Anesthesia Consents- question

[Keysnurse2008]

Hi...I have a question. Our anesthesiologists at our hospital always talk to the patients pre op to get a thorough H&P. However, when they get the pt to sign the anesthesia consent they always tell them what they will be doing for them intra op/ and post op. But...when the procedure starts they often times get another anesthesiologist to do the case or get a SRNA to do the case and they do paperwork in the office and only wander in for the intubation and induction and extubation. The patients belive the anesthesiologist that got them to sign the consent will be present and managing their entire case. My question is this: When a anesthesiologist gets a patient to sign a consent for the surgery do they have the obligation to physcially do their case or can they substitute another anesthesia MD ....or even get a student SRNA do the case without the patients knowledge?

I cant help but think of it like this- If I get a cardiothoracic sugeon to do my open heart surgery, and that CT MD gets me to sign a consent for the surgery.....then to me ....that MD better be doing my surgery.....or else my consent is invalid . But with anesthesia is it the same ....what is ok ?

[Keysnurse2008]

i have to speak up for the srna, #1 was the srna aware of the request? it is quite possible that they were not. #2 was the srna able to say no to the the md?

but i absolutely agree that the request should have been honored by the md. in some practices in may have been a long time since the md actually did hands on case management, and the srna could have been quite capable of providing a high level of care, but if that's what the agreement was, then it should be honored.

even in a teaching hospital , you have the right to a say in your care. you have the right to be told truthfully who is participating in your care and to refuse care from a person who is " still learning" however astute and capable they might be. you could be diagnosed with a glio brain tumor tomorrow. you would choose where to have the surgery at, whom the surgeon would be and you could say " no residents are to perform my surgery". the residents might be very capable, but that is your life and you do not feel comfortable having that resident perform your surgery so how would you feel if post op you found out your surgery had been done by a resident? would you feel as if your trust in that facility had been misplaced? i am just saying...it is wrong. it is a violation of trust.....i am not even touching the legal implications.......it is a violation of trust.

[Qwiigley, BSN, MSN, DNP, RN, CRNA]

Depending on the level of the SRNA, they could possibly be competent to take the care, but the point is you asked for NO SRNA. The anesthesiologist is at fault. I would pursue this otherwise other people will become at risk also. The state of California says that SRNAs are "medically directed" meaning they can not do a case on their own, although they can be left in a room after induction to manage the case. They have to have the ability to call for help and that help should come asap. The problem with this is some students (rememer they were the best ICU nurses to get in the program) they may not want to ask for help, therefore put pts at risk.

We hae students in our facility. New and experienced students. They are not to be left alone in the room; at any time. They may do the case, depending on their level, but we watch everything and do not leave the room. That way, we can assess what they are doing and determine if we should intervene.

Personally I do not like MDAs teaching SRNAs. They teach them poor habits, do not emphasize the importance of doing things by the book and the MDAs in our facility can be even lazier by reading the paper etc. But that is a whole different complaint.

[NiteyNite]

IMO the best ICU nurses know their limit and when to ask for help...

But everybody's different.

[foraneman]

It doesn't matter if it is a teaching institution or not. If you specifically state, written or orally, that you do not want a student nurse anesthetist (or a resident or whatever) to participate in your care, you have every right to do that, and every right to expect that request to be honored. To do otherwise is battery. It's that simple.

Actually, that is not true. You DO NOT have a right to expect a teaching hospital to change its standard operating procedure in caring for patients to accommodate your desires. Your general consent to treatment spells out the fact that in a teaching hospital you may be cared for by students or professionals in training. Should you come to some written agreement with an attending physician, a surgeon for example, that he/she will personally perform the operation, AND something goes wrong AND it turns out his resident did the operation (or his partner, or his dog) only THEN do you have any sort of a 'battery' claim which you can take to court...and you still have to prove the outcome would have been different if the big wig surgeon had done the case. What DOES happen, is that the surgeon becomes liable for the acts of those he placed in his stead (they are liable for their own acts too of course).

As far as criminal or civil battery, they both require intent. The SRNA would have to intentionally (had to know that no SRNA was to be in the room) engaged in harmful (did not harm patient) or offensive (have to be conscious to be offended in most instances...sexual battery is an exception) touching. No crime since there was no intent to harm or offend. Civil battery must have actual damages which a court can award compensation for. The MDA cannot be charged with battery for the SRNAs touching.

Sorry, but a teaching hospital is not a personal private clinic for it's employees, nor should it be for rich folks or the mayor. The function of the hospital as it pertains to all patients outweighs any special service requests. Now you can certainly say "Dr. Butterfingers is not to come near me"...but you cannot request that an entire department, save one individual, keep their distance if this hinders the customary services provided to others.

