When devising a plan of anaesthesia care, the anaesthesia planning process includes educating the patient, his or her family, or decision maker on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia.
Educating the patient, his or her family, or decision maker on the risks include the following factors to consider when formulating a planned anaesthetic, usually hampered by individual patient variability:
- persuading patients who may express a fear of dying during anesthesia that anaesthesia is very safe (Ronald & Manuel, 2011)
- certain prescription drugs (antihypertensive, tranquilisers, steroids, and diuretics) and over-the-counter (OTC) medications and herbal preparations, can increase (Sue & Patricia, 2011) the patient’s anaesthesia risks. Surgical patients with chronic diseases at risk taking numerous medications can cause complications during the perioperative period and also increase the patient’s anaesthesia risks. The anaesthesiologist will advise the patient, family, and decision makers which medication(s) must be stopped at least 2 weeks prior to surgery, or the surgery may be canceled.
- the patient’s co-morbid conditions i.e coexisting diseases
- other risks include peripheral nerve damage, brain damage, airway trauma (most often caused by difficult tracheal intubation), intraoperative awareness, eye injury, fetal/newborn injury, and aspiration.
The use of regional anaesthesia has significant benefits for patients and facilities. For example, regional anaesthesia for patients undergoing orthopedic procedures decreases (Ronald & Manuel, 2011) overall anaesthesia when compared to general anaesthesia and postanaesthesia care unit (PACU) discharge time can be shortened and the immediate postoperative period made more pleasant for the patient.
The patient, his or her family, or decision maker will be educated on the choice of anaesthesia, whether it is to be either general, or regional or sedation and will be influenced by (Ronald & Manuel, 2011):
- site of the surgery
- position of the patient during surgery
- risk of aspiration
- age of the patient
- patient cooperation
- anticipated ease of airway management
- coagulation status
- previous response to anaesthesia
- preference of the patient
This discussion on the risks, benefits, and alternatives related to the planned anaesthesia and postoperative analgesia occurs as part of the process to obtain consent for anaesthesia (including moderate and deep sedation) as required in PFR.6.4, ME 2, which I have already blogged about in the post Informed Consents – 5 required documentation in the medical record providing information to patient and family (this link will open in a new link of your current window).
An anaesthesiologist or a qualified individual provides this education.
If a hospital has been accredited for Joint Commission International (JCI) accreditation status or already enjoying JCI accreditation status or because a hospital is going for a re-survey by JCI surveyors for another new term of JCI accredited status, then a Health Information Management (HIM) / Medical Records (MR) practitioner is likely to be part of a team using the Medical Records Review Tool form during any one Medical Records Review session which contains the JCI Standard ASC.5.1 to test for conformance to its requirement which states that “The risks, benefits, and alternatives are discussed with the patient, his or her family, or those who make decisions for the patient.”
Although this standard does not require any form of documentation in the medical record, HIM/MR practitioners must take note that risks, benefits, and alternatives that are discussed with the patient, his or her family, or those who make decisions for the patient are normally recorded by the surgeon or anaesthetist in the Preanaesthesia Evaluation Note.
References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
Ronald, DM & Manuel, CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA
