Re: Conscious/Moderate Sedation and Consent

mshultz · Aug 7, 2006

As a person w/Crohn's disease I've read of so many Crohn's disease and/or UC patients who have encountered a colonoscopy where for whatever reason they were not adequately sedated. Many not only endured a lot of pain but asked, pleaded and begged the doctor to stop and the doctors did not. I'm always aghast as that. I know reimbursement for an incomplete scope can be a real PITA but nonetheless is it really ethical for a doctor to continue when the patient has asked that he/she stop? I know the doctor and I would part company in a hurry plus I would file a complaint w/the hospital, the state licensing board and his state professional organization if I were to encounter such a situation.

I would analyze this ethics problem by asking the following questions:

Is the patient warned about the potential pain? Since the patient is required to sign an informed consent, he should have been provided with an explanation of benefits, risks, and reasonable alternatives. Clearly, pain control should have been covered under the risks section.

Is there any harm to the patient in stopping the procedure? No, there is not.

Are there alternatives to pain control? Yes, propofol and MAC are two options. These require advanced training, such as CRNA.

I conclude that failing to stop upon patient request is unethical. There used to be a website hosted by a doctor in favor of colonoscopy without sedation. He claimed that only about 2% of doctors would stop a colonoscopy under sedation, even with repeated patient requests. Although I had a paid membership to this site, I was unable to find the source of his claim. However, in addition to reports on the web, I know of a relative who remembers repeatedly saying "This hurts", so lack of effective pain control can be a problem.

EricJRN, MSN, RN · Aug 7, 2006

Some interesting legal questions. Crohnie, sounds like the situations you describe are crossing the line into assault/battery. The only solid defense might be if the patient were making these