Download Anticoagulants-Consent1

PLACE LETTERHEAD HERE AND REMOVE NOTE.
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Version 4/15/14
NOTE: THIS FORM IS INTENDED AS A SAMPLE FORM. IT CONTAINS THE
INFORMATION OMIC RECOMMENDS YOU AS THE SURGEON PERSONALLY
DISCUSS WITH THE PATIENT. PLEASE REVIEW IT AND MODIFY TO FIT YOUR
ACTUAL PRACTICE. GIVE THE PATIENT A COPY AND SEND THIS FORM TO THE
HOSPITAL OR SURGERY CENTER AS VERIFICATION THAT YOU HAVE OBTAINED
INFORMED CONSENT.
OMIC is grateful to the ophthalmologists on our Board for their expertise. This specific
document reflects the input of the following Board and staff members: Anne M. Menke,
RN, PhD; Tamara R. Fountain, M.D., and Ronald W. Pelton, M.D..
INFORMED CONSENT FOR STOPPING OR CONTINUING BLOODTHINNERS (ANTICOAGULANTS)
WHAT ARE BLOOD-THINNERS?
Blood-thinning medications (“anticoagulants”) are powerful tools to prevent
complications of life-threatening blood clots and have proven benefits in preventing
heart attacks and strokes. They are prescribed to prevent these blood clots from
forming in people who are at risk. The benefits of these drugs must always be weighed
against bleeding risks, particularly in patients undergoing elective surgical procedures.
One of the side-effects of anticoagulants is an increase in bleeding. Patients who take
blood thinners like aspirin, Coumadin, Plavix, Pradaxa, etc,. present challenges when
surgery is needed.
HOW WILL BLOOD-THINNERS AFFECT MY VISION AND CONDITION?
Bleeding is a potential complication of any surgical procedure. People who take bloodthinning medicine around the time of their procedure are more likely to have bleeding
complications during and after surgery. For operations in and around the eye, this
bleeding may, in rare cases, cause loss of vision or blindness.
If you stop taking your blood-thinner(s) before surgery to lessen the chance of bleeding,
you may be at greater risk of developing a life-threatening blood clot, which can cause
very serious conditions such as heart attack, stroke, pulmonary embolism, and deep
vein thrombosis. If, on the other hand, you continue your anticoagulants you may be at
increased risk of bleeding complications. If you are on blood-thinners and need to
have surgery, you must be willing to accept the potential for increased risk of one
of these complications—blood clot or bleeding.
Your surgeon and your primary doctor/cardiologist will weigh the relative risks and
benefits of stopping or continuing your medications before surgery and counsel you
accordingly. On rare occasion, this may mean that elective surgery will be postponed or
cancelled.
There is always a chance that you may develop a complication related to how your
blood thinners are managed around the time of your surgery. Your doctors will help you
understand the relative risks involved so you can make an informed decision about how
to proceed.
PATIENT’S ACCEPTANCE OF RISKS
As a patient on blood-thinners (such as aspirin, Plavix, Coumadin, Pradaxa, etc), I
understand that stopping these medicines before surgery may increase my risk of a
having a heart attack, stroke or other life-threatening blood clot. I also understand that if
I continue my blood-thinners, I have an increased risk of bleeding complications that
may result, in rare cases, in vision loss or blindness.
Patient (or person authorized to sign for patient)
Date
SAMPLE INSTRUCTIONS
NOTE: INCLUDE THE FOLLOWING INFORMATION IF YOUR PATIENT WILL BE
STOPPING AND RESTARTING ANTICOAGULANTS. REMOVE IF THE PATIENT WILL
BE CONTINUING. MODIFY AS NEEDED TO FIT YOUR PRACTICE.
GIVE THE PATIENT A COPY, PLACE A COPY IN THE MEDICAL RECORD, AND SEND
A COPY TO THE SURGERY CENTER OR HOSPITAL SO THAT THEY MAY VERIFY
THAT THE PATIENT HAS STOPPED MEDICATION AS INSTRUCTED PRIOR TO
SURGERY
INSTRUCTIONS ON HOW TO TAKE YOUR BLOOD-THINNERS BEFORE AND
AFTER SURGERY
Blood thinners are very important medications that may save your life. However, they
can complicate surgery by making both the procedure and the after-care more difficult.
It is very important to discuss your blood thinner medication with your eye surgeon and
your prescribing doctor. Please follow the directions below concerning the stopping and
re-starting of your blood thinners. Do not hesitate to call our office or the office of your
primary care doctor if you have questions about these instructions
 Your blood-thinner medication(s) is:
Aspirin _____
Plavix (clopidogrel) _____
Aggrenox _____
Pradaxa (dabigatran _____
Coumadin (warfarin) _____
Xarelto (rivaroxaban) _____
Eliquis (apixaban) _____
Other: ____________________

Your surgery date is _____________

STOP your blood-thinner medication on [date], which is _________ days before
surgery or ______________________________________________

RESTART your blood-thinner medication on [date], which is __________ days
after your surgery or ______________________________________
If you note ANY abnormal symptoms after stopping your blood thinner, please call your
prescribing doctor or go to the nearest emergency department as soon as possible.
As always, if you have questions or concerns, please call us anytime at the number
below.
[Add contact information for the eye surgeon]