consent for an anaesthetic can be a nebulous entity. There are no detailed
manuals, but there are many articles written on this subject. The Australian
and New Zealand College of Anaesthetist’s (ANZCA) Guidelines
on consent for anaesthesia or sedation provides some guidance on the consent process.
understanding of the anaesthetist’s role is also poor, with many patients still
holding the belief that the anaesthetist leaves the operating room after
anaesthesia has been induced. Furthermore, in the current era of surgery on the
day of admission, anaesthetists often have limited opportunity to have more
than a brief, but necessary discussion pre-operatively.
rarely arise from consent to anaesthesia issues, unlike surgery, and if they
do, it is usually due to unanticipated dental damage. Unfortunately, an
increasing number of complaints to regulatory bodies like AHPRA arise from a
perception of poor anaesthetist performance or communication, real or perceived.
In the 2015-16
financial year, Avant’s claims data showed that almost
half (49%) of anaesthetists’ claims were for complaints referred to the
regulatory authorities for conduct, performance and health impairment
important to allow enough time for a pre-operative consultation and not to rush
this with your patients. Those impressions of you obtained during your brief
encounter with the patient, count. Achieving a good rapport with your patient
pre-operatively is essential.
for ASA 1 patients having minor surgery, a consultation should take up to 10 minutes.
Medically complex patients will take a lot longer. Many anaesthetists are now
making pre-operative phone calls and obtain completed pre-operative medical
questionnaires to avoid lengthy last minute consent discussions on the day of
surgery. A pre-operative discussion may be
lengthy, especially if there are alternative options for anaesthetic technique.
These can include sedation, regional anaesthesia, central neuraxial blockade
and others depending on the circumstances, each with their unique set of risks
all patients are anxious, some almost to the point of psychological
decompensation. For many, this is not the ideal time to discuss risk,
especially if significant risk exists.
legal principles as to what is a material risk that needs to be discussed with
a patient was established in the case, Rogers vs Whittaker 1992. Risks can be
divided into objective risks and subjective risks. Objective risks are those which
any reasonable person in the patient’s position would believe material or
relevant in making a decision about the anaesthesia, such as dental damage,
adverse drug reactions, aspiration and awareness etc. Few patients are aware of
the risk of dental damage and anaesthesia. This is an issue I spend a little
time on, particularly if a patient has restorative dental work affecting the
incisor teeth. It’s important to warn patients of the
possible risk of dental damage and to document this
discussion and their consent to undergo anaesthesia. From a legal
standpoint, safeguards are then in place to refuse reimbursement to the
patient, if dental damage occurs.
risks are those which the anaesthetist is aware or should reasonably be aware that
the particular patient, if warned of the risk, is likely to attach significance
to. Your discussion of these types of specific risks should be tailored around
issues that are relevant to each patient. Discuss what the patient has raised
with you and what you feel your patient wants to discuss – this takes practice.
This could include problems with previous anaesthesia, potential issues with
the current surgery including ICU admission, problems friends or relatives have
experienced, or even related to information gathered from social media.
my opinion, financial consent should not be sought from a patient immediately
pre-operatively as it creates a negative impression in the patient's mind as to
your motives for providing the anaesthesia care. Organise this requirement pre-operatively
at another time. Patients having urgent surgery are often in no state to
discuss financial matters. This information should be provided
with serious illnesses such as advanced malignancy or other terminal illnesses
may have an advanced care directive (ACD). It’s important to check beforehand
if your patient has an ACD in place so that you can discuss the patient's
wishes prior to surgery.
central neuraxial blockade is to be part of your technique, ideally this should
be discussed well in advance to allow your patient time to consider the risks.
of the public or private setting, a doctor's duty of care should not compete
with any perceived obligation to train or educate junior doctors or other
staff. Consent should be obtained for all key aspects of the anaesthesia if
anybody other than the anaesthetist is to perform these tasks, for example, endotracheal
intubation. It is inappropriate to obtain this consent immediately prior to
surgery. Patients may be sedated, under duress or feel that if consent is not
given their care may be compromised.
many anaesthetists still rush through the consent process. For many, we can and
must do better. A consent discussion is essential and requires a thoughtful
approach to successfully accomplish informed patient consent.
Gaining patient consent and material risk (video)
advice whenever you need it
For more information visit Avant’s website or, for immediate advice, call
Avant’s Medico-legal Advisory Service (MLAS) on 1800
128 268, 24/7 in emergencies.
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