Ethical aspect of patient information in anesthesiology and resuscitation.

Gonzalo Herranz, department of Bioethics, University of Navarra
lecture delivered at the VIIth International Anesthesiology-Resuscitation meeting
Pamplona, June 5-6, 1998
Session IV: Patient information.

Index

The peculiarity of the anesthesiologist-patient relationship

Basic objectives of patient information

Contents of patient information

Good morning to all and my thanks to the organizers for inviting me to participate in this session. It will be an occasion to hear about medical ethics, something that should happen today whenever physicians get together to discuss their business. I do so gladly, because those of us in medical ethics owe a priceless debt to a great anesthesiologist, Henry Beecher, the man who not only established anesthesiology as an academic discipline , but the man who, by denouncing the abuses of certain researchers of his time, forced the growth of the doctrine and standards of biomedical research ethics, and also the man who chaired the Harvard Commission that, by developing the notion of brain death, opened the way to the internship of transplantation. I would not want this recollection of Beecher to be interpreted as a sign of erudition or as flattery to the gallery. I have brought it up to begin my speech by reminding all of you that ethics and anesthesiology can go hand in hand and form a very strong alliance.

In addition, the hasty preparation of this intervention has not allowed me to thoroughly review the bibliography on the subject. One conclusion must be drawn: what I am about to say is all provisional. Anyway, it is a topic that, being very attractive, has been, that is my impression, very little elaborated.

It is surprising to see, on the one hand, how little is bibliography on the specific ethics of clinical anesthesiology, of the dominant activity of anesthesiologists, which is to administer anesthetic care to patients before, during and after the operations to which they are subjected. At least, that impression of scarcity is what one gets from consulting the database of Bioethicsline. There are many articles there on intensive care, on the value and meaning of do-not-resuscitate orders at operating room, on the limits of pain management, or on the fortunately not too frequent situations of anesthesia in HIV-positive patients, of perioperative transfusions to Jehovah's Witnesses, and the like.

It is also surprising that in this scarce bibliography there are very few references to the relationships of anesthesiologists with the patients who receive their care. There is much more judicial than ethical information. It is even curious that when one examines the protocols, guidelines, and declarations of the major anesthesiology societies (of the United States, Canada, the United Kingdom, Spain, etc.), I have found nothing more than the "Anesthesiology and Ethics of the United States, Canada, and the United Kingdom; from Spain, I have only found the 1985 Supplement of the Spanish Journal of Anesthesiology and Resuscitation dedicated to Standardization in Anesthesiology and Resuscitation), one finds documents that are more legal than ethical, with standards that seek with the utmost scrupulousness technical correctness, hermetic safety to failures and errors, the multiplication of the so-called parameters of internship to deal with an infinite number of clinical situations. And that is very good: but it is more technical than ethical.

There is, in anesthesiology, very little presence of the patient as a person. There is no indication of the obligation to inform in the guidelines of the American Society of Anesthesiologists and, unfortunately, in all the documents derived from them (the closest case is the Professional Code of Anesthesiology and Resuscitation proposed by the group of the General Hospital of Valencia, in 1985, whose ethical analysis would be very interesting). (I would appreciate more modern information on the subject). I have the impression that the somewhat fatalistic idea predominates that the anesthesiologist does not choose his patients, who are given to him by the surgeons. Once the latter is convinced by the surgeon of the need for an operation, consents to it and is admitted to the hospital, it is taken for granted that there is no need for specific consent to anesthesia, since such consent is implicit in the more general consent to the operation. Thus, a kind of cultural prejudice has been created that consent to anesthesia is a matter of secondary importance. But ethics requires the anesthesiologist to act with full freedom and responsibility, to exercise his professional judgment with full skill and autonomy. The anesthesiologist cannot today, either ethically or legally, play the role of a subordinate to the surgeon, since his responsibility to the patient is full, not diluted by being part of a team.

It is surprising to see that anesthesiologist-patient relationships have not been the subject of much study and reflection. A recent English work has shown that many patients are unaware that anesthesiologists are physicians, that they do not know that anesthesiologists work in operating rooms. This finding is very interesting, as it highlights the special circumstances in which the medical act of anesthesia takes place, the tenuousness of the ethical features peculiar to the anesthetist-patient relationship, the nebulous nature of the perianesthetic report , the eclipse of anesthesia by surgery.

I will discuss these ethical peculiarities before referring to the ethical obligation of anesthesiological information. I will then discuss the basic ethical objectives of the information that the anesthesiologist must give to his patient, and I will end with a list of some of the contents of this information. I believe that I will then be able to hear many interesting observations from you.

1. The peculiarity of the anesthesiologist-patient relationship.

The first point to reconsider is the very special dependence that anesthesia creates in the patient with respect to his anesthesiologist. This is not limited to the incommunication induced by general anesthesia, in what is physiological, but also in what is physiological staff. To begin with, unlike what happens in most medical procedures, the anesthetized patient can no longer abandon the treatment once it has begun; he cannot withdraw his consent. General anesthesia strips the patient of all sensory information, renders him incapable, takes away his consciousness, leaves him dispossessed of all control of himself. As a person he temporarily loses the capacity to decide, to participate in his own care and defense. It is the extreme of the reification process to which, to a greater or lesser extent Degree, every patient must submit in his relationship with the physician.

On the other hand, it should not be forgotten that nothing sample more eloquently expresses the patient's trust in his physician than the fact of allowing himself to undergo general anesthesia. This is why general anesthesia can never be taken lightly. This is the source of many ethical obligations, since no medical act creates more ethical tension than the anesthetic act: in no other medical status is the doctor's responsibility towards his patient greater in intensity.

The anesthesiologist, with his equipment but, above all and decisively, with his attention, has to make up for the nullified homeostatic springs of a patient who does not feel and whose physiological reaction springs have been deliberately nullified to a greater or lesser extent Degree. Under these conditions, the Hippocratic precept "first, do no harm: primum non nocere" takes on particular importance. The anesthesiologist must perceive, feel and react for the patient. And this at all levels: from the metabolic and physiological level to staff, from oximetry to the protection of the body and the preservation of modesty, from thermal protection to the protection of psychic intimacy, so often uninhibited in the twilight moments of the post-anesthetic period.

Monitoring creates a special communication: it is not a dialogue with machines, but with a human being. There is a wonderful article by Saunders in Anaesthesia, 1997, on the dangers of the idolatry of monitoring, that dangerous overconfidence in devices, in which he speaks very arguably and critically in favor of the priority of direct observation of the patient, to which the data provided by monitoring instruments should be subordinated.

At this point in my talk I think we should be persuaded that doctor-patient communication is very important in all phases of the process: not only in the anesthetic phase, but especially in the important moments that precede and follow it.

2. Basic objectives of patient information

From what has been said, it is clear that the main opportunity for the anesthesiologist to report is concentrated in the preanesthetic phase. Once the technical part of the preanesthetic interview, so meticulously described in so many protocols and which leads to the essay of the patient's anesthesiological history, has been completed, the time comes to add the human and ethical part. This informative moment has a legal aspect that leads to signature of the informed consent document, but, underneath it, there is an ethical aspect.

Ethical reporting should be strongly impersonal, strongly staff, done face to face, calling people by name, and treated with the necessary respect and circumspection.

Ethical respect for the patient has immediate implications. One, the first, is to treat everyone equally, each according to his needs and condition, his age and culture: it is easy to treat the educated and dignified with respect, but it is much more difficult, and more demanding of human quality in the physician, to treat the ignorant and rude with the same delicacy and respect.

It is very important, decisive, to dedicate the necessary time to the preoperative interview. In the Supplement to the Revista Española de Anestesiología y Reanimación there is a hyper-realistic picture by Toro Jiménez of the difficulties encountered in real life, in real time, in carrying out the enquiry of Anesthesiology. However, and recognizing that the modern hospital leaves much to be desired in human ecology, it is worth remembering that, ethically, reporting is not a trivial thing, a routine that must be complied with because it is required by regulation or imposed by the Code. Reporting is always a human meeting , which requires effort and attention to detail. Information has an addressee staff, the patient, who is the one who determines its intensity and extent, and the cultural level and content it should have.

