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Consent in obstetric anaesthesia
ETHICS
Consent in obstetric anaesthesia
Learning objectives After reading this article you should: C know what mental processes render a patient competent C be able to describe what constitutes valid consent C be aware of guidelines produced by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) for obtaining consent in obstetric anaesthesia
Rhys Clayton Ross Clark
Abstract Consent to medical treatment is a vital process that should occur prior to any procedure or intervention in a competent adult. There are ethical and legal reasons for doctors to ensure that valid, adequate consent has been obtained from a patient. It is generally accepted that written consent is acceptable, however, discussions regarding consent should be clearly documented, including specific risks discussed. Labouring women may have to consent for procedures when in severe pain, under the influence of strong analgesics, or in a time-pressured situation. However, the parturient is presumed to be competent. A competent pregnant woman may decline treatment for any reason, even if it puts her or her unborn child at risk of harm or death.
Ethical: clinicians have an ethical duty to respect a patient’s autonomy, which is their right to be involved with decisions which involve them. Legal: legal requirements for consent reflect the ethical ones; it must be given voluntarily, by a competent, informed patient, even if the patient comes to a decision that appears irrational to the clinician. For a patient to be considered competent, they must be able to comprehend, retain, believe and weight information given to them. They must also be able to communicate any decision they come to. There can be serious consequences if consent is either inadequate or not obtained prior to a patient intervention. These include charges of assault, or actual bodily harm, even if the patient has come to no harm. A more likely claim in the UK is medical negligence, usually after the development of a complication which the patient was not warned about.
Keywords Autonomy; capacity; consent; Mental Capacity Act 2005 Royal College of Anaesthetists CPD Matrix: 1F01
Consent
Valid consent
What? Consent can take many different forms. It may be written or oral, express or implied. It may be complicated by several factors in obstetric anaesthesia. These factors include: limited time for consent due to the need for rapid anaesthetic intervention to prevent maternal or fetal harm impairment of labouring women’s capacity by pain, extreme fatigue or analgesic drugs such as opiates or nitrous oxide. The Department of Health produced a useful definition of consent: ‘Consent is the voluntary continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment including the likelihood of success and any alternatives to it.’.1
Valid consent involves three components, as follows. Competence, as defined above. It is appropriate to assume that a patient has capacity unless there is reason to believe otherwise. Adequacy of consent. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) suggests the following factors should be considered when deciding what should be explained to patients:2 the gravity of the risks of the anaesthetic technique; the frequency of the complication according to the literature (if it is encountered more frequently in the doctor’s own practice, then this frequency should be described); estimated risks of alternative techniques; estimated added risks for the individual patient; estimated capacity of the patient to want to know, and to understand the risks; the degree of urgency of the proposed treatment. Absence of coercion. The patient must not be manipulated into making a decision, either by persuasion or selective withholding of information, which includes failure to discuss alternatives to the treatment being discussed. The patient should be allowed to ask questions and time to deliberate upon the information provided.
Why? There are ethical and legal reasons that clinicians have a duty to obtain consent from patients.2
Rhys Clayton MBChB FRCA is an ST7 in Anaesthesia on the North West Anaesthesia Rotation, UK. Conflicts of interest: none declared.
Patients who lack capacity
Ross Clark MBChB MA FRCA is a Consultant Obstetric Anaesthetist at Central Manchester Healthcare Trust, Manchester, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:8
The Mental Capacity Act 2005 came into force in 2007, and supports patients who lack capacity.3 It ensures that such
326
Ó 2013 Elsevier Ltd. All rights reserved.
ETHICS
It is important that each obstetric unit develops a policy to ensure that patients are given detailed, unbiased information antenatally, ideally by an anaesthetist as labour is the wrong time to burden a woman with excessive information. However, this process should not replace adequate information being provided at the time of procedure. Birth plans may be treated as an advanced directive if a woman loses capacity during labour. However, it should be understood that a woman may well change her mind during labour, and this should be respected, with the presumption of capacity unless there is strong evidence that it has been lost. A competent pregnant woman can refuse any treatment, even it puts the unborn child at risk of harm or death. If the woman lacks capacity, an emergency court order should be obtained, and the facility to apply for one should be available 24 hours a day. Generally, 16- and 17-year-olds are considered as adults in terms of making decisions about their care. Children younger than this should be assessed on an individual basis but may be competent. They may be more likely to become temporarily incompetent under the strain of labour, and units should have guidelines in place to ensure that these patients have been adequately informed antenatally, which may include an appointment with an anaesthetist. A
patients are not denied necessary treatment because they cannot consent to it. It achieves this by appointing a proxy decisionmaker via lasting power of attorney or using an advanced directive by the patient. An advanced directive must be signed, unamended, and specific about any treatment refused or accepted. Ideally it would have been witnessed. In the case of an emergency, and in the absence of an advanced directive, the principle of necessity justifies treatment without consent, acting in the best interest of the patient.