Back to the original question: The MD creates liability for himself when he leads the patient to beleive e will personally perform the anesthetic. Where the law is well settled in its view that CRNAs are liable for their actions and MDAs are laible for theirs (and not each others), the MD may become liable for ALL actions of anesthesia providers if he misrepresents his participation during consent. He likely is always liable for ALL SRNAs actions if he is supervising 1 on 1 with no CRNA mentor.

[Keysnurse2008]

back to the original question: the md creates liability for himself when he leads the patient to beleive e will personally perform the anesthetic. where the law is well settled in its view that crnas are liable for their actions and mdas are laible for theirs (and not each others), the md may become liable for all actions of anesthesia providers if he misrepresents his participation during consent. he likely is always liable for all srnas actions if he is supervising 1 on 1 with no crna mentor.

like you said the surgeon creates liability for himself when he misleads / aka untruthfully states he will be the one doing the surgery. you see......he had a choice. he could have chosen to tell the patient that he could not guarantee he would be the actual one doing her/his sugery if if if it infact was against the hospitals operating procedures......and in this hospital it was not. the physcian had a choice and chose to misrepresent the fact that he was doing this patients case. that is a nice way of putting it......chose to misrepresent....it sounds much nicer than he lied. life is full of choices and if the physcian is honest and says it violates operating procedure....then the family and pt has a choice to proceed or not proceed. i am not touching the legal implications of this.....i am saying it is ethically wrong to misrepresent like that. and alot of teaching hospitals have these requests all the time, no students , no residents to do procedures and it is never a big deal. as a patient you have the right to choose who your doctor will be and to choose that doctor based on his years of experience, track record , specialty etc. alot of patients...and you know this is true ......will say i dont want a resident or student doing my surgery. and then the physician has the choice to say i am sorry you have to alllow my resident that just graduated medical school yesterday do the surgery.....or the srna whom by the way you will be his first patient ever do the surgery. life is about choices and those consents...a.re suppost to be honest contracts . this is how the public begins to distrust healthcarem ...misrepresentations etc etc .......i am not even touching the legal implications.......ethically it is wrong.

lets take this to another step......lets say your pt said no residents or srnas are to do my surgery......and you allowed a resident or srna to do the surgery.......and then they crumped intra op. how nervous would you be? see...that is my test....if your stomach would be churning....you know.....ethically you did something wrong. i am not even touching legal implications...ethically it was wrong...your misled your patient and they proceeded on with surgery based on your misrepresentations. i am not even talking legally.....but ethically it is wrong.

[foraneman]

I absolutely agree that ethically it is wrong, and it is pure arrogance.

Your characterizations of residents and SRNAs having major responsibilities (i.e. performing surgery or doing anesthesia for the first time on any patient, and doing so anywhere CLOSE to independently) which they have not yet earned was , i know, exaggerated to make a point. However, unless the hospital is a particularly crappy one (in which case why are you in surgery there) residents and SRNAs are not running about doing their own thing, without proper experience or supervision.

[Keysnurse2008]

i absolutely agree that ethically it is wrong, and it is pure arrogance.

your characterizations of residents and srnas having major responsibilities (i.e. performing surgery or doing anesthesia for the first time on any patient, and doing so anywhere close to independently) which they have not yet earned was , i know, exaggerated to make a point. however, unless the hospital is a particularly crappy one (in which case why are you in surgery there) residents and srnas are not running about doing their own thing, without proper experience or supervision.

absolutely i extremely extremely overexaggerated to make my point. i have had srnas that were more attentive and just as skilled as the attending anesthesiologist....and same thing for the residents/surgeons. but too.....you know that with experience comes the refining of skills and the wider knowledge base to "see" when things are heading slightly down the wrong path. when it is your first few cases you dont have that knowledge base attained from your experiences to draw from .i am just saying that i have worked in large hospitals that have had patients occassionally ask for his/her case to be nonteaching and i have never heard a physician refuse that accomodation. but....when patients are misled to believe that a physician/crna will be doing their case when everyone knows that isnt true it obviously does create mistrust....and ethically it is wrong.:redpinkhe:deadhorse:deadhorse:deadhorse

[markuskristian]

Check the book Complications: A Surgeon's Notes on an Imperfect Science

The author talks about how medical professionals are suppose to be without error, which would mean students never practice. He says active learning is something to remain secret.. Like the resident surgeon that will be "assisting" is actually the one slicing and dicing.

It's how students learn.