Can J Anesth/J Can Anesth (2014) 61:832842
DOI 10.1007/s12630-014-0188-8
REVIEW ARTICLE/BRIEF REVIEW
Informed consent for anesthesia: a review of practice
and strategies for optimizing the consent process
Consentement eclaire pour lanesthesie: une etude de la pratique
et des strategies destinees a` optimiser le processus dobtention du
consentement
Alan R. Tait, PhD Magnus K. Teig, MBChB
Terri Voepel-Lewis, PhD
Received: 6 February 2014 / Accepted: 21 May 2014 / Published online: 5 June 2014
Canadian Anesthesiologists Society 2014
Abstract
Purpose Patients must receive information in a manner
that promotes understanding so they can make informed
decisions about anesthesia and other medical
interventions. Unfortunately, history is replete with
examples of the negative consequences of inadequate
disclosure of information and lack of patient
understanding. While obtaining consent for anesthesia
poses unique challenges, the ability of the anesthesiologist
to engage the patient in meaningful discussion is critical as
a means to ensure that the patient is truly informed. This
narrative review aims to: 1) discuss the process of
informed consent as it applies to anesthesia practice; 2)
describe the salient issues related to patient capacity,
disclosure, understanding, decision-making, and
documentation of the informed consent process; and 3)
discuss current strategies to improve the presentation and
understanding of consent information.
Author contributions Alan R. Tait conceived the idea for this
article and wrote all drafts of the manuscript. Magnus K. Teig
reviewed the background literature and was responsible for critically
reviewing the manuscript for intellectual content and for editing all
drafts. Alan R. Tait and Terri Voepel-Lewis reviewed the literature.
Voepel-Lewis was involved in substantive manuscript preparation
including critically reviewing and editing all drafts of the manuscript.
A. R. Tait, PhD (&)
M. K. Teig, MBChB

T. Voepel-Lewis, PhD
Department of Anesthesiology, University of Michigan Health
System, 1500 E. Medical Center Drive, Ann Arbor, MI 48109,
USA
e-mail: atait@umich.edu
A. R. Tait, PhD
The Center for Bioethics and Social Sciences in Medicine,
University of Michigan Health System, Ann Arbor, MI, USA
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Source Review of the extant literature, including the
authors own research.
Principal findings Despite the ethical imperative of
informed consent, many decision-makers have limited
understanding of medical information. The reasons for this
are multifactorial but often result from incomplete disclosure
and presentation of generic information that does not take into
account differences in information needs, values, and
preferences of individual patients. Several simple strategies
are available, however, that can enhance decision-makers
understanding of both written and verbal information.
Conclusions Despite the unique challenges of obtaining
consent for anesthesia on the day of surgery, attention to
the manner in which information for anesthesia care is
provided and adoption of simple strategies to enhance
understanding can go a long way to ensure that decision-
makers are appropriately informed.
Resume
Objectif Les patients doivent recevoir de linformation
dune facon qui facilite la comprehension pour quils
puissent prendre des decisions eclairees sur lanesthesie et
les autres interventions medicales. Malheureusement,
lhistoire deborde dexemples des consequences negatives
dune divulgation inadaptee de linformation et de
labsence de comprehension par le patient. Alors que
lobtention du consentement pour lanesthesie cree des
defis particuliers, la capacite de lanesthesiologiste a`
amener le patient a` participer a` une discussion
approfondie est un moyen essentiel qui permet de
sassurer que le patient est veritablement informe. Cette
synthe`se narrative vise a`: 1) expliquer le processus de
consentement dans le contexte de la pratique de
lanesthesie; 2) decrire les proble`mes principaux, lies
Informed consent for anesthesia practice
aux capacites du patient, a` la communication, a` la
comprehension et la prise de decision, ainsi qua` la
documentation de la procedure du consentement eclaire; et
3) expliquer les strategies actuelles pour ameliorer la
presentation et la comprehension de linformation sur le
consentement.
Source Synthe`se de la litterature existante, y compris les
recherches personnelles des auteurs.
