Practice of taking consent for anaesthesia in Great Britain and Ireland

R .A. Stewart1, S. Deshpande2

 

1. ST3 in Anaesthesia, Nuffield Department of Anaesthesia, John Radcliffe Hospital, Headley Way, OXFORD, OX3 9DU

2. Consultant in Anaesthesia, Department of Anaesthesia, South Tyneside District Hospital, Harton Lane, South Shields, Tyne and Wear, NE34 OPL

Correspondence to Dr R.A. Stewart, Nuffield Department of Anaesthesia, John Radcliffe Hospital, Headley Way, OXFORD, OX3 9DU E-Mail: richard.stewart@mac.com

Abstract

We conducted a nationwide survey assessing the practice of the taking of consent for anaesthesia and to gauge opinion of the future of this subject in the field of anaesthetics.

A postal survey was sent to all college tutors in Great Britain and Ireland.

Compared with a similar survey published in 2001 we demonstrated an increase in the number of departments with no documented guidelines for taking consent (27% to 79%) and an increase in the number of departments with plans to introduce a section to document written consent (2% to 8%). Over half (55%) of responders feel written consent will become a legality in the future but only 28% feel it would provide better protection against litigation.  We recommend wider use of departmental guidelines on the taking of consent for anaesthesia, and would encourage preemptive discussions within the specialty into the need for separate written consent forms for anaesthesia.

 

Introduction

In current medical practice, patients who have consented to a surgical procedure are considered to have implied consent to undergo anaesthesia, despite anaesthesia being associated with specific risks and consequences that are quite distinct from those of surgery. It has been widely appreciated in recent times that it is unacceptable for doctors other than anaesthetists to advise patients about the risks of anaesthesia when they will be neither administering it nor have adequate knowledge of what is involved. This is particularly important in patients with complex medical co-morbidities where anaesthesia may carry more risk to the patient than the surgical procedure itself.  Nonetheless, the methods by which consent is documented remain a more controversial issue.

As the incidence of medical litigation and pressure to comply with the Clinical Negligence Scheme for Trusts continues to rise, we believe the subject of written consent to be increasingly important. The recommendation from The Association of Anaesthetists of Great Britain and Ireland (AAGBI) on this subject has been consistent and the “Consent for Anaesthesia” document released by the AAGBI in January 2006 re-emphasised that written and patient-signed consent should not be a formal requirement (1). The Department of Health (DH), however, recommends that written consent is obtained for general anaesthesia (2).

In 2001, Watkins et al published results of a survey into the practice of taking consent for anaesthesia in Great Britain and Ireland and specified three areas of concern including, identification of a substantial number of departments without a specific policy on taking consent for anaesthesia (11).  We have completed a nationwide questionnaire-based survey to follow up some of the issues raised in the previous publication. We aimed to: firstly, assess how practice has changed since 2001; secondly, to review the impact of the AAGBI’s 2006 guidelines; and finally, gauge opinion on how the specialty of anaesthesia may change with respect to written consent in the future.

Materials and Methods

The questionnaire comprised ten questions with simple YES, NO or not applicable (N/A) tick-box responses. As some questions were based on issues surrounding the AAGBI ‘Consent for Anaesthesia’ document published in 2006, full support from the Association was obtained before distributing the questionnaire.

Questionnaires were sent to college tutors in anaesthetic departments of hospitals with operating departments listed in the ‘Handbook of Operating Departments 2006’. It was appreciated that not all hospitals with operating departments would have an anaesthetic college tutor but this method was believed to allow as many intended recipients as possible to be contacted. The completed questionnaires were returned by pre-paid envelope.

The first question asked whether specific anaesthetic departmental guidelines exist in their department for the process of taking consent. Questions two to four related to how the process of consent is taken within respective departments and questions five to eight were concerned with the new AAGBI guidelines. We asked whether the guidelines were received and were readily accessible in departments for anaesthetic staff to view. In addition, we asked whether the guidelines were considered useful and whether any changes in departmental policy had ensued as a result of their recommendations. The last two questions sought the recipient’s opinion regarding whether written consent will become a legal requirement in the future and if they believe it will afford the anaesthetist better protection against litigation.