It should never be forgotten that there is an irreducible asymmetry between anesthesiologist and patient at the moment of informing about the anesthetic procedure: to the anesthesiologist it may appear as the umpteenth repetition of a routine procedure, like a formula worn out by use. For the patient, this moment is a new and risky experience, in which he is going to put his integrity staff, his own life, the only one he has, in the hands of a man he does not know. This is an enormous act of human faith. The anesthesiologist must make every effort to ensure that the patient's act of faith is reasonable, not a blind gamble. Undoubtedly, in this meeting, the anesthesiologist as a physician has the leading role, but it is the patient who, with his gestures or questions, directs the physician's effort to make a rational and manager leap into the void of placing his life in the hands of another. This moment should never be trivialized, making it less serious, especially with that irritating way of playing down the importance of things, which is to treat the patient as if a mature man were a child, a mature woman were a girl.

I would like to make a small digression here so that it will be understood that the human value of the information given to the patient cannot be stressed enough. Both in the Christian tradition and in secularist culture, information plays a decisive role in clinical decision-making, not because it is a matter of legal implications, but because it incorporates the recognition of the patient as a person. Informed consent is not just a matter for American judges or for the liberal bioethics of the four principles, so much to the liking of so many in the ethics committees of our hospitals. Nor is it the business of certain modern patients, armed with their rights, their readings and their wise-ass arrogance. I am gathering data which tells us that - long before the postmodern idea of the individual as the master of himself, the sole and ultimate manager of his body and his destiny, and whose consent is obligatory for the physician to intervene on him - there is a long tradition, human and Christian, based on the notion that the individual is the sole and ultimate manager of his body and his destiny, and whose consent is obligatory for the physician to intervene on him, based on the notion that man is a creature of God, that he receives life and the body as a gift which he must administer and be accountable for, and which also points out with great force that the physician cannot take any measure or attempt any intervention without the patient's consent: "the physician," said Pius XII in 1952, summarizing the Christian moral tradition, "has over the patient only that power and those rights which the patient himself confers on him, either explicitly, or implicitly and tacitly. But the patient cannot confer more rights than those which he himself actually possesses. The decisive point in this question is the ethical limit of the patient's right to dispose of himself: this is where the moral boundary of the action of the physician acting with the patient's consent rises".

From an ethical perspective, informing, rather than reciting the points of a minimal but legally sufficient script, consists of answering the questions that the patient may ask so that he can assume the responsibility he has for himself. And in this respect, as we all know, patients have very different quantitative and qualitative information needs. But each one of them, out of justice, must be given their own, each one's specific need for information must be satisfied. The anesthesiologist's work is not just about "sleeping" patients. The best part of their salary or fee is earned by anesthesiologists in the pre-anesthetic interview.

That is also where they earn the consideration of their patients. It is worth spending the necessary time on preoperative information. It always pays off: in the reduction of anxiety. It is true that the risks of anesthetic accidents are very small, and those of death are minimal. But there are undoubtedly many patients who arrive at the operation frightened and anxious. One measure of the quality of the anesthesiologist as a physician is the ability to convert the patient's anxiety into confidence.

It pays off in the prevention of litigation due to bad internship. A patient who feels cared for and respected is a patient friend. A patient who is sincerely informed is a patient friend. The truth is that not always, but almost always. There is a famous case of a British anesthesiologist, condemned by the GMC as a serious misconduct, because of a defect of information to the patient. Very interesting and very irritating, worth commenting on.

An essential aspect of the information is to disclose the different technical alternatives compatible with the intervention the patient is going to undergo. Insofar as the operative strategy is compatible with different types of anesthesia/analgesia/amnesia, the anesthesiologist must explain the different alternatives, with the aim of allowing the patient to choose, purpose . It is a complex matter, but it is a gift of great value to the respect of people.

The process of debriefing also pays off for the anesthesiologist, in the form of professional satisfaction. When informing, the anesthesiologist is sample before the patient as a full-fledged physician. It is at enquiry and pre-anesthetic information that the anesthesiologist reveals himself as an independent physician, not as an undefined element that is part of the operating team, a employee of the surgeon.

3. Contents of patient information

The information to the patient has some basic ethical contents, which should extend and grow from agreement with the patient's needs and questions. I will point out average dozen ingredients of it.

