House Staff Manual - Winthrop University Hospital

The following is the procedure for obtaining autopsy consent:The attending physician or resident is responsible for ensuring that the “Authorization for Autopsy” isproperly completed by the person authorizing the autopsy. Any limitations or restrictions should beclearly indicated in the appropriate space on the form. If consent is given for biopsy only, it should beindicated whether the biopsy is by percutaneous needle or by incision.The nursing personnel will bring the patient’s Medical Record to the Admitting Office at the time ofdeath. The Death Certificate and the completed Authorization for Autopsy should be attached to theMedical Record.The Admitting Office will notify the Department of Pathology that an autopsy is to be performed. Theattending physician and House Staff are encouragedto communicate with the Pathologist who will perform the autopsy concerning any specific problemsor concerns regarding the case and may attend the autopsy. The responsible physician will be notifiedwhen the autopsy is about to be performed. The back page of the autopsy consent form should becompletely filled out indicating pertinent clinical data and specific questions to be addressed during theautopsy.In the event that a written consent cannot be obtained, the following are acceptable substitutes: Telegram consent Fax consent Telephone consentThe telephone consent must be witnessed and signed by at least two members of the hospital staff, onebeing a physician. Any limitations must be listed. The routine consent form is to be filled out and is toinclude the time, date, family member authorizing the autopsy, whether all members of equal kinshipauthorize the autopsy and the reason why written consent was not obtained.PATIENT PHOTOGRAPHS, VIDEOTAPING, OR SOUND RECORDING CONSENTIf photographs, videotaping or sound recording are done for research and medical education, consentform #55-018NS must be used. It is available at nursing stations or from Educational Media Services (ext.2665) and upon completion is made a part of the patients chart.If photographs (etc.) are for publicity purposes, consent forms from the Department of External Affairs(ext. 2706) are to be used. (Please note that permission from the Vice President for External Affairs isrequired before talking to representatives of the Press, as per Hospital Policy P-50-1.) Both types of consentmust be obtained in writing, in advance, and a copy should be placed in the patient's chart.PROCEDURES OR TREATMENT CONSENTBefore any non-emergency operation, procedure or treatment, all patients must give written informedconsent. The "General Consent for Procedure/Treatment" (Medical) and "Consent to Operation" (Surgery)must be signed by adult patients, and by the parents or guardian for minors. (Additional informed consentforms are described in Hospital Policy H-10-5).If the patient is incompetent, the health care agent or next-of-kin needs to give written permission. If apatient is incompetent and no next-of-kin or health care agent is available and the procedure is neededemergently, this should be clearly stated in the progress notes. This note should include the procedureplanned and the emergent nature of the patient's condition.In order for consent to be considered "informed consent", a physician must disclose to the patient the natureand purpose of the proposed procedure, the reasonable appropriate alternatives and the reasonablyforeseeable risks and benefits involved, in a manner permitting the patient to make a knowledgeableevaluation. A note of the explanation given must be entered into the patient's medical record. The caseRev. 1/08