Constatations principales Malgre les imperatifs ethiques
du consentement eclaire, de nombreux decideurs ont une
comprehension limitee de linformation medicale. Les
raisons en sont multiples, mais aboutissent souvent a` une
communication incomple`te et a` la presentation dune
information generique qui ne prend pas en compte les
differences dans les besoins dinformations, les valeurs et les
preferences de chaque patient. Toutefois, quelques strategies
simples sont disponibles en vu dameliorer la comprehension
de linformation ecrite et orale des decideurs.
Conclusions En depit des defis uniques que represente
lobtention du consentement a` une anesthesie le jour de la
chirurgie, une attention a` la facon dont linformation
concernant les soins anesthesiques est fournie et ladoption
de strategies simples pour ameliorer la comprehension
peuvent faire beaucoup pour garantir que les decideurs
sont correctement informes.
Every human being of adult years and sound mind has a
right to determine what shall be done with his own
body. So wrote Justice Benjamin Cardozo in his 1914
U.S. ruling regarding the case of Mary Schloendorff who
had consented to examination under anesthesia of a
suspected fibroid tumour, but not to its removal.1 At the
heart of this classic case was a lack of informed consent,
which set an important precedent for the way in which
physicians are now required to disclose salient
information to patients. Today, informed consent is the
accepted mechanism for providing the patient with
pertinent information that will allow them to make an
autonomous informed choice.
Unique to anesthesia practice is the fact that the first
meeting with the patient is typically on the day of surgery.
In addition, unlike many other specialties, routine
anesthesia does not involve a decision to treat or not to
treat (i.e., anesthesia vs no anesthesia), but it may require
involving patients in decisions regarding the type of
anesthesia (e.g., general, neuraxial, or regional) and
techniques for postoperative pain management. Uniquely,
anesthesiologists often also provide anesthesia for
procedures in which informed consent was obtained by
others. As such, anesthesiologists may be liable if that
informed consent is later deemed inadequate.2
833
While the decisions regarding anesthesia may appear
less complex compared with other specialties; nevertheless,
common challenges remain. For example, Waisel et al.
identified several challenges in obtaining consent which
anesthesiology trainees had acknowledged, including
assessing the patients capacity to understand, time
limitations, communication barriers, and the amount of
information to disclose.3
Beauchamp and Childress4 have described three basic
elements of informed consent that serve as the framework
for this review:
1) Threshold elements (i.e., competence, capacity, and
voluntariness in deciding);
2) Information elements (i.e., disclosure, recommendation
of a plan, and understanding);
3) Consent elements (i.e., decision to consent [or to refuse],
authorization). We would also add documentation of
consent as an important component of this element.
While the focus of this review is primarily on anesthesia
practice, the underlying principles are also relevant to the
process of obtaining consent for anesthesia-related research.
Threshold elements (competence, capacity,
and voluntariness)
Adult capacity for consent
Anesthesiologists not only must disclose salient
information about the services to be provided, but they
also must assess the patients ability to give consent.
Competence and capacity are often used interchangeably;
however, competence alone has a basis in law. Competence
requires that the patient is able to understand the
information offered, retain it, and use it to formulate an
informed decision.2
Although there is no set consensus definition of
capacity, some think that capacity should reflect the
ability of the patient to understand, appreciate, reason,
and make a rational unambiguous choice free from
coercion.5 Although some jurisdictions allow for the
presumption of capacity unless there are reasonable
grounds to think otherwise,6 misconceptions can occur.
This can result from insufficient time to assess the patient,
the notion that a patient must have understood because they
gave their consent, the need to expedite cases, and the lack
of a valid tool with which to measure capacity.5
Anesthesiologists are often faced with patients of
varying levels of decision-making capacity. These
include those with permanent or fluctuating decisional
impairments (such as dementia or delirium), those who are
distracted with anxiety or pain, those who have temporary
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altered mentation as a result of preoperative self- or doctor-
administered medications, and lastly, young children who
may not have legal decision-making capacity.7 While it is
common for patients to receive preoperative medications,
on occasion, these medications may also be deliberately
withheld in anticipation of obtaining consent. This practice
may be potentially coercive in that patients might feel
pressured to consent in order to obtain pain relief.
Although, it is well accepted that pain might diminish
decision-making capacity and that pain medications may
improve the ability to make decisions, this is likely
dependent on the patient and/or the situation.8 One study
showed that 68% of obstetric anesthesiologists considered
women in active labour to be capable of providing consent
for neuraxial anesthesia.9 Furthermore, studies have shown
that labouring women are mentally capable of
comprehending their anesthesia plan.7,10,11
Emergency settings also present a unique situation in
that they may negate the ability to assess capacity and
obtain consent. In general, anesthesiologists should provide
as much information as the situation dictates, either to the
patient or to the surrogate, but typically, informed consent
for emergency care is based on the assumption that the
patient would want to consent to life-saving care.
Given the wide variety of anesthetic, opioid, and
anxiolytic drugs administered by anesthesiologists,
residual effects of drugs can impact the retention of
information both preoperatively and postoperatively.12-14
However, the data are somewhat equivocal. Lucha et al.
found no correlation between valid measures of capacity
and narcotic dose and that administration of narcotics did
not impair the ability to consent.15 In another study,
however, 64% of patients had little or no postoperative
recollection of information give preoperatively.16 In yet
another study investigating information recall in the
immediate postanesthetic period, results showed that
recall of new information given in the immediate
postanesthetic period was poor, while delaying the
information by 40 min resulted in improved recall.17
Regardless of these findings, the concerns that patients
might not be able to retain information after anesthesia or
that they may have impaired judgment as a result of opioids
or sedatives reinforces the importance of assessing capacity
and documenting the discussion (i.e., information
disclosed, questions asked, and any issues related to
understanding or reasoning) at the time of consent.
Child capacity for assent
In North America, unless a child is considered either
legally emancipated (e.g., married, in the military,
financially independent, etc.) or a mature minor,
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parents, as legal proxy decision-makers for their children,
are required to give their permission for their childs
treatment together with the assent of the child. Although
there has been some debate regarding the operational
definition of assent,18 the Canadian Paediatric Society,
Bioethics Committee19 and the American Academy of
Pediatrics Committee on Bioethics20 have both issued
position statements outlining the important concepts
related to informed consent in pediatric practice,
including parental permission, child assent, and dissent.
One difficulty expressed by physicians in seeking assent
is determining when a child is capable of providing it.
Although the maturity of the child is considered foremost
in assessing the ability to assent, the statutory age at which
children can provide their assent for treatment varies
considerably within and between countries, ranging from
12-19 yr.21,22 In Canada, Quebec is the only province to
have specified an age (14 yr) below which parental consent
is required for treatment. The practical implications of such
arbitrary cutoffs for assent, however, remain unclear. A
survey of pediatric anesthesiologists found that only 12%
would respect the wishes of a six-year-old refusing to
undergo elective surgery, whereas 87% would do so if the
reluctant child were aged 15 yr.23 Thus, the use of age
cutoffs as criteria for determining child capacity is
potentially discriminatory in that it ignores the individual
childs development and maturity. For example, Tait
et al.24 showed that there is considerable variation in
childrens understanding of medical information even
within age groups, suggesting that age alone as a
criterion for capacity may not be an optimal metric.
Indeed, some young children, particularly those who are
chronically ill, may have an acute awareness of their
condition and treatments, while many older children appear
to lack simple decision-making ability.21 Thus, in the
absence of any objective measure to assess the capacity to
assent, it is important that the anesthesiologist
communicates with the parent(s) and the child to
determine if the child has a developmentally appropriate
awareness of his/her condition and an age-appropriate
understanding of the information.
Voluntariness
Although a patient may have the capacity to make a
decision, it is important that the decision to consent (or not)
is made voluntarily without undue influence or coercion
from either the physician or family and friends. Beauchamp
and Childress4 note that a person acts voluntarily if he or
she wills the action without being under the control of
another person or condition. In addition, Nelson et al.
argue that it is important not only to recognize that an
influence might exist but also to appreciate how the patient
Informed consent for anesthesia practice
subjectively perceives that influence and the degree to
which it controls their decision.25 In anesthesia practice,
undue influence may manifest as persuasion, manipulation,
or coercion. For example, while it may be perfectly
appropriate for the anesthesiologist to offer an opinion, it is
important for this to occur in the context of a balanced
disclosure without manipulation of information (i.e.,
deliberately withholding, exaggerating, or misleading).
