Patient perceptions and recall of consent for regional anaesthesia compared with consent for surgery

Regional Anesthesia in the Elite Athlete

Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.

The involvement and autonomy of young children undergoing elective paediatric cardiac surgery: a qualitative study

Background

Standards generally reported in the literature about informing children and respecting their consent or refusal before elective heart surgery may differ from actual practice. This research aims to summarize the main themes in the literature about paediatric anaesthesia and compare these with research findings on how health professionals counsel young children before elective heart surgery, respect their consent or refusal, and maintain patient-centred care.

Methods

This qualitative research involved: literature reviews about children’s consent to surgery and major interventions; observations of wards, clinics and medical meetings in two paediatric cardiology departments, October 2019 to February 2020; audio-recorded semi-structured interviews with 45 hospital staff, including 5 anaesthetists, and related experts, November 2019 to April 2021; interviews with 16 families, with children aged 6- to 15-years and their parents shortly after elective heart surgery, and some months later (reported in other papers); thematic data analysis; and research reports on how different professions contribute to children’s informed decisions for heart surgery.

Results

The medical, ethics and English legal literature tend to assume legal minors cannot refuse major recommended treatment, and cannot consent until they are 12 years or older. Little is said about informing pre-competent children. If children resist, some anaesthetists rely on sedation and distraction, and avoid much informed discussion, aiming to reduce peri-operative anxiety. However, interviewees reported informing young children, and respecting their consent or refusal before elective surgery. They may delay elective surgery and provide further information and support, aiming to reduce fear and promote trust. Six years of age was commonly cited as the threshold for respecting consent to heart transplantation.

Conclusion

Differing views about younger children’s competence, anxiety and best interests support different reactions to children’s consent and refusal before elective heart surgery. This paper reports the zero-restraint policy followed for over a decade in at least one leading surgery centre. The related law and literature need to be updated, to take more account of evidence of actual practice.

Regional Anesthesia in the Elite Athlete

Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.

Preoperative assessment of expectations, anxiety and preferences for anesthesia in patients undergoing ambulatory knee arthroscopic surgery

Objective : In this observational study, we aimed at measuring preoperative anxiety and preferences for anesthesia in patients undergoing knee arthroscopic surgery. Background : Little is known about preoperative anxieties, expectations and preferences of patients undergoing surgery, for which both spinal or general anesthesia can be provided. Literature shows that spinal anesthesia is associated with lower postoperative co- morbidity and mortality rates as compared to general anesthesia (1-2). Anxiety itself is an important factor influencing patients’ outcome (3). Methods : Every patients >18 years old undergoing an ambulatory arthroscopy of the knee in the surgical day care center of the AZ Nikolaas (in Sint-Niklaas and Beveren), was asked preoperatively to fill in a questionnaire. The questionnaire focused both on the patients’ knowledge about and preference of anesthesia, as well as their preoperative anxieties and worries. Patients were asked to score preoperative anxiety on a 5-point anxiety scale for any of 9 aspects/complications of the anesthetic (placement of the IV cannula, spinal puncture, death, awareness, pain, postoperative nausea and vomiting, cognitive impairment, infection, blood loss). During the study period, from January 11/01/ 2019 to 11/06/2019, a total of 806 patients were asked to fill out the questionnaire. 201 of these patients completed the questionnaire and were consequently enrolled in the study. This work has been approved by the Ethics Committee of the AZ Nikolaas on 11/11/2018 and by the Ethics Committee of the University Hospital in Antwerp (UZA) on 19/11/ 2018. Results : Seventy-five % of patients had a clear preference for their anesthesia technique. Of these, 2/3 opted for general anesthesia. Patients mainly based their preference on a subjective feeling ; a minority had discussed the choice with their surgeon or general practitioner. Rarely, patients indicated the wish to talk to the anesthesiologist about their choice. Fear for a spinal puncture occurred in 40% of patients (median anxiety score 3/5, range 1-5) and was therefore the most prominent anxiety in this patient population. Conclusions : Patients’ greater preference for general over spinal anesthesia was clearly based rather on a subjective than an objective basis. Forty 40% of patients had a substantial fear for spinal puncture. By informing patients about the risks and complications of the different anesthesia techniques, anxiety feelings can probably be alleviated, and a well-judged decision about their anesthesia technique can be made. There is room for improvement in communication and discussion between patients and anesthesiologists about the patients’ choice of anesthesia technique.

