American Society of Regional Anesthesia and Pain Medicine May 2017 - 15
Shared Decision-Making in Regional Anesthesia
C
onsider this all too common scenario: You meet a patient
scheduled for a total joint arthroplasty. This is your first time
meeting the patient, and he has not spoken with anyone
from anesthesia before today. You believe this patient is a perfect
candidate for a spinal anesthetic, but the patient is nervous and
instead opts for a general anesthetic. He tells you that he is afraid
of being paralyzed and/or he knows someone who had a bad
experience with a spinal. As an anesthesiologist you wonder if this
patients' reluctance could have been avoided with a preoperative
meeting on another day, before the day of surgery and separated
from the stress of the preoperative holding area. And if so, how
might preoperative anesthesia education affect his decision?
Anesthetic choice on the day of surgery can be influenced by
multiple factors: patients' comorbidities, coagulation status, body
mass index, culture of the institution, surgeon preference, and also
the comfort level of the anesthesiologist.1-4 But how does patient
preference factor into this decision? This is an important question,
especially in the era of the perioperative surgical home (PSH)
where patient satisfaction with surgical care is highlighted. With
this in mind, how can we, as anesthesiologists and perioperative
physicians, involve patients more concretely in decision-making
for their anesthetic in a timely and meaningful way? The first step
along this road is making sure the patient is appropriately informed
and educated, and that often means preoperative education
regarding anesthetic options.
PATIENT EDUCATION AND HOW IT CAN AFFECT ANESTHESIA
Preoperative patient education is certainly not a new concept. In
fact, patient education forms the underpinnings of the informed
consent process. Ideally, the informed consent process includes
enough information for patients to make educated decisions
about their health care. When it comes to anesthesia, throughput
pressures in the operating room can influence the consenting
process when it occurs immediately preoperatively. This situation
is especially evident when there are several anesthetic options to
choose from, as is the case when offering blocks to patients for
pain control or as an anesthetic. Patients are often not sure about
the different anesthetic options available to them when presenting
for surgery. It is possible that patients may harbor incorrect
assumptions regarding anesthetic management that is derived
from a previous occasion, a family member's experience, or even
information researched online.5,6 In a practice with a preoperative
clinic, a fully informed dialogue about anesthetic options can be
conveyed in a calm environment.7 If a preoperative clinic does not
exist, the first interaction that a patient has with an anesthesiologist
is often in the preoperative holding area before surgery. This is
usually a time when the patient's anxiety level is high, possibly
interfering with his or her ability to process new information, and
therefore potentially affecting the patient's ability to appropriately
weigh the anesthetic options presented.8 With this in mind, it is
Daniel Abraham, MD
Fellow, Regional Anesthesia and
Acute Pain Medicine
Johns Hopkins University
Baltimore, Maryland
Melanie Donnelly, MD
Assistant Professor
Department of Anesthesiology
University of Colorado
Denver, Colorado
Section Editor: Nabil Elkassabany, MD, MSCE
worth considering the utility and merit of introducing information to
the patient earlier and in more diverse formats.
Researchers at the University of Pennsylvania examined the
impact of incorporating anesthetic information into a preoperative
education course for patients scheduled to undergo total knee
arthroplasty. They found that patients who had this early education
on anesthetic options were more likely to choose a regional
anesthetic in the form of neuraxial anesthesia than those who
did not have that educational experience.9 This study helps
demonstrate that patient education is a crucial step toward
fostering an environment for informed decision-making. Brooks
et al10 examined similar principles by using an iPad and providing
patients with an informational brochure about regional anesthesia
options in the preoperative clinic. They discovered that not only did
this intervention lead to a 10% increase in their regional anesthesia
acceptance rate, but also it reduced delays to operating room. This
reduction in delays to the OR reflects a decreased need to exhaust
preoperative time discussing the various anesthetic options with
patients who are undecided. Groves et al11 also demonstrated a
similar principle. They were able to establish that by providing
patients with "relevant websites" of anesthesia information and
education, the utilization of neuraxial anesthesia increased.
These studies demonstrate that there are a number of ways to
educate patients before the day of surgery. These improvements
can be further reinforced by creating a service whereby an
anesthesiologist is available for questions and concerns that
a patient may have by way of telephone calls or e-mails. By
introducing this information to patients and educating them before
the day of their surgery, we give them the tools necessary to
successfully take part and share in the decision regarding their
anesthesia.
American Society of Regional Anesthesia and Pain Medicine
2017
15
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