(1) General profile of the recipient and the donor |
(a) A brief medical history of the recipient |
(b) Family tree |
(2) Informed consent |
(a) When and how did you come to know about living related donor liver transplant? |
(b) Who explained the details of the transplant surgery, and how many times? |
(c) Under what circumstances (one to one, or with others present)? |
(d) Do you clearly understand the procedure of the surgery? |
(e) Do you fully understand the risks and benefits of the treatment (including short term and long term risks for the donor, and the success rate of graft attachment for the recipient)? |
(f) Have you been given information and explanations about alternative therapies? |
(g) Have you been given enough time to ask questions? Have you been invited to ask questions? |
(3) Decision making process |
(a) Have you consulted with anyone? |
(b) Was there any coercion by other family members or relatives? (For example, if you do not agree to be a donor, the patient will surely die.) |
(c) Is your decision completely voluntary? |
(4) Psychosocial aspects |
(a) Do you have any anxiety about your surgery? |
(b) Do you have any problems in your life (for example, business or social relationships)? |
(c) Do you have any financial problems? |
(5) Protection of the donor's right |
(a) You have the right to refuse or withdraw your consent until the last moment. |
(b) You will not suffer any disadvantage if you decide to refuse or withdrawal. |
Interviewer's assessment |
(1) The donor is well informed. □Yes □No |
(2) The donor has a good understandings of the entire process. □Yes □No |
(3) The donor is fully capable of making a decision. □Yes □No |
(4) The donor's decision is completely voluntary and firm. □Yes □No |
(5) The decision has been reached without any evidence of coercion. □Yes □No |
(6) The donor's right has been fully protected. □Yes □No |
(7) The donor is without significant psychosocial problems. □Yes □No |
Time of interview min |
Interviewer's signature (a member of ethics committee) |
Date |