Clinical Case: A 45-year-old woman is scheduled for a hysterectomy. She is being treated for hypertension, and is otherwise healthy. During your informed consent discussion, do you tell her there is a chance that she could die?
Discussion: “Hi, Mrs. Smith. It looks like you are in good health. I need to tell you that there is about a 1 in 100,000 chance that you could die from your anesthetic. I need to tell you that so you don’t sue me if you die. Don’t look so worried, Mrs. Smith. Do you have any questions?”
“Yes. What is that sticker on your forehead?” she asked.
“It says ‘I just got out of residency yesterday’ ”, the doctor answered with a smile.
Sound absurd? Let’s start by looking at data that is available on anesthetic risks. A review article by Jenkins and Baker (Anaesthesia, Oct 2003,58,962-84) summarizes the incidence of mortality and morbidity associated with anesthesia. The authors conducted a Medline search from 1966 to the present for all anesthesia publications with keywords relevant to mortality and morbidity.
Anesthetic-related mortality was found to be rare. The incidence of death related to anesthesia was 1:50,000, and the incidence in ASA I and II patients was 1:100,000. Total perioperative mortality within 30 days of surgery was much higher, with rates of 1:200 for elective surgery, and 1:40 for emergency surgery. Thirty day mortality was two times higher in 60-79 year olds, five times higher in 80-89 year olds, and seven times higher in patients over 90 years old.
What were the most common complications of anesthesia? The complications and their incidences were: drowsiness (1:2), sore throat after tracheal tube (1:2), pain (1:3), post-op nausea and vomiting (1:4), dizziness (1:5), headache (1:5), and sore throat after laryngeal mask (1:5).
Informed consent is a discussion of the risks and benefits of the anesthetic proposed, and discussion of any alternative methods available. It is followed by documentation that the patient understands and consents to the plan. Our original question today regarded what risks to discuss. Per Benumof and Saidman (Anesthetic and Perioperative Complications, Mosby, 1999, 781-2), “There must be a balance between giving enough information to allow a reasoned decision and frightening the patient with a long list of potential, extremely rare, severe complications, the latter making a trusting doctor-patient relationship difficult.”
I collected opinions from 20 private-practice anesthesiologist colleagues at Stanford via e-mail. Only one of the twenty replied that he would tell the hysterectomy patient that she could die. He cited the philosophy that if she consented despite the risk of death, that any smaller complication such as the loss of her singing voice due to the endotracheal tube, was trivial in comparison.
Another private attending disagreed, using the following reasoning, which I agree with: “If you tell the healthy patient that they could die, and they die, you are still in trouble. If you do something negligent and you are sued, you will lose the lawsuit, despite your anxiety-producing informed consent.”
For healthy patients, most private attendings discuss only the common risks such as drowsiness, pain, nausea, and sore throat. Many ask if the patient wants to know any more details about more serious risks. If the patient wants to, the anesthesiologist will then give more information about incidence of serious complications, possibly quoting numbers such as the 1:50,000 to 1:100,000 noted above. Others will reassure each patient with a statement such as “anesthesia is safer than the risk you take each time you drive your car on a freeway,” implying that you could have a bad outcome in either situation, yet not using the words “you could die.” For less healthy patients, older patients, emergency or more complex surgeries, the increased risks are discussed so the patient can make a well-informed choice.
In discussing the risks of anesthesia to healthy patients, I commonly say, “The chance that any serious complication to your heart, lungs, brain, or blood pressure is very close to zero, but it’s not zero. If anything unexpected occurs, I will be right there with you the entire time, and based on my training and experience, I will do the right thing for you.” This sentence informs them that although risks are rare, risks are possible, and reassures the patient that their anesthesiologist is there to treat any unexpected problems.
The purpose of obtaining consent is to give the patient enough information to make an informed decision whether to agree to the anesthetic plan, or not. Most private-practice anesthesiologists at Stanford would handle the informed consent for today’s patient without telling her she could die. Patients are nervous enough when they put on the gown and hop onto that gurney before surgery.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: