The physician must be ready, not only to do his duty himself, but also to secure the cooperation of the patient...
Hippocrates The ethics of patient-doctors relationship have been quite complex and somewhat controversial for >2,500 years, starting from the times of the Father of Medicine and his colleagues1,2. Medical deontology and medico-legal system developments, and other factors greatly influence the informed consent (IC) standards. While we still follow many principles of the Hippocratic Oath and his many imperatives, ‘Do not harm’, in particular, the paradigm of IC has shifted far away from the ‘Conceal everything from your patient’.
Numerous IC guidelines have been updated recently3–6; clinicians are obliged professionally and medico-legally to follow them. IC becomes even more electrifying for Regional Anaesthetists when we seek our patients’ agreement - for their benefits, of course! - for us to ‘stick’ sharp needles in proximity to their spinal cords and nerves and inject potentially lethal drugs close to their arteries and veins. Some conflict is inevitable, with clinicians finding some guidelines ‘unrealistic, unethical, untenable’ 7. It is just possible that one day there will be another shift from a legal claim-centred to patient-centred IC.
My talk will concentrate on discussing the following regarding IC for RA:
• Types, principles and key points
• Recent landmark publications3–9
• Risks disclosure for RA: which, when and how
o General and Specific
o CNBs and PNBs
o ‘Large’ print, ‘small’ print and ‘special circumstances’
o Patient’s recall
o Situation awareness
• Why anaesthetists may be reluctant to follow guidelines?
• ‘Not documented not done’. Oxford standardised consent labels (pic 1&2). The ‘up the hill, down the hill’ quality improvement ‘battle’ in one busy teaching orthopaedic centre10–12
• Can IC harm the anaesthetist?
• Can IC harm the patient?
• Lessons from personal experience
Antoniou GA, Antoniou SA, Georgiadis GS, Antoniou AI. A contemporary perspective of the first aphorism of Hippocrates. J Vasc Surg. 2012 Sep;56(3):866–8. doi: 10.1016/j.jvs.2012.05.002. PMID: 22917047.
Miles SH. Hippocrates and informed consent. Lancet. 2009 Oct 17;374(9698):1322–3. doi: 10.1016/s0140-6736(09)61812-2. PMID: 19847959.
Sardesai A, French J, Pawa A. RA-UK: Consent for Peripheral Nerve Blocks 2015: Regional Anaesthesia UK. 2015 https://www.ra-uk.org/index.php/guidelines-standards/5-guidelines/detail/255-patient-consent-for-peripheral-nerve-blocks
Yentis SM, Hartle AJ, Barker IR, Barker P, Bogod DG, Clutton-Brock TH, Ruck Keene A, Leifer S, Naughton A, Plunkett E. AAGBI: Consent for anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2017 Jan;72(1):93–105. doi: 10.1111/anae.13762. PMID: 27988961; PMCID: PMC6680217.
RCOA: Your spinal anaesthetic 2020. https://rcoa.ac.uk/sites/default/files/documents/2022-03/03-YourSpinal2020web.pdf
GMC: Decision making and consent 2020. https://www.gmc-uk.org/-/media/documents/updated-decision-making-and-consent-guidance-english-09_11_20_pdf-84176092.pdf
Cyna AM, Simmons SW. Guidelines on informed consent in anaesthesia: unrealistic, unethical, untenable…. Br J Anaesth. 2017 Dec 1;119(6):1086–1089. doi: 10.1093/bja/aex347. PMID: 29028983.
McCombe K, Bogod D. Regional anaesthesia: risk, consent and complications. Anaesthesia. 2021 Jan;76 Suppl 1:18–26. doi: 10.1111/anae.15246. PMID: 33426664.
Ahmed HM, Atterton BP, Crowe GG et al. Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project. Reg Anesth Pain Med. 2022 May;47(5):301–308. doi: 10.1136/rapm-2021-103136.
Janes CS, Galitzine SV, Matthews J. Another tool for documenting peripheral nerve block performance. Reg Anesth Pain Med. 2011 Nov-Dec;36(6):631–2. doi: 10.1097/AAP.0b013e318230b74c. PMID: 22024705.
Burumdayal A, Janes C, Matthews J, Galitzine S. Introduction of standardised consent labels for central neuraxial blocks – a useful tool to help documentation. Anaesthesia 2012 Vol 67, Suppl 1 (Jan), p 29 (abstract 46). doi: 10.1111/j.1365-2044.2011.07058.x
Jones T, Bhaktavatsalam B, Wilson K, Matthews J, Galitizine S. Improving documentation of consent and procedure for regional anaesthesia at the Nuffield Orthopaedic Centre. Anaesthesia 2022. Volume 77, (Suppl. 2) pg 23. https://doi.org/10.1111/anae.15630
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