Are We Meeting the Current Standards of Consent for Anesthesia? An International Survey of Clinical Practice

Background

International application of existing guidelines and recommendations on anesthesia-specific informed consent is limited by differences in healthcare and legal systems. Understanding national and regional variations is necessary to determine future guidelines.

Material/Methods

Anonymous paper surveys on their practices regarding anesthesia-specific patient informed consent were sent to anesthesiologists in Estonia, Latvia, and Lithuania.

Results

A total of 233 responses were received, representing 36%, 26%, and 24% of the practicing anesthesiologists in Lithuania, Latvia, and Estonia, respectively. Although 85% of responders in Lithuania reported using separate forms to secure patient informed consent for anesthesia, 54.5% of responders in Estonia and 50% in Latvia reported using joint forms to secure patient informed consent for surgery and anesthesia. Incident rates were understated by 14.2% of responders and overstated by 66.4% (P<0.001), with the latter frequently quoting incident rates that are several to tens of times higher than those published internationally. Physicians obtaining consent in the outpatient setting were more satisfied with the process than those obtaining consent on the day of surgery, with 62.5% and 42.6%, respectively, agreeing that the informed consent forms provided a satisfactory description of complications (P=0.03). Patients were significantly less likely to read consent information when signing forms on the day of surgery than at earlier times (8.5% vs. 67.5%, P<0.001). Only 46.2% of respondents felt legally protected by the current consent process.

Conclusions

Anesthesia-specific informed patient consent practices differ significantly in the 3 Baltic states, with these practices often falling short of legal requirements. Efforts should be made to improving information accuracy, patient autonomy, and compliance with existing legal standards.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Compassionate behavior in clinicians is described as seeking to understand patients’ psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery.

Methods

Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion.

Results

Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η2 = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not.

Conclusions

In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

[Informed consent for anaesthesia: Presential or non-presential information?]

INTRODUCTION

The anaesthesia informed consent (AIC) is a process of communication between a clinician and a patient that results in the patient agreeing to undergo a specific anaesthetic procedure after understanding all the information needed to make a free, voluntary and conscious decision. This information is traditionally given during a face-to-face pre-operative visit.

OBJECTIVE

To evaluate patient perceptions when they receive the information about AIC, face-to-face or by phone.

PATIENTS AND METHODS

A single centre, randomised, double-blind, parallel-group pilot clinical trial was conducted on patients > 18 years of age undergoing major ambulatory surgery procedures with a surgical complexity that did not require a face-to-face pre-operative visit. Patients were randomly assigned to be informed by telephone (experimental group) or in a face- to-face visit (control group). Fifteen days after the surgery a questionnaire was used to gather patient perceptions in understanding the anaesthetic procedure and risks, autonomy (to ask for explanations), as well as and satisfaction.

RESULTS

Of the 160 patients that gave their consent, 142 were interviewed: 70 from the experimental group and 72 from the control group. Both groups were comparable in age, gender, anaesthetic risk, and surgical complexity. The percentage of patients that understood the information provided on the anaesthetic technique was 71% and 81%, respectively (P=.429); on its risks: 67% and 69% (P=.951); autonomy: 56% and 74% (P=.036) and satisfaction rate: 46% and 46% (P=.835).

CONCLUSION

There is no difference between the groups in the level of understanding of the information that the patient perceives and the level of satisfaction. Nevertheless, almost half of them did not remember to have been given the possibility to clear-up doubts.