The responses to each question were analysed independently in order that, where answers were not provided, the remaining responses could still be interpreted.

The results were transferred onto a Microsoft Excel (Excel:mac 2004) spreadsheet. They are reviewed below and can be seen in full in Table 1.

 

Results

Of the 423 questionnaires sent out 176 were returned giving a response rate of 42%.

The results can be seen in Table 1.

 

Table 1

	Yes n (%)	No n (%)	No answer n (%)
Do you have departmental guidelines for taking consent?	33 (19)	140 (79)	3 (2)
Do you have a separate written consent form for anaesthesia or space on the standard form for patients to sign written consent?	16 (9)	159 (90)	1 (1)
If not, do your anaesthetic forms have space to document verbal consent?	101 (63)	52 (33)	6 (4)
If you do not have provision for documenting written consent, do you plan to introduce this in your department?	10 (8)	116 (84)	10 (8)
Has your department received the new guidelines for consent (January 2006)?	139 (79)	28 (16)	9 (5)
If so, is this readily available in your department?	105 (64)	54 (33)	6 (3)
If you received them, did you find them useful and informative?	98 (70)	32 (23)	9 (7)
Will your department be altering your practice of taking consent based on any of the recommendations?	23 (15)	112 (75)	15 (10)
Do feel written consent will become a legal requirement in the future?	96 (55)	70 (40)	10 (5)
Do you feel written consent would provide better protection against litigation?	49 (28)	116 (66)	11 (6)

In our survey, 79% of departments were found not to have documented guidelines for the practice of taking consent. This is an increase from the 27% in Watkins’ survey in 2001. We also found that 90% of departments did not have a separate consent form or a space on the anaesthetic chart for the patient’s signature. There was little change over the last 5 years in the percentage of departments with space to document verbal consent since 2001 (63% in 2001 v. 70% in 2006). When recipients were asked whether plans were being made to introduce a section to document written consent, there was a small increase from 2 to 8%.

Almost four fifths of anaesthetic college tutors stated that they had received the 2006 AAGBI guidelines on consent and of these, 64% stated it was readily available for consultation in the department.  Of those that received the guidelines, 70% found them useful and informative and 15% stated they would be implementing change to their departments practice on taking consent as a result of the new guidelines. 

Our survey found that 90% of departments do not have a separate form for written consent for anaesthesia but over half of responders stated they feel written consent will become mandatory in the future. However, 66% do not feel such a move would provide better protection against medical litigation.

Discussion

Consent is defined as ‘permission’ or ‘agreement’ and is something that should be arrived at between a healthcare practitioner and his/her patient before any interventional procedure is undertaken (7). Anaesthetists have a duty to explain to the patient, in non-technical language, the nature, purpose and material risk of the proposed anaesthetic procedure.

However, opinion is divided over the most appropriate method for obtaining consent and documenting that a suitable conversation between anaesthetist and patient has taken place (1.12).  The practice of taking consent for anaesthesia varies between countries, between hospitals within the UK and between individual colleagues (8,4).

Our survey aimed to follow on from a similar survey by Watkins et al in 2001 (11). We aimed to assess any change in the practice of taking consent over the last 5 years and gauge opinion on the future of consent in the specialty of anaesthesia.

Our survey found that nearly 80% of anaesthetic departments do not have their own departmental guidelines for taking anaesthetic consent. This is a notable increase from 27% in 2001. We also found that 90% of departments did not have a separate consent form or a space on the anaesthetic chart for the patient’s signature. This practice is in accordance with the AAGBI guidelines.

While it is reassuring that almost 8 out of 10 departments received the AAGBI guidelines on consent in 2006 and the majority (70%) found them useful, we feel that more could be done to ensure they were available in the department for quick reference. This may be particularly important in view of the small numbers of departments with their own local guidelines. The small proportion of college tutors (15%) that stated they would be implementing any change in practice as a result of the new guidelines reflects, in part, the fact that the working party’s recommendations on written consent have not changed since 2001.

Our survey revealed a weight of opinion that written consent for anaesthesia will become a legal requirement in the future. This is paralleled by an increase in number of departments with plans to introduce a separate form to document written consent.

The literature casts doubt over written consent’s usefulness both as protection against litigation and in improving the quality and validity of informed consent and studies across various specialties have shown, patient understanding following the taking of consent is extremely variable and not necessarily improved by insisting on a patient’s signature (6,3). Many argue it can become a ‘tick-box’ exercise and detract from patients’ individual consent requirements. Patient information leaflets are another way of providing information regarding risks and side effects of anaesthesia. While there is little literature on the benefits of such leaflets detailing risks specific to anaesthesia, with respect to surgical consent taking, opinion is divided as whether they are beneficial in aiding patient recall and understanding (9,10,5).

However, if done well, written consent is one way of ensuring that our professional discussions are correctly documented and can act as a stimulus for active discussion with patients about treatment options. Provided we do not lose sight of the two-way nature of consent, it may also be invaluable in retrospectively protecting both the patient and doctor if a dispute over information disclosure occurs. As reports of litigation against anaesthetists continue to rise, it is a natural reaction to wish to ensure that any conversations between anaesthetists and patients are accurately documented. While written consent is unnecessary to defend cases of alleged assault by anaesthetists it seems logical that there will be occasions when such documentation would prove invaluable in retrospect (12).

In summary, our survey has shown a fall in the number of departments with documented guidelines for taking consent since 2001. This was highlighted as an area of concern in 2001 and one we would re-emphasize needs targeting for improvement. The recent AAGBI guidelines for the practice of taking consent have been widely received and been considered both useful and informative. As a result, it is our view that they should be made more accessible for reference in anaesthetic departments than seems evident from our survey.

This survey suggests that many members of the Anaesthetic community feel written consent will become of increasing importance in the future. Many in the profession however, have reservations over its effectiveness and value from both a clinician and patient perspective.

As a result, we feel that the specialty would be well served by preemptively initiating widespread discussion into the use of a standardized separate consent form in order that the limitations outlined above can be addressed. As a consequence, if written consent does indeed become a legal requirement in the future, the specialty is well prepared and can move forward with coherence.

References

• Association of Anaesthetists of Great Britain and Ireland (2006). Consent for Anaesthesia
• DoH guidelines: 12 points to consent: the law in England 2001
• Graham P. (2003) Type of consent does not influence patient recall of serious potential radiation toxicity of adjuvant breast radiotherapy. Australasian Radiology 47(4), 416-421.
• Guidelines on consent for anaesthesia and sedation (2005). Australia and New Zealand College of Anaesthetists
• Langdon IJ, Hardin R, Learmouth ID. (2002) Informed consent for total hip arthroplasty: does a written information sheet improve recall by patients? Annual Report. Royal College of Surgeons of England. 84(6): 404-8.
• Lavelle-Jones C, Byrne DJ, Rice P. (1993) Factors affecting quality of informed consent. Britsh Medical Journal 306 (6887): 1273
• Oxford English Dictionary (2007). Oxford University Press
• Sakaguchi M. and Maeda S. (2005) Informed consent for anaesthesia: survey of current practice in Japan. Journal of Anaesthesia
• Stanley BM, Walters DJ, Maddern GJ. (1998). Informed consent: how much information is enough? Australia and New Zealand Journal of  Surgery. 68(11): 788-91
• Turner P. and Williams C. (2002) Informed consent: patients listen and read, but what information do they retain? The New Zealand Medical Journal Vol 115 No.1164
• Watkins E.J., Milligan L.J, O’Beirne H.A. (2001). Information and consent for anaesthesia: a postal survey of current practice in Great Britain. Anaesthesia Volume 56 (9), pp 879-882
• White, S.M; Baldwin, T.J. Consent for anaesthesia (2003) Anaesthesia. 58(8):760-774

Acknowledgements

We would like to thank Dr J Kamel, Senior House Officer, Anaesthetics for his assistance with this project and the Audit and Anaesthetics departments at South Tyneside District General Hospital for their data analysis and funding respectively.

 

First Published February 2008

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