American Society of Regional Anesthesia and Pain Medicine August 2017 - 27
Informed Consent and the Postoperative Pain Control Conundrum
Consider the following scenario: A surgeon requests an epidural for
a patient who underwent an elective laparoscopic cholecystectomy
that has converted to open. The patient has a history of opioid
dependence and is currently on methadone maintenance as an
outpatient. In the recovery room, the patient is reporting 10/10
pain. Intravenous opioids and attempts at multimodal analgesia
provide minimal relief. Unfortunately, consent for regional
anesthesia was not obtained by your colleague prior to general
anesthesia for surgery. Would you consider this patient able to
consent for a regional block? Are you comfortable placing an
epidural in this patient? What about an abdominal wall block? Some
anesthesiologists may lean toward intervening in the attempt to
"do the right thing," but others might fear legal consequences and
refuse to perform any interventional procedure. Do you discuss
the risks and benefits of opioids as the alternative to a regional
technique?
Informed consent has long been criticized as being merely a tool
to avoid physician liability. However, informed consent is in the
intersection point between a physician's obligation to protect a
patient's health through beneficence and a physician's obligation
to respect patient autonomy (Figure 1).1 We no longer live in "the
good old days" when the physician made decisions based on what
he or she thought was in the patient's best interest. The foundation
of informed consent lies within the principle of autonomy, and
we have no choice but to place it at the forefront of patient care.
The process of obtaining informed consent must respect patient
autonomy, ensure adequate decision-making capacity, and provide
necessary information. All of the above should take place while
practicing in the best interest of the patient.
Figure 1. The foundations of informed consent.
In health care, informed
consent has been described
as a process by which patients
learn the purpose, benefits,
and risks of a treatment
or intervention as well as
alternatives to the proposed
treatment and voluntarily
agrees to undergo the
procedure. Typically, this has
been formalized by a signature
or attestation to confirm the
Elizabeth Wilson, MD
patient's understanding. In
Assistant Professor
an ideal world, informed
Department of Anesthesiology
consent would occur prior
University of Wisconsin
to a scheduled surgery or
Madison, WI
procedure, without stress or
Section Editor: Kristopher Schroeder, MD
duress. Delivery of appropriate
information at an adequate
literacy level should be provided free from time constraints.
Patients would be allowed time to review the information
and formulate questions and concerns and then be given the
opportunity for follow-up and to express a decision or choice.
Anesthesiologists are uniquely subject to many vulnerabilities and
challenges specifically related to informed consent. They often meet
complex patients on the day of surgery and sometimes minutes
prior to proceeding to the operating room. Patients are anxious, and
the anesthesiologist can be the victim of production pressure. It is
rarely a decision of treat or not treat in the preoperative setting.
In this short amount of time, it is difficult to tease out patients'
concerns, priorities, and cultural preferences. Family dynamics are
often at play and challenging to discern. Documentation can also
be an issue, with poorly written notes, often lacking details and
sometimes with ineligible handwriting, or reliance on a generic
surgical consent that doesn't discuss specific anesthesia risks.
Lastly, anesthesiologists are often placed in situations in which
informed consent has been obtained by others, such as when
assuming care for a patient already anesthetized or being asked to
provide regional anesthesia in the recovery room. Providers in this
situation have never met the patient and are unaware of any patient
concerns or preferences or what exactly was talked about in the
preoperative period when consent was obtained.
Specifically, in the case referenced above, one is faced with a
decision to treat pain by performing a skilled procedure on a
patient when the ability of that patient to consent becomes clouded
by the presence of duress and polypharmacy. In this situation, the
question must be asked, "Is this patient able to make a medical
decision under these circumstances?" Determining if a patient
has decision-making capacity is the responsibility of the treating
physician. There are several tools available to help guide an
American Society of Regional Anesthesia and Pain Medicine
2017
27
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2017
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American Society of Regional Anesthesia and Pain Medicine August 2017 - 2
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