An example of this might be withholding disclosure of
the benefits of general anesthesia based on a desire to gain
experience with a regional technique. Ultimately, of
course, there can never be any suggestion of coercion, be
it real or perceived, in making recommendations to the
patient.26
Information elements (disclosure and understanding)
Formalizing disclosure
Although checklists, such as the World Health
Organizations Best Practice Protocols,27 might help guide
the disclosure of information to patients, there are national
and local-specific standards to which doctors may be held in
a court of law. The most commonly applied standard in both
statute and case law in Canada, the United States, and
elsewhere is the reasonable person standard. This requires
that disclosure be commensurate with what a hypothetical
reasonable person would want in order to make a decision.2,4
In Canada, this standard was upheld in the 1980 landmark
case of Reibl vs Hughes.28 The legal standard for this
approach is the materiality or significance of the desired specific information on all possible anesthetic
information towards making a decision. In some cases,
however, (as in Reibl vs Hughes) the reasonable person
standard may be considered in concert with a subjective
standard that examines what the patient would have done
had they had more information. Regardless of how these
standards are applied, it is important to remember that
informed consent is a process and not simply a signature to
satisfy legal requirements and, as such, should be driven by
the patient and not by legal concerns.29
For routine anesthesia, there should be a basic discussion
regarding the nature of the patients condition, procedures to
be performed, risks, and consequences. This might include a
description of how anesthesia will be administered (e.g.,
inhalational or intravenous) together with any potential risks
(e.g., chipped tooth, sore throat, nausea and vomiting, etc.)
and how postoperative pain will be managed. Nevertheless,
for procedures that offer anesthetic options (e.g., epidural vs
intravenous analgesia) or pose increased risks due to
comorbidities, anesthesiologists may need to present a
more detailed, yet balanced, explanation of the risks and
benefits of each option so that the patient can make an
835
informed decision based on the risk-benefit tradeoffs.
Overall, however, these discussions should always follow
the tenet of the reasonable person standard.
Although routine anesthesia is considered safe, serious
life-threatening situations may occur unexpectedly, and
thus, the question remains as to how much risk
information to reveal to the patient. While discussions
regarding the possibility of postoperative nausea and
vomiting or post-extubation sore throat may be routine,
current newsworthy topics, such as intraoperative
awareness, postoperative cognitive dysfunction in adults,
and learning difficulties in children, are less likely to be
discussed. There is a fine balance between informing and
scaring patients with information that may not be material
to the decision at hand. Although studies show that
decision-makers desire specific risk information, many
anesthesiologists report uncertainty regarding the type and
amount of information that patients require.3 Studies have
revealed that doctors sometimes convey less information
than they think they should, disclose information not
considered important, and underestimate the amount of
information that patients want.30-32 It is hardly surprising,
therefore, that disclosure of anesthesia information may
vary considerably amongst providers.33
Studies suggest that patients want information. In one
study, 88% of patients desired information on
postoperative pain, 77% on the different methods of
anesthesia, and 63% on all possible complications of
anesthesia.34 For children, Litman et al. reported that 75%
of parents requested information on all possible anesthesia
risks, including death.35 In another study, 96% of parents
complications.36 Furthermore, one review found that
patients preference for information increased when they
preferred a more active role in decision-making.37
Although these studies suggest that most decision-
makers want information about anesthesia, it is unclear
how much they actually receive. Lagana et al. observed
pediatric anesthesiologists during their consent discussions
and noted that nausea and vomiting was discussed in only
36% of cases, sore throat in 35%, and emergence delirium
in 19%.38 A quarter of the observed discussions involved
only general statements about risk, and 30% of cases
involved no discussion of anesthetic risk at all. In a survey
of regional anesthesia practices, Brull et al.39 found that
common non-serious risks, e.g., headache and local pain,
were frequently discussed, while the more serious but less
common complications were infrequently disclosed, e.g.,
paralysis (43%), cardiac arrest (14%), and death (29%).
Interestingly, while 74% of respondents reported that they
disclosed these risks to inform the patient, 26% reported
doing so primarily for medical-legal reasons. In another
study, Bray and Yentis40 found that most patients thought
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that informed consent was necessary for specific non-
routine airway procedures (e.g., fibreoptic intubation),
while most anesthesiologists did not.