1. The last one is that there is a mandatory ethical rule : never leave any question from the patient unanswered, no matter how "silly" it may seem to the doctor. The crème de la crème of ethical information is to be able to tell the patient: you answered clearly all the questions I wanted to ask you. The first piece of information is to tell the physician his own name. Only then will he be able to call the patient by his own name. This is a symbolic act, because it impersonates both of them. Calling the patient by his name means to him that he is someone, that he is known, that it is him and not someone else, that he is not confused with someone else. And it is the same with the doctor: knowing the doctor's name is the patient's right. By revealing his name, the doctor is telling the patient that the hospital is not a collective and faceless monster, but a moral community, made up of real and free human beings, who each assume, nominally, their responsibilities, that these are not diluted in anonymity.

2. The presentation is the beginning of the anesthesiological history, a special and circumscribed history that is made up of both information that is taken and information that is given. And one piece of information that must be recorded in this history, as summary of what happened, is to record not only the information given by the physician, but also the information given by the patient, which has been captured, understood and noted, and which will be taken into account.

3. Report on one's own experience and skill. Important for everyone, especially young people. It is not known when the time will come when the patient will be able to choose the anesthesiologist. In the meantime, the patient must be assured that the anesthesiologist and his collaborators have skill and experience staff, that they are in a position to offer the most suitable for the case, according to the art of the moment.

4. Inform the patient that the anesthesiologist assumes all the responsibilities of an expert in anesthesiology, resuscitation and pain management. A responsibility staff, of a specialist who knows and assumes the risks and responsibilities. The anesthesiologist must ensure that his presence will be continuous, that he will not abandon the patient until the end of the post-anesthetic period, that he, or a member of his team who has skill to accept the delegation of his duties and functions, will be vigilant at the patient's side from beginning to end, that he will mitigate pain already before the operation until it is entrusted to the physicians who will take care of him.

5. Describe the details. I always have in mind the image of Dr. Reynolds, a character who makes very fleeting but full of quality appearances in that wonderful novel To Kill a Mockingbird, by Harper Lee. Of the attention doctor that Reynolds lavished on the little ones, the little protagonist says: "He never lost our trust: he always told us what he was going to do to us. And he never cheated us." "Saying what is going to be done and never deceiving" could be a magnificent and simple formula of the ethical duty to inform, a duty that implies the convenient detail and truthfulness.

Legal language can have a lot of fine print, a complicated lexicon. Ethical language is simple and true. An anesthesiologist describes what he tells his patients to begin with this way: "Tomorrow, at 7 o'clock, a couple of hours before the operation, the nurse will give you some pills that will leave you relaxed. We will meet before going to operating room. Then I will give you an injection that will put you completely asleep. Afterwards, I will connect you to a device that will very accurately dose you with the necessary oxygen and a gas that will make you insensitive to pain while the surgeon operates. I will also give you an injection to relax your muscles and prevent you from moving during the operation. I will be there all the time, watching how things are going, ready to intervene when necessary, observing your vitals with the financial aid of some monitors. When the operation is over I will give him an injection to mitigate the pain. He will wake up breathing oxygen through a tube that we will have placed in his trachea: there is nothing special about this because we do it with all the patients who undergo surgery. When you are more awake and able to breathe without the financial aid of that tube, we will remove it. And then you will go back to the room. And we will give you what you need so that you don't have any pain. From agreement? Do you have any questions to ask me?"

It is then the time to talk about any remaining fears, to know what is meant by an injection to prevent muscle movements, what is the tube that will be placed in the trachea, etc. It is the moment to reassure: to say that the risks are well known and how to prevent them. To communicate reassurance. The questions that the patient may ask are as different as the people. Some will want to know if safety protocols are in place, if the instruments are subject to preventive revision, and some will ask if the doctor has ever had a patient die from anesthesia.

No question is idiotic. We physicians have to get used to responding with infinite understanding and patience to patients. People's culture is growing, and so is the medical culture. Sometimes, by the hand of journalists who are friends of sensationalizing accidents. At other times, by popularizers who, in newspapers or on television, turn medical progress into a fairy tale, simplify the complex and raise public expectations. I do not know what will happen in the future, but, to put it graphically, many patients who have been read are today, in relation to their health Education , in the age of the turkey. This is where they must necessarily pass through to reach maturity.

The task of informing has strong servitudes, but it is a decisive manifestation of the physician's humanity. There are no tasks that are ethically superior to it.