Tracheostomy (Tracheotomy)
Informed Consent
Tracheostomy (also called tracheotomy) is a surgical opening of the windpipe to allow breathing when the larynx (voice box) is obstructed, to permit long-term ventilation of the lungs through a tube inserted into the neck opening.  Although often performed as an emergency for life-threatening situations, tracheostomy may also be required for urgent or elective reasons.   The main complication is bleeding.  Other complications include infection and air under the skin.  Because most patients who require a tracheotomy are very sick, cardiac complications could also occur, including heart arrest.

I have discussed the risks, benefits and alternatives of the procedure/treatment to the patient/patient representative. I answered the patient’s/patient’s representative’s questions regarding the procedure/treatment.

I/We have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, and I/we have sufficient information to give this informed consent. I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

_______________________________ ________________________________________________________
Patient / Legal Guardian

Date:__________________________________          Time:________________________________

Bechara Y. Ghorayeb, MD
Otolaryngology - Head & Neck Surgery

Memorial Hermann Professional Building
1140 Business Center Drive, Suite  560
Houston, Texas 77043
For appointments, call: 713 464 2614
This page was last updated: November 1, 2019