Ethics in Anesthesia: Preoperative Considerations

Ethics in Anesthesia: Preoperative Considerations

As anesthesia transforms into perioperative medicine, anesthesiologists have fewer opportunities to consult with patients. Often, the patient will consult primarily with an operating doctor, who will then refer them to an anesthesiologist. At the same time, a study by Hariharan et al. found that 45% of patients who had surgery under anesthesia did not recall meeting with an anesthesiologist [1].

According to the American Society of Anesthesiologists, a preoperative consultation should be performed before any operation that requires anesthesia [2]. These consultations allow anesthesiologists to establish a good rapport with patients prior to the procedure and to address potential issues. In a study by Lam et al., preoperative consultations also reduced commonly expressed patient concerns such as fears of waking up or feeling pain during the surgery [3].

During a consultation, doctors should be mindful of the varying levels of comfort that patients have with anesthesia, as well as religious or cultural objections to certain procedures. For example, it is well known in the medical community that many Jehovah’s Witnesses will not receive blood transfusions, which they view as a violation of a Biblical imperative [4]. Such concerns should be discussed during a consultation so that proper care can be provided.

When preparing a patient of the Jehovah’s Witness faith for anesthesia, doctors should optimize a patient to reduce the risks of intraoperative hemorrhage. According to an article by Milligan and Bellamy, specific attention should be paid to hematology [5]. This can include stopping use of anticoagulant and antiplatelet drugs and using drugs such as vitamin K and B12 that promote clotting and red blood cell production. Likewise, patients with a low preoperative packed cell volume (PCV) or microcytic anemia may benefit from preoperative iron supplementation. Even if patients do not exhibit signs of anemia, iron supplementation can help avoid a reduction in hemoglobin concentration in the period immediately following an operation.

Preoperative testing is a common part of the consultation process and carries significant ethical considerations. Some tests, such as those screening for pregnancy or HIV, are often treated as routine preoperative checks. However, these tests sometimes result in unexpected positive results. Less obvious is the ethical dilemma of false positives, which are an unfortunate byproduct of many testing processes [6]. In both cases, it is imperative for the doctor to consider the impact of these tests on the patient before discussing results.

Some patients will also have do-not-resuscitate orders, which may have implications regarding which anesthetic procedures can be performed.  The ASA’s guidelines for administering anesthesia to patients with a DNR recommends that doctors review a patient’s directives during the preoperative consultation and revise them accordingly [7]. However, patients may continue to opt out of certain resuscitation procedures. In these instances, the guidelines dictate that anesthesiologists should inform patients about which procedures are essential to the success of the anesthesia and which may be refused. For example, a study by Clemency and Thompson discusses a patient with a DNR that requests no vasopressors be administered [8]. If the aforementioned patient requires a slowly dosed epidural, a vasopressor may not be necessary [9].

In sum, preoperative consultations are an ethical imperative and can assuage patient concerns regarding anesthesia. During these consultations other concerns, such as religious objections or the existence of a DNR, may arise. As clinically-relevant considerations emerge, it is essential that anesthesiologists take precautionary measures to optimize patients to reduce the risk of complications.   

Sources

[1] Hariharan, Seetharaman. “Ethical Issues in Anesthesia: the Need for a More Practical and Contextual Approach in Teaching.” Journal of Anesthesia, vol. 23, no. 3, 2009, pp. 409–412.

[2] Fischer, Stephen P. “Development and Effectiveness of an Anesthesia Preoperative Evaluation Clinic in a Teaching Hospital.” Anesthesiology, The American Society of Anesthesiologists, July 1996.

[3] Lam, Eunice, et al. “Effect of Anesthesia Consultation on Patients’ Preoperative Concerns.” Canadian Journal of Anesthesia, Oct. 2007.

[4] Tran, Connie K, and C. LaToya Mason. “Caring for the Jehovah’s Witness Parturient : Anesthesia & Analgesia.” Anesthesia & Analgesia, International Anesthesia Research Society, Dec. 2015.

[5] Milligan, Lisa J, and Mark C Bellamy. “Anaesthesia and Critical Care of Jehovah’s Witnesses.” OUP Academic, Oxford University Press, 1 Apr. 2004.

[6] Van Norman, Gail A, and Stanley H Rosenbaum. “Ethical Aspects in Anesthesia Care.” ClinicalKey, 17 Sept. 2016.

[7] “Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders or Other Directives That Limit Treatment.” American Society of Anesthesiologists, 1 Oct. 2001.

[8] Clemency, Mary V, and Nancy J Thompson. “Do Not Resuscitate Orders in the Perioperative Period:… : Anesthesia & Analgesia.” Anesthesia & Analgesia, International Anesthesia Research Society, Apr. 1997.

[9] Sumrall, William D, et al. “Do Not Resuscitate, Anesthesia, and Perioperative Care: A Not So Clear Order.” The Ochsner Journal, The Academic Division of Ochsner Clinic Foundation, 2016.