Written or verbal consent The working party of the AAGBI published the document ‘Consent in Anaesthesia’ in 19994 and updated it in 2006.2 The initial document discussed issues surrounding consent in anaesthesia. The revised edition was produced to cover legal developments such as the Mental Capacity Act, and the increased emphasis placed by the courts on patient’s autonomy. It also increased the scope of its advice, covering areas not discussed in the previous document such as critical care and chronic pain. It recommended the following actions. The process of gaining consent should be emphasized over the need for gaining formal written consent, particularly as a signed document does not increase the validity of consent. Clinicians should clearly document any discussions that occur regarding consent, including specific risks discussed. Documentation should be particularly clear when either a patient makes a decision against anaesthetic advice, or when a patient wishes to reverse a previous documented decision. Instances where these situations may arise in obstetrics would be a patient declining a general anaesthetic in the face of a suboptimal regional anaesthetic, and a labouring women requesting an epidural despite have documented in a birth plan that she did not want one.
REFERENCES 1 Department of Health. Reference guide to consent for examination or treatment. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_103643 (accessed 24 Jan 2013). 2 AAGBI. Consent for anaesthesia. Available at: http://www.aagbi.org/ publications/guidelines/docs/consent06.pdf; 2006 (accessed 21 Jan 2013). 3 Mental Capacity Act: deprivation of liberty safeguards. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/ LocalAuthorityCirculars/DH_096868 (accessed 24 Jan 2013). 4 AAGBI. Consent for anaesthesia. Available at: http://www.aagbi.org/ publications/guidelines/docs/consent05.pdf; 1999 (accessed 21 Jan 2013). 5 Brooks H, Sullivan WJ. The importance of patient autonomy at birth. Int J Obstet Anaesth 2002; 11: 196e203. 6 Affleck PJ, Waisel DB, Cusick JM, Van Decar T. Recall of risks following labour analgesia. J Clin Anaesth 1998; 10: 141e4.
Guidelines for obtaining consent in obstetric anaesthesia2 The adult parturient is presumed, as are all adults, to be competent. Certain factors may compromise this ability, such as drugs, pain, fatigue, anxiety and distress, but the compromise must be unusually severe to render her incompetent. It is worth noting that women in labour believe they are capable of consent5 and that they can recall information accurately as readily as other patient populations.6
ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:8
327
Ó 2013 Elsevier Ltd. All rights reserved.
Consent in obstetric anaesthesia
Learning objectives After reading this article you should: C know what mental processes render a patient competent C be able to describe what constitutes valid consent C be aware of guidelines produced by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) for obtaining consent in obstetric anaesthesia
Rhys Clayton Ross Clark
Abstract Consent to medical treatment is a vital process that should occur prior to any procedure or intervention in a competent adult. There are ethical and legal reasons for doctors to ensure that valid, adequate consent has been obtained from a patient. It is generally accepted that written consent is acceptable, however, discussions regarding consent should be clearly documented, including specific risks discussed. Labouring women may have to consent for procedures when in severe pain, under the influence of strong analgesics, or in a time-pressured situation. However, the parturient is presumed to be competent. A competent pregnant woman may decline treatment for any reason, even if it puts her or her unborn child at risk of harm or death.
Ethical: clinicians have an ethical duty to respect a patient’s autonomy, which is their right to be involved with decisions which involve them. Legal: legal requirements for consent reflect the ethical ones; it must be given voluntarily, by a competent, informed patient, even if the patient comes to a decision that appears irrational to the clinician. For a patient to be considered competent, they must be able to comprehend, retain, believe and weight information given to them. They must also be able to communicate any decision they come to. There can be serious consequences if consent is either inadequate or not obtained prior to a patient intervention. These include charges of assault, or actual bodily harm, even if the patient has come to no harm. A more likely claim in the UK is medical negligence, usually after the development of a complication which the patient was not warned about.
Keywords Autonomy; capacity; consent; Mental Capacity Act 2005 Royal College of Anaesthetists CPD Matrix: 1F01
Consent
Valid consent
What? Consent can take many different forms. It may be written or oral, express or implied. It may be complicated by several factors in obstetric anaesthesia. These factors include: limited time for consent due to the need for rapid anaesthetic intervention to prevent maternal or fetal harm impairment of labouring women’s capacity by pain, extreme fatigue or analgesic drugs such as opiates or nitrous oxide. The Department of Health produced a useful definition of consent: ‘Consent is the voluntary continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment including the likelihood of success and any alternatives to it.’.1
Valid consent involves three components, as follows. Competence, as defined above. It is appropriate to assume that a patient has capacity unless there is reason to believe otherwise. Adequacy of consent. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) suggests the following factors should be considered when deciding what should be explained to patients:2 the gravity of the risks of the anaesthetic technique; the frequency of the complication according to the literature (if it is encountered more frequently in the doctor’s own practice, then this frequency should be described); estimated risks of alternative techniques; estimated added risks for the individual patient; estimated capacity of the patient to want to know, and to understand the risks; the degree of urgency of the proposed treatment. Absence of coercion. The patient must not be manipulated into making a decision, either by persuasion or selective withholding of information, which includes failure to discuss alternatives to the treatment being discussed. The patient should be allowed to ask questions and time to deliberate upon the information provided.
Why? There are ethical and legal reasons that clinicians have a duty to obtain consent from patients.2
Rhys Clayton MBChB FRCA is an ST7 in Anaesthesia on the North West Anaesthesia Rotation, UK. Conflicts of interest: none declared.
Patients who lack capacity
Ross Clark MBChB MA FRCA is a Consultant Obstetric Anaesthetist at Central Manchester Healthcare Trust, Manchester, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:8
The Mental Capacity Act 2005 came into force in 2007, and supports patients who lack capacity.3 It ensures that such
326
Ó 2013 Elsevier Ltd. All rights reserved.
ETHICS
It is important that each obstetric unit develops a policy to ensure that patients are given detailed, unbiased information antenatally, ideally by an anaesthetist as labour is the wrong time to burden a woman with excessive information. However, this process should not replace adequate information being provided at the time of procedure. Birth plans may be treated as an advanced directive if a woman loses capacity during labour. However, it should be understood that a woman may well change her mind during labour, and this should be respected, with the presumption of capacity unless there is strong evidence that it has been lost. A competent pregnant woman can refuse any treatment, even it puts the unborn child at risk of harm or death. If the woman lacks capacity, an emergency court order should be obtained, and the facility to apply for one should be available 24 hours a day. Generally, 16- and 17-year-olds are considered as adults in terms of making decisions about their care. Children younger than this should be assessed on an individual basis but may be competent. They may be more likely to become temporarily incompetent under the strain of labour, and units should have guidelines in place to ensure that these patients have been adequately informed antenatally, which may include an appointment with an anaesthetist. A
patients are not denied necessary treatment because they cannot consent to it. It achieves this by appointing a proxy decisionmaker via lasting power of attorney or using an advanced directive by the patient. An advanced directive must be signed, unamended, and specific about any treatment refused or accepted. Ideally it would have been witnessed. In the case of an emergency, and in the absence of an advanced directive, the principle of necessity justifies treatment without consent, acting in the best interest of the patient.
Written or verbal consent The working party of the AAGBI published the document ‘Consent in Anaesthesia’ in 19994 and updated it in 2006.2 The initial document discussed issues surrounding consent in anaesthesia. The revised edition was produced to cover legal developments such as the Mental Capacity Act, and the increased emphasis placed by the courts on patient’s autonomy. It also increased the scope of its advice, covering areas not discussed in the previous document such as critical care and chronic pain. It recommended the following actions. The process of gaining consent should be emphasized over the need for gaining formal written consent, particularly as a signed document does not increase the validity of consent. Clinicians should clearly document any discussions that occur regarding consent, including specific risks discussed. Documentation should be particularly clear when either a patient makes a decision against anaesthetic advice, or when a patient wishes to reverse a previous documented decision. Instances where these situations may arise in obstetrics would be a patient declining a general anaesthetic in the face of a suboptimal regional anaesthetic, and a labouring women requesting an epidural despite have documented in a birth plan that she did not want one.
REFERENCES 1 Department of Health. Reference guide to consent for examination or treatment. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_103643 (accessed 24 Jan 2013). 2 AAGBI. Consent for anaesthesia. Available at: http://www.aagbi.org/ publications/guidelines/docs/consent06.pdf; 2006 (accessed 21 Jan 2013). 3 Mental Capacity Act: deprivation of liberty safeguards. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/ LocalAuthorityCirculars/DH_096868 (accessed 24 Jan 2013). 4 AAGBI. Consent for anaesthesia. Available at: http://www.aagbi.org/ publications/guidelines/docs/consent05.pdf; 1999 (accessed 21 Jan 2013). 5 Brooks H, Sullivan WJ. The importance of patient autonomy at birth. Int J Obstet Anaesth 2002; 11: 196e203. 6 Affleck PJ, Waisel DB, Cusick JM, Van Decar T. Recall of risks following labour analgesia. J Clin Anaesth 1998; 10: 141e4.
Guidelines for obtaining consent in obstetric anaesthesia2 The adult parturient is presumed, as are all adults, to be competent. Certain factors may compromise this ability, such as drugs, pain, fatigue, anxiety and distress, but the compromise must be unusually severe to render her incompetent. It is worth noting that women in labour believe they are capable of consent5 and that they can recall information accurately as readily as other patient populations.6
ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:8
327
Ó 2013 Elsevier Ltd. All rights reserved.