Room for Improvement: A Systematic Review and Meta-analysis on the Informed Consent Process for Emergency Surgery

OBJECTIVE

To compare recall of complications and surgical details discussed during informed consent and perception of the consent process in patients undergoing emergent vs elective surgery.

METHODS

Studies were identified from PubMed, Cochrane, Web of Science, and Scopus from January 1, 1966, through April 18, 2018. Included studies compared patient recall and perception regarding informed consent in those undergoing emergent vs elective surgery. Pooled odds ratios (ORs) were calculated for recall of complications and surgical details, patient satisfaction, perception of sufficient information being delivered on surgical risks, report of having read written consent, and factors that interfered with consent.

RESULTS

Eleven observational studies (3178 patients) were included. The rate of recall of surgical complications (255 of 504 [50.6%] vs 321 of 446 [72.0%]; OR, 0.29; 95% CI, 0.11-0.80) was lower in patients undergoing emergent vs elective surgery. Meta-analysis revealed a decreased rate of patient satisfaction with the consent process (319 of 459 [69.5%] vs 882 of 1064 [82.9%]; OR. 0.53; 95% CI, 0.34-0.83) and fewer patients having read the consent form (130 of 395 [32.9%] vs 424 of 714 [59.4%]; OR, 0.35; 95% CI, 0.27-0.46) when undergoing emergent compared with elective surgery. Patients undergoing emergent surgery listed pain, analgesic medications, and fatigue as factors likely to interfere with consent.

CONCLUSION

Patients undergoing emergent surgery have poor recall of the informed consent process and surgical complications. Furthermore, patients report lower rates of satisfaction, and with fewer patients reading written consent documentation, our findings illuminate problems with the current communication process. There is a need to develop effective tools to improve informed consent in emergency surgery.

Say what? Patients have poor immediate memory of major risks of interscalene block disclosed during the informed consent discussion

BACKGROUND

Poor memory of disclosed risks can undermine informed consent and create medicolegal challenges. The extent to which patients remember the risks of peripheral nerve blockade following the informed consent discussion is unknown. This prospective cohort study evaluated patients' immediate memory of risks related to interscalene block (ISB) that were disclosed during the preoperative informed consent discussion.

METHODS

Using a standardized script, patients scheduled for arthroscopic shoulder surgery were informed of the risks of ISB by an anesthesiologist in the preoperative assessment clinic. Immediately thereafter, consenting participants were asked to identify the risks of ISB from a printed list of nine true risks (four major and five minor) and nine 'distractor' items, which were unrelated adverse events and not disclosed. The primary outcome was the proportion of participants who remembered all four true major risks including long-term nerve damage, seizure, life-threatening event, and damage to the covering of the lung.

RESULTS

Among 125 participants, only 26 (21%) remembered all four major risks of ISB. The mean number of major risks remembered was 2±1 out of 4. Fifteen (12%) participants remembered all nine true risks. The mean number of true risks remembered was 6±2 out of 9. Multivariable analysis revealed that participants' self-rated assessment of their memory was not associated with actual recall.

CONCLUSION

Patients have poor immediate memory of the major risks related to ISB disclosed during the informed consent discussion. Under the present study conditions, the validity of the informed consent process for patients undergoing ISB may be undermined.

Informed consent for regional anesthesia

PURPOSE OF REVIEW

This narrative review describes the current framework for informed consent discussions for regional anesthesia practice from an ethical and medicolegal stand point as the cornerstone of the patient-physician relationship and the respect for patient autonomy. Recent guidelines and position statements from anesthesia societies have emphasized the importance of these discussions and their appropriate documentation.

RECENT FINDINGS

Recent studies have shown that patients want to know more about both common and benign, as well as rare but serious adverse events, as it relates to their anesthetic care. Several strategies have been recently recommended as a means to facilitate a meaningful consent discussion and proper documentation in the perioperative environment.

SUMMARY

Defining the material risks of ultrasound-guided regional anesthetic procedures remains challenging, due in part to the difficulty in quantifying incidence rates of relatively rare events. However, well informed discussions are of great importance to support patient autonomy and lay a strong foundation for the patient-anesthesiologist relationship.

A survey of doctors at a UK teaching hospital to assess understanding of recent changes to consent law

BACKGROUND

The UK Supreme Court recently ruled that when consenting patients for treatments or procedures, clinicians must also discuss any associated material risks. We surveyed medical staff at a large UK teaching hospital in order to ascertain knowledge of consent law and current understanding of this change.

MATERIALS AND METHODS

Email survey sent to medical staff in all specialities at Norfolk and Norwich University Hospital in February 2016.

RESULTS

245 responses (141 Consultants and 104 junior doctors, response rate 32%). 82% consent patients for procedures at least monthly and 23% daily. 31% were not familiar with the concept of material risk. 35% were familiar with the recent change in consent law, 41% were not. 18% were "very uncertain" and 64% "a little uncertain" that their consenting process meets current legal requirements. >92% think that landmark cases and changes in law should be discussed through professional bodies and circulated better locally.

CONCLUSION

The majority were not familiar with the concept of material risk and recent legal changes. A majority were not confident that their practice meets current requirements, suggesting that recent changes in consent law may not be widely understood at this hospital. We suggest more guidance and education may be necessary than is currently available. Increased understanding of recent changes to consent law will reduce the risk taken by NHS trusts and offer patients a service compliant with Supreme Court guidance.

The Effect of Written Information on Recall of Surgical Risks of Carpal Tunnel Release Surgery: A Randomized Controlled Study

BACKGROUND

Written information has been thought to help patients recall surgical risks discussed during the informed consent process, but has not been assessed for carpal tunnel release, a procedure with the rare but serious risk of complex regional pain syndrome. The authors' objective was to determine whether providing a pamphlet would improve patients' ability to remember the risks of surgery.

METHODS

Sixty patients seen for carpal tunnel release were included in this prospective, single-blind, randomized study. Patients received either a written pamphlet of the risks of surgery or no additional information following a standardized consultation. Two weeks after the initial consultation, patients were contacted to assess their risk recall and whether they had read about the operation from any source.

RESULTS

There was no difference in terms of the number of risks recalled between pamphlet (1.33 ± 1.21) or control groups (1.45 ± 1.22; p = 0.73). Recall of infection was better in the pamphlet group (p < 0.05). No patients remembered complex regional pain syndrome. There was no difference in the proportion of people who read additional information about carpal tunnel release surgery between the pamphlet (34.8 percent) and control groups (21.4 percent; p = 0.39), but reading about carpal tunnel release surgery was associated with improved recall (2.45 ± 1.13 versus 0.77 ± 0.91; p < 0.01).

CONCLUSIONS

Reading about surgery improved risk recall, but providing this information in the form of a pamphlet did not, nor did it affect patients' ability to recall the risk of complex regional pain syndrome. These results demonstrate that surgeons should implement additional measures to improve comprehension of surgical risks.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

A review of consent practices and perspectives for pharmacogenetic testing

AIM

We aimed to understand consent practices for pharmacogenetic (PGx) testing.

METHODS

We conducted a literature review and analysis of consent forms from clinical laboratories offering PGx testing.

RESULTS

Our review of the literature shows a lack of consensus about the need for and type of informed consent for PGx testing. We identified 35 companies offering PGx testing and were able to confirm consent practices for 22 of those. We found a range of variability in the consent practices regarding the consent approach and information disclosed.

CONCLUSION

Variability in the consent practices among laboratories offering PGx testing mirrors the ambiguous practices and recommendations reported in the literature. Establishing a minimal set of information to be disclosed to patients may help address the disparities in consent practice.