care directives/NFRs in place

Question 3

Indication

Answer 3

In this case;

• Jaundice likely secondary to obstruction
• Investigative +/- therapeutic procedure

Question 4

Procedure

Answer 4

Explain the procedure

• twilight sedation
• under CT guidance (radiation)
• camera through the mouth down to stomach and into large intestine, pass catheter up to allow for imaging of the CBD and pancreas
• biopsy if needed, stenting if required
• recovery for a few hours
• dietary restrictions post procedure
• may or may not require hospital stay depending on the severity of the patient presentation.

Question 5

Risks

Answer 5

Risks
Common to all procedures
- pain (give analgesia)
- N/V (give antiemetics)
- infection (prophylactic antibiotics - augmentin, one dose)
- failure - go to further definitive management options
- sedative effects (short-term only)
- bleeding: chronic (due to sphincterotomy)

Specific to this procedure

• Pancreatitis - necrotising, go to ICU
• Damage to loco-regional structures (spincterotomy)
• Allergy to contrast
• Injury to surrounding structures (unlikely in this procedure)

Risks of not having a provedure

• Worsening pain and symptoms
• Progression of disease process, require more surgery
• Risk of conversion to open procedure

Question 6

Alternatives

Answer 6

• Laparoscopic cholecystectomy
• CT guided drainage
• MRI for investigation

Question 7

Consent

Answer 7

Go through formal consent process

• Appropriately document
• ensure appropriately signed and dated