It is noteworthy that despite patients apparent desire for
information, studies suggest that they are generally
satisfied with the information they receive even if they
dont fully understand it.41-44 Interestingly, one study
showed that a majority of patients randomized to receive
one of three anesthesia information leaflets with
minimal, standard, or full information judged the performing the case. To mitigate some of these concerns, it
information they received to be just right until they were
shown the other leaflets. On seeing the alternatives,
approximately two-thirds of the patients thought that the
information they had initially received was now either too
little or too much.41 anesthesiologist will be in attendance at all times to
The belief that disclosure of information may negatively
affect the patients psychological well-being has been cited
as reason not to disclose the risk of potentially serious
events.22 Indeed, because the perception of risk is often
subjective or based on emotion, information may create
anxiety that is not always rational. This view, however,
appears outdated; recent studies suggest that the disclosure
of risks associated with anesthesia might actually alleviate
anxiety rather than increase it.45 This may occur because
the provision of information may increase the patients
perceived sense of control over their hospital experience.46
Recently, Tait et al. showed that 53% of parents reported
that knowing the risks of anesthesia had no effect on their
level of anxiety, and 39.4% reported feeling less
anxious.45 Even patients who report significant levels of
anxiety have been shown to desire risk information.47
Although the disclosure of a laundry list of risks is
unnecessary for routine anesthesia for the healthy patient,
disclosure of the likelihood and severity of risks needs to
be tailored to the individual based on the patients
preferences, comorbidities, and procedure. Siegal et al.48
suggest the concept of information on demand as a
means to discern the patients desire for information prior
to disclosure. Green and MacKenzie49 emphasize the
importance of information tailoring, stating, It is
ethically unsound to assume that one knows so much
about the benefits of a technique that it trumps ones moral
obligation to respect a patients right to self-determination.
That right can only be respected by a thorough elucidation
of alternatives and exploration of the details of each
patients unique circumstances. As such, it is not merely
sufficient to present the medical facts, but it is also
important to consider non-medical facts, including patient
preferences, values, and expectations. We live in an age of
ever-increasing information availability, and information
expectation is high. Patients have often researched their
procedure and anesthetic options using internet search
engines before their surgery, and thus, they deserve more
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than a few lines of information of possibly uncertain
accuracy from Google or Wikipedia.
One important issue regarding disclosure involves the
potential inclusion of trainees in medical care. In general,
trainees, such as medical students or other paramedical
staff, cannot examine or be involved in procedures on
patients without the express understanding and consent of
the patient. This is particularly important when the consent
is obtained by someone other than the anesthesiologist
is good practice to inform the patient that a trainee may be
involved in their care and to outline the extent of the
learners likely involvement. If possible, the trainee should
be introduced to the patient with an assurance that the
supervise learner activities.
Understanding
Although many physicians do provide detailed
information, it does not guarantee that patients will
actually understand it. This becomes particularly
important when options are presented requiring tradeoff
decisions between competing risks and benefits. Despite
our best efforts, however, many patients have difficulty
recalling the information presented. In a study of consent
practices in Spain, Rosique et al.16 showed that 21% of
patients who signed a required consent form did not read it,
and two-thirds were unable to recall the information given
to them by the anesthesiologist. The literature is also
replete with examples where patients, parents, and research
subjects were unable to recall or comprehend the
information given to them by medical staff.17,50-54
There are many reasons why patients have difficulty
understanding medical information, including insufficient
time, anxiety, volume of information, use of medical
jargon, poor physician communication, cognitive
difficulties, age, low educational achievement, and poor
literacy or numeracy skills. Cultural barriers to
understanding also exist with respect to both language
differences and levels of trust in the medical system.
Functional illiteracy is frighteningly common in North
America. In the U.S., the National Literacy Survey
estimates that approximately 45 million American adults
have below basic literacy,55 and in Canada, 42% of adults
from the ages of 16-65 years have less than level 3 reading
proficiency.56
Although it is unreasonable to expect that patients will
have complete understanding of all the information
presented to them, their failure to do so is not a good
reason to question the importance of informed consent.57
Several studies have examined the effect of different
strategies to improve the way in which medical information
Informed consent for anesthesia practice
is presented and understood. A review of the literature58,59
suggests that these strategies fall into three primary
categories:
a) enhanced consent forms
b) enhanced communication
c) video/multimedia presentations
Enhanced consent forms
Although anesthesia consent forms (if used) should never
replace the physician-patient discussion, an understanding
of what is needed to enhance the written word can often
help enhance the spoken word. The effect that enhanced
consent forms have on understanding has been
described.58,60 In general, these strategies have focused
on i) improved readability and simplified forms, ii)
improved formatting and layout, and iii) the use of
graphics. While these enhancements focus primarily on
consent forms, they are equally relevant in preparing
informational handouts or web-based information for
anesthesia and pain management.
