The illusion of informed consent

Simulated anesthesia consent discussions demonstrate high level of comprehension and education requirements for patients: A pilot study

Objective

Patient comprehension of informed consent and demonstration of procedural understanding is often lacking in anesthesiology. The purpose of this study was to determine if patient communication in anesthesiology is being conducted effectively, and in a manner that ensures adequate communication between anesthesia professionals and their patients regarding procedures with associated risks and benefits.

Methods

Anesthesia professionals were recorded in a simulated setting explaining anesthesia procedures of increasing complexity with one control scenario. Score means were calculated, and statistical comparisons made between discussion of anesthesia procedures and the control scenario.

Results

Calculation of means for 6 readability tests demonstrated the grade level required to understand the medical practitioners' verbal communication was high and increased with complexity of the anesthesia procedure described. The control scenario required a statistically significant lower level of comprehension for the recipient of the information.

Conclusion

In simulated settings, anesthesia professionals regularly communicate procedural details in a manner that is difficult for the general public to understand. Subjects could communicate in simple terms when discussing a control.

Innovation

This pilot study demonstrated effective methodology, using artificial intelligence technology for transcription, to assess patient comprehension of verbal communication.

Autonomous patient consent for anaesthesia without preoperative consultation: a qualitative feasibility study including low-risk procedures

Background

Informed consent for anaesthesia is mandatory and requires provision of information and subsequent consent during consultation between anaesthesiologist and patient. Although information can be provided in an electronic format, it is unknown whether this a valid substitute for a consultation. We explored whether provision of digital information is equivalent to oral consultation and whether it enables patients to give electronic informed consent (e-consent) for anaesthesia.

Methods

Qualitative feasibility study using semi-structured interviews in 20 low-risk adults scheduled for minor surgery under general anaesthesia or procedural sedation at a university hospital. Data were analysed using a thematic content analysis approach. During the interviews, patients followed an application that provides information and subsequent e-consenting.

Results

The mean age was 50 yr and patients had good digital skills. Fifteen patients (75%) had previous experience of anaesthesia. The digital application provided enough information for all patients, but eight (40%) preferred consultation with an anaesthesiologist, mainly for personal contact. Patients had different information needs, with previous experiences leading to lower information needs. Nineteen patients had sufficient information to consent autonomously. Most patients considered separate anaesthesia consent superfluous to the surgical consent.

Conclusion

The digital application provided sufficient information and patients valued the information offered and the advantage of processing information at their own pace. This information made patients feel empowered to autonomously consent to anaesthesia without consultation. Remarkably, consent for anaesthesia was considered unimportant, because patients felt they had 'no choice' if they wanted to undergo surgery.

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

BACKGROUND

Calls to better involve patients in decisions about anesthesia-e.g., through shared decision-making-are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia.

METHODS

This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia.

RESULTS

The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences.

CONCLUSIONS

Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists' attention away from important humanistic aspects of communication such as decreasing patients' anxiety.

EDITOR’S PERSPECTIVE

Human factors and the safety of surgical and anaesthetic care

Safety of patients in the operating theatre relies on a cordial and efficient working relationship between all members of the theatre team. A team that communicates well, defines the roles of its members and is aware of their limitations will provide safe patient care. In this review, we will examine how human factors engineering - the science of how to design processes, equipment and environments to optimise the human contributions to performance - can be used to improve safety and efficiency of surgery. Although these are often dismissed as 'common sense', we will explain how these solutions emerge not from healthcare but from diverse disciplines such as psychology, design and engineering.

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.