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Ventilator Consent Form

A ventilator consent form is used when an individual is being placed on a ventilator for medical reasons. The form documents the individual's consent to the use of the ventilator and the individual's understanding of the risks and benefits associated with the use of the ventilator.

2 minutes to complete

Eligibility

The Ventilator Consent Form must be filled in by a person who has the legal authority to do so. Usually, this will be the patient or a next of kin. If the patient has been declared incompetent by a court, the consent form must be filled by a legal guardian. If the patient is a minor, the consent form must be filled by a parent or legal guardian. If the patient is an adult and has designated a health care surrogate, the health care surrogate will give consent.

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Questions for Ventilator Consent Form

Questions

1.

Name of the Patient

The answer should be a single choice:
2.

Patient Medical ID number

The answer should be a number input.
3.

I understand that the purpose of the ventilator is to help me breathe, the ventilator will be placed in my mouth and/or nose, and that it will be connected to my lungs.

The answer should be a single choice:
  1. Yes
  2. No
4.

I understand that the ventilator will be turned on and off as needed, and that I may be able to talk while it is on.

The answer should be a single choice:
  1. Yes
  2. No
5.

I understand that the ventilator may cause some discomfort, but that the nurses and doctors will do everything they can to make me comfortable.

The answer should be a single choice:
  1. Yes
  2. No
6.

I understand that I will be monitored closely while on the ventilator, and that the nurses and doctors will make sure that I am getting the air that I need.

The answer should be a single choice:
  1. Yes
  2. No
7.

I understand that I will be closely monitored by my healthcare team while I am on mechanical ventilation and that they will make every effort to minimize any discomfort or side effects that I may experience.

The answer should be a single choice:
  1. Yes
  2. No
8.

I understand that the ventilator may cause some discomfort, such as a sore throat, and that I may have to stay in the hospital for a while.

The answer should be a single choice:
  1. Yes
  2. No
9.

I hereby consent to receive mechanical ventilation as directed by my healthcare team.

The answer should be a single choice:
  1. Yes
  2. No
10.

Signature

The answer should be a signature.
11.

Date

The answer should be a date input.

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Here are some FAQs and additional information
on Ventilator Consent Form

Does the Ventilator Consent Form give the provider permission to intubate and ventilate me?

No. The Ventilator Consent Form does not give the provider permission to intubate and ventilate you. It does, however, give the provider permission to assess your need for intubation and ventilation.

Am I required to sign the Ventilator Consent Form?

No. You are not required to sign the Ventilator Consent Form. However, if you do not sign the form, the provider may not be able to assess your need for intubation and ventilation.

What is informed consent?

There are 4 components of informed consent including decision capacity, documentation of consent, disclosure, and competency.

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