The informed consent process for surgery usually begins long before the patient enters the operating room environment, with the patient's first visit to the surgeon's office. In contrast, the informed consent for anesthesia is often obtained in the minutes before surgery in which the anesthesiologist and patient meet for the first time. (See also the main topic page for Informed Consent.)
What are some common situations in which a patient's ability to make decisions about surgery and anesthesia may be questioned?Many situations commonly arise around the time of surgery, in which a patient's ability to make health care decisions may be, rightfully or wrongfully, called into question. Some of them include:
- the premedicated patient
- the patient in labor
- the patient under stress
- the patient with known mental illness
- the patient with organic brain disease
- the immature patient (i.e. patient who is minor in age, or who has immature mental capacity, such as some forms of mental handicap)
How does medication affect a patient's ability to give valid consent to a procedure?It is common to encounter patients who have received sedation and/or pain medication prior to coming to surgery, and it is also common for such medications to be deliberately withheld prior to surgery in anticipation of the necessity to obtain consent. When pain medications are withheld, patients may feel pressured to consent in order to obtain medication to relieve their suffering.
In some instances, premedication may actually enhance a patient's ability to make decisions, by providing pain relief or relief from emotional distress, so that they can focus on the choices they are making. Clearly, if premedication has rendered the patient unable to listen, to understand their situation, the need for care, the risks, and alternatives, or to communicate a decision, then it has negated the informed consent process. But pain medication should never be withheld from a suffering patient under the guise of obtaining informed consent.
How does the physical or mental stress of the OR affect the informed consent process?Many studies have examined the ability of laboring patients to give informed consent. While many patients do not later remember the informed consent process, laboring patients in general demonstrate the capacity to understand their situation, understand proposed care, risks, and alternatives, and express consent. Legal cases have recognized the complex voluntary physical control required from a laboring woman to permit epidural placement, and cite the physical cooperation of the woman in the process as an indication of motivation and consent for the procedure.
While many, if not most patients coming to the OR are experiencing stress, there is little evidence that most are not able to meet the standards mentioned on the main topic page (Informed Consent) to make decisions regarding their health care.
Patient immaturity can be relevant when the patient is of a very young age (minor) and presumed to not have the cognitive development to make meaningful decisions, or when the patient suffers from mental handicap which impairs her cognitive development. Once again, neither condition in itself precludes participation of the patient in decision making, but expert consultation may be needed to determine whether the patient is capable of understanding their situation and options, and making a decision based on them. In the case of minor patients, legal precedents determine when a minor can give legal consent, but do not address the issues of when a minor patient should be invited ethically to participate in the informed consent process. A more detailed discussion of these issues will occur in the Pediatrics Clerkships.
What information should be provided to surgical patients in the consent process?General rules to follow in consent for surgery and anesthesia are to inform the patient of common risks even if they are not serious, and very serious risks, such as death, even if they are not common. By asking the patient if they have any specific concerns, you can invite the patient to let you know of any "special" informational needs that they may have which are not obvious to you.
When discussing risks with patients, understand that mere recitation of statistical risks may mean little to patients, and it can be helpful to relate the information to risks which have some meaning for the patient. The approximately one in 50,000 risk of death during general anesthesia in a healthy patient can be compared to that of the risk of death in an automobile accident (about twice that), as a way of putting perspective on the information being provided.
Can I influence patients during the informed consent process?Influence can be applied to the information given to patients, and generally falls into three categories:
Coercion is the application of a credible threat to the patient, and is always unethical. Manipulation involves incomplete or nontruthful presentation of information, such as lying, omitting vital information, or deliberately deceiving. Manipulation is always ethically suspect. Persuasion involves the presentation of a rational argument for a choice, and is permissible, even desirable during the consent process. Patients recognize that physicians have expertise and advice to offer about their care, and expect physicians to be forthright with recommendations.
Do we harm patients by causing stress and anxiety when we tell them about the risks of anesthesia and surgery?"Therapeutic privilege," or the idea that information may harm patients, is often cited as a reason to curtail the discussion of risks with patients about to undergo anesthesia and surgery. Multiple studies have failed to demonstrate differences in the way patients and observers rate the stress levels of patients who receive detailed information when compared with patients who received little or no information about risks.
What do I do in an emergency, or when the patient is incapable of making a decision?Conscious, competent patients have the right to make choices regarding their health care in emergencies, just as in routine care.
When patients are incapacitated, it is important to seek the advice of appropriate surrogate decision makers and others who know the patient and are aware of his or her usual choices. When such information cannot be obtained, the physician should try to act in the best interest of the patient until such a surrogate can be found.
Is the surgical consent sufficient to cover anesthesia care?Principles involving the informed consent process require that the best available information about procedures and risks be provided to patients. Just as anesthesiologists lack the expertise to discuss risks of surgery, surgeons lack expertise to discuss the nature and risks of anesthesia. While the surgical consent form does contain a phrase regarding consent for anesthesia care, the informed consent process requires that a separate discussion of anesthesia risks be carried out by the anesthesia provider.
What if the patient requests not to hear about risks?Patients have the right to refuse information, but the request must originate from the patient and not the physician.