Anesthesia for Children: Getting Informed Consent Under Duress
Anesthesiology residents categorize the difficulties they face
March 5, 2009
Boston, Mass. -- The practice of obtaining informed consent from patients and families enters difficult territory when it comes to administering anesthesia, finds a study from Children's Hospital Boston and the Institute for Professionalism & Ethical Practice (IPEP). The study appears in the March issue of Anesthesiology, accompanied by an editorial.
Anesthesiologists often need to get consent from patients and families under less than ideal circumstances--such as when the child is about to undergo surgery and the family is anxious and stressed. It is critical that doctors learn how to ease anxiety and establish trust and confidence quickly with the family--a skill that is not always a large focus in medical training.
57 Anesthesiology residents and fellows from several Boston- area hospitals voluntarily participated in a workshop with the Program to Enhance Relational and Communication Skills (PERCS)--Anesthesia, offered by IPEP. Of those participants, 39 submitted written narratives citing a specific challenge that arose when trying to gain informed consent. Lead researcher David Waisel, MD, Senior Associate in Perioperative Anesthesia, at Children's, and his team studied these narratives and categorized their experiences. "From those narratives, we were able to delve deeper and begin to search for commonalities in terms and phrases. These commonalities helped identify the core problems these doctors were facing," says Waisel.
The researchers independently read the narratives and marked key words and phrases to identify reoccurring challenges described by anesthesiologists. They were then able to compare and agree on the challenges that were faced, and finally, calculated their frequency.
Comprehensive research into each narrative lead to identifying the three types of challenges anesthesiologist were facing; ethical, practical and relational. Each of those types had specific examples researchers recognized. In each of the three categories, actual examples from narratives are included in the study to provide realistic representation for each concern.
"In two-thirds of the cases submitted for this research, anesthesiologists described ethical challenges in their experiences," said Robert Truog, MD, Senior Associate in Critical Care Medicine at Children's and Executive Director, IPEP. "Most commonly, it was found that patients' wishes not being honored, conflict between patient and family wishes and medical judgment, patient decision-making capacity and concerns about upholding professional standards were the biggest obstacles."
Practical challenges, identified in 56 percent of the difficult cases submitted, included the amount of information that had to be provided; communication barriers; and time limitations as the main concerns.
Relational challenges, that is problems successfully relating to the patient, were also expressed. Questions about trainee competence, mistrust associated with past negative experiences, and misunderstandings between physicians and patients or families were all key concerns from the residents.
The findings ultimately show that having an open flow of communication regarding concerns of informed consent may lead to a more productive and less stressful process for physicians. Training programs may wish to offer guidance about identification and management of potential ethical challenges, as well as ways to address practical or relational difficulties that arise. This study serves as a way to identify the initial problem, giving readers the opportunity to address the situation, in their own setting, as they see fit.
An accompanying editorial, by Audrey Shafer, MD, Department of Anesthesia, Stanford University School of Medicine, notes that "the study offer us the pangs of acknowledgment of human-human encounters as we read the narratives." She goes on to mention that the findings "bring to the fore the fact that the practice of anesthesiology can be stressful - even without a drop in oxygen saturation."
To access the article online, click here.
Children's Hospital Boston is home to the world's largest research enterprise based at a pediatric medical center, where its discoveries have benefited both children and adults since 1869. More than 500 scientists, including eight members of the National Academy of Sciences, 11 members of the Institute of Medicine and 12 members of the Howard Hughes Medical Institute comprise Children's research community. Founded as a 20-bed hospital for children, Children's Hospital Boston today is a 397-bed comprehensive center for pediatric and adolescent health care grounded in the values of excellence in patient care and sensitivity to the complex needs and diversity of children and families. Children's also is the primary pediatric teaching affiliate of Harvard Medical School. For more information about the hospital and its research visit:www.childrenshospital.org/newsroom.