Readability/simplified forms
Despite the fact that most guidelines recommend simplifying
the reading level of medical material, many consent
documents are written above the abilities of most
individuals. Text-heavy, poorly formatted consent
documents can be very intimidating and are an impediment
to comprehension. Forms that are easier to read are better
accepted than conventional forms and may decrease
anxiety;61 however, they do not always improve
understanding.61,62 This suggests that it may not be
sufficient to improve readability alone. Nevertheless, it
would seem important to lower the reading level of any
written information, if possible, to at least the eighth grade
level. Readability formulae, such as the Flesch Reading
Ease, Flesch-Kincaid,63 and SMOG64 (Simple Measure of
Gobbledygook), are available within Microsoft Word and
on the internet, respectively.
Formatting and layout
Improved formatting can aid understanding. Dresden and
Levitt showed improved understanding among asthma
patients when using a consent form with simpler
vocabulary, bullet points, and enlarged font.60 Another
study, however, showed no improvement in parents
understanding of a consent form that employed bolded
headings and increased white space.65 Recently Tait et al.
showed that modified consent forms with improved
readability (reading level) and processability (format)
837
resulted in greater overall understanding and acceptance by
parents and children when compared with standard forms.66-68
Risk and benefit graphics
Although risks and benefits are the two most important
elements that patients need to understand in order to make
healthcare decisions, they are often misinterpreted.69,70
Perception of risk may be influenced by a number of
factors, including an understanding of the probability and
severity of the risk, a sense of vulnerability (particularly
while anesthetized), familiarity with anesthesia, and general
acceptability of medical processes.71 Poor numeracy is also
an impediment to risk/benefit comprehension. Individuals
with low numeracy are less likely to make decisions based on
numbers than numerate individuals, choosing instead to rely
more on emotion and trust in the doctor.72
Framing risks and strategies for risk communication are
important in the perception of risk.73 Many individuals, for
example, have difficulty converting numerical values into
qualitative terms, such as rare or common, and vice-
versa. Fagerlin et al. recommend several strategies,
including presenting risks in absolute (e.g., 20% risk of
nausea) rather than relative terms (e.g., 50% reduced risk
of nausea) and presenting incremental risk (e.g., additional
5% risk of nausea) to highlight how a treatment might
change risk over a preexisting baseline level.74
Furthermore, outcomes are typically perceived more
favourably when presented as gains (e.g., surviving)
rather than as losses (e.g., dying). Additionally, although
the data are somewhat conflicting, risks and benefits may
be better understood if presented as natural frequencies
(e.g., one in 100,000) rather than as percentages.74
Graphical formats provide greater visual salience than
text and require less cognitive effort. Graphical
presentations of risks have been shown to aid the
processing of quantitative information and to be
particularly helpful to individuals with poor literacy and
numeracy.75-79 Pictographs, in particular, have been shown
to be superior to text and other graphical formats in
presenting risk/benefit statistics.76-78,80
Verbal disclosure and communication
Good communication is the cornerstone of the informed
consent process, but not all physicians are good
communicators.81 High-quality concise verbal
communication in plain language is particularly important
for anesthesiologists given the narrow window of
opportunity afforded for disclosure and the fact that many
anesthesiologists do not use written consent forms. The
importance of good communication has been verified in a
number of studies.66 McGuire et al. reported that the use of a
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simplified language was helpful in improving recall when
talking with older patients.82 Furthermore, good
communication that includes encouragement in decision-
making promotes active involvement in health, whereas
inadequate information and time pressures discourage
involvement.37 Thus, despite hospital pressures to expedite
surgical turnover, sufficient time should be allotted for
meaningful preoperative discussion with the patient.
