1 of 6 Patient Name: ______________________________

Identification Number: _______________________


*2CNTT* 2CNTT 04/09/2013

I, have been asked to carefully read all of the
(name of patient or substitute decision-maker)

information contained in this consent form and to consent to the procedure described below on behalf of

. I have been told that I should ask questions
(name of patient)

about anything that I do not understand. (If the decision-maker signing this form is not the patient, references to

“I,” “my” or “me” should be read as if referring to “the patient,” when applicable).

I understand that the information about the procedure described in this consent form, in addition to discussions

with my physicians and any other written materials they may provide, is intended to help me make an informed

decision whether to voluntarily undergo the proposed treatment.

I understand that after evaluation including, but not necessarily limited to an interview, physical examination

and a review of diagnostic studies, such as blood tests and x-rays, my physician(s) have recommended that I

have my gallbladder removed. I understand that surgical removal of my gallbladder, also known as a

cholecystectomy, has been recommended because my gallbladder may be causing symptoms such as pain after

eating, nausea, excessive belching or vomiting. My gallbladder may also contain an abnormality for which

removal may be advisable. The abnormality (ies) of my gallbladder that are suspected to be present and/or the

cause of my symptoms are:

Stones or sludge in the gallbladder

Inflammation of the gallbladder

Abnormal contraction of the gallbladder (biliary dyskinesia)

A mass of the gallbladder

Abnormal calcifications (hardened areas) of the gall bladder


I understand that the gallbladder stores fluid produced by my liver. In response to eating food, the gallbladder

contracts and empties its fluid into the intestine where the fluid mixes with food. I also understand that the

gallbladder connects to passageways coming out of my liver known as bile ducts. One or more blood vessels

travel to my gallbladder from the blood vessels that supply my liver. I understand that to remove my

gallbladder, my physician(s) must identify and cut the connection of my gallbladder to the bile duct(s) and the

blood vessels traveling to the gallbladder. My gallbladder must also be separated from my liver and other

structures to which it may be attached.

Description of the Surgery: After I have been identified I will be anesthetized. This will usually mean I will

be put to sleep under general anesthesia. The type of anesthesia and the risks of anesthesia will be explained to

me by a representative of the Anesthesia

DUE DATE 3/26/22

Assessment Description

When examining the communication between a medical professional and a patient, it is important to see a real-world example of what that communication looks like. Please examine the example of a basic patient informed consent form for the common surgical procedure of gallbladder removal entitled, “Cholecystectomy Consent Form,” located in your readings for this topic and answer the following questions in a paper of 1,000-1,200 words:

1. Based on what you have learned about the Patients’ Bill of Rights and autonomy, do you believe this basic patient consent form adequately informs patients of their medical rights? Explain your answer in detail and use a reference for support.
2. Would the basic consent form for Laparoscopic Cholecystectomy be understood by the average person in the United States with a reading ability of a typical 8th grader? Explain your answer.
3. Describe at least three steps health care providers can take in order to ensure patients understand their care as well as prepare them to give acceptable consent for the procedure.
4. Discuss the patient’s right to terminate care with a health care professional. Identify the steps a patient would take to terminate care. Explain the ethical components that would take place in that process.
Include at least three scholarly, peer-reviewed references from the GCU Library to support your positions.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competencies:

BS Health Care Administration

5.1: Practice unbiased communication and decision-making in health care by recognizing and respecting the diversity of patients and populations.

5.4: Practice ethical behavior and moral decision-making when resolving ethical dilemmas.

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