Furthermore, because anesthesiologists frequently obtain
informed consent numerous times during the work week,
there may be a tendency for the discussion to become
mundane. We must never lose sight of the fact that the
information is almost always novel and important for the
individual patient.
Video or multimedia presentations
Visual perception has long been known to play a key role in
learning. Visual perception drives conceptual processing and
facilitates rapid absorption of complex materials.83,84 The
pictorial superiority effect, the ability by which individuals
remember concrete items more easily when presented as
pictures rather than as words, has been reflected in the maxim
a picture is worth a thousand words and is now founded in children or for others than they would for themselves.98,99
science.85,86 Technological advances in computer graphics
and smart phone applications enable higher-quality
interactive visual models that can convey medical
information to patients in a coherent way. Several studies
have confirmed the effectiveness of video and multimedia
presentations in presenting information regarding knee
arthroscopy,87 ankle fracture surgery,88 colonoscopy,89 and
thyroidectomy.90 Presentation of preoperative videos and
web-based material has also been shown to improve parent
understanding of anesthesia and decrease their concerns.91
Recently, interactive multimedia computer-based programs
have been shown to enhance patients understanding of
cardiac catheterization,42 the risks and benefits of statins,77
and parents and childrens understanding of an asthma trial.92
Assessing understanding
Simply asking the patient if they understand the
information provided may be insufficient, since
individuals typically overestimate their level of
understanding.24,52,93 This may be critical, since a lack of
understanding can lead to misinterpretation of risks and an
inability to follow the doctors orders and can reduce the
patients ability to make an informed decision. As
recommended by the Canadian Medical Protective
Association (CMPA),94 one useful technique is to employ
a teach-back approach wherein patients are asked to in the U.S., and the Association of Anaesthetists of Great
paraphrase the important elements of the information
provided. Having the patient repeat the information and
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A. R. Tait et al.
providing corrected feedback has been shown to result in
greater recall of medical information.95,96
Consent elements (decision-making, authorization,
documentation)
Decision-making
Despite a desire for information, many patients have
difficulty with comprehension and consequently struggle
with decision-making. Part of the problem is an inability of
some physicians to engage the patient in the decision-
making process and inadequate disclosure of material
information. Patients may also have difficulty in the
assessment of uncertain risks and outcomes. In the
presence of uncertainty, individuals can be overwhelmed
by having to weigh different risks and benefits and may
resort instead to emotion, intuition, and rules of thumb
(heuristics) that often ignore critical information. These
strategies can lead to an under- or overestimation of risks
and confusion with treatment options.97,98 Importantly,
individuals will also perceive risks differently for their
While these observations may be troubling in the context
of achieving informed consent, physicians can facilitate
decision-making by considering not only the decision itself
but also how that decision meets the patients values and
needs. As Ubel and Loewenstein97 point out, To meet the
moral goals of informed consent, physicians need to find a
method to combine patients values with medical facts in a
way that produces superior medical decisions. Involving
patients in their own healthcare decisions has been shown to
improve understanding, satisfaction, and outcomes.100,101
Individuals who feel that their emotional and informational
needs have not been met are far more likely to complain, be
dissatisfied with their care, or, indeed, to sue.102 Establishing
a rapport with the patient, respecting their concerns, and
taking time for discussion and answering questions will go a
long way to improve patient satisfaction, reduce the potential
for litigation, and validate the anesthesiologists importance
as a healthcare provider.103 This latter point is particularly
important given that the percentage of patients who believe
that anesthesiologists are actually medically qualified ranges
from 50-88.7%.103,104
Consent and authorization
Currently, the CMPA, Medicare and the Joint Commission
Britain and Ireland22,105 do not require a separate written
consent form for general anesthesia, only that there is a
Informed consent for anesthesia practice
discussion between the anesthesiologist and the patient and
that consent is documented in the medical record. During
this discussion, usually on the day of surgery, the
anesthesiologist is required to evaluate the patient,
discuss the proposed nature of treatment, describe the
expected risks and benefits of both the proposed and any
alternative treatments, and obtain verbal consent.
Many institutions, however, do require a separate signed
consent form for specific procedures, e.g., obstetric
anesthesia. In one survey, 47% of U.S. anesthesiologists
reported obtaining separate written consent for obstetric
anesthesia compared with only 22% among their U.K.
counterparts.106 For general anesthesia, however,
combined surgical-anesthesia consent forms are often
used and typically signed in the presence of surgical
personnel. Recently, however, there has been renewed
discussion in both North America and the U.K. regarding
the pros and cons of separate (from surgical) consent forms
that are specific to anesthesia.22,105,107 Proponents of
separate anesthesia-specific consent forms argue that only
anesthesiologists have the expertise to present information
about anesthesia.22,105,108,109 As Marco commented, Do
we as practitioners of the medical specialty of
anesthesiology believe it appropriate to allow consent
for anesthesia to be an afterthought of the general surgical
consent?105 Moore goes on to suggest that having a performed, the risks (minor and major), any questions or
surgeon obtain consent for anesthesia is not only
inadequate consent but also demonstrates a lack of
respect for the specialty of anesthesiology.110
Furthermore, Marcucci et al. suggest that consent for
anesthesia requires greater cognitive capacity than consent
for surgery and, as such, should be obtained separately by
anesthesiologists.107 Tait et al. recently showed that
parental recall of anesthesia information was greater
when the consent document was presented by anesthesia
personnel rather than by surgical providers.45 The
effectiveness of procedure-specific consent forms over
conventional forms has also been shown.111,112
Opponents of separate anesthesia-specific consent forms
believe that the preoperative discussion is sufficient and
that presenting a written consent form at this time hinders
the consent process. Others suggest that getting a signed
consent for anesthesia on the day of surgery is an extra step
requiring more administrative effort and added cost113 and,
furthermore patients do not remember much of the
information anyway.16,52 Furthermore, they argue that
there is no evidence to support such a practice and that a
signature on a consent form guarantees neither
understanding nor protection against litigation.113,114
Indeed, Waisel29 believes that focusing on the legal
requirements of consent suffocates the purpose of the
anesthesia informed consent process to satisfy the decision-
makers needs.
839
Documentation
Regardless of obtaining a consent signature, it is important
to retain a record that a discussion took place and that the
patient understood the information at the time it was given.
This is important in light of a U.K. survey showing that
anesthesiologists are generally poor at recording
discussions on informed consent.115 This is certainly not
unique to the U.K.; a survey from Japan showed that only
59.9% of anesthesia departments kept records
documenting that informed consent had been obtained.33
Marco105 notes that The issue is not whether there is a
separate consent for anesthesia care, but how it is
documented. Without this documentation, it may be
difficult for the doctor to argue in court that informed
consent had actually been obtained. Although issues
relating to informed consent as the primary allegation are
rare in anesthesia-related lawsuits (\ 1%), anesthesia
consent was found to be inadequate in 22% of cases in
the U.S. Anesthesia Closed Claims Project.116 As such,
these inadequacies are often brought into play as secondary
allegations in malpractice claims. Although the degree of
documentation will likely vary with the situation, CMPA
guidelines suggest, at minimum, a record of what the
patient was told in terms of the procedures to be
concerns that were raised and how they were addressed, an
assessment of the patients or surrogates understanding,
and any additional information or leaflets given to the
patient.94
In summary, informed consent for anesthesia presents a
unique situation both in terms of the time allotted for
disclosure and the fact that routine anesthesia does not
typically offer options. Nevertheless, this in no way
diminishes the importance of consent as a means to
inform the patient regarding their anesthetic care. Indeed,
because of the somewhat perfunctory nature of the patient
encounter, it is perhaps doubly important that
anesthesiologists are able to optimize their message by
providing information that is relevant to the individual
patient and that enhances their understanding.
Despite the debate regarding the need for written
informed consent for anesthesia, the literature reinforces
the importance of the fundamental doctor-patient
interaction. Indeed, regardless of ones view on how
informed consent for anesthesia should be obtained, it is
critical that the discussion with the patient be meaningful
and not simply a box to be ticked. This discussion must be
guided by the need to inform the patient and to meet their
individual needs, not simply as a means to satisfy any legal
requirements. Meaningful discussions with the patient are
crucial to the ethical intent of the informed consent
process and to affirm the patients perceptions of the
123
840
anesthesiologist as a respected and indispensible member
of the perioperative team.
Funding source Department of Anesthesiology, University of
Michigan.
Conflicts of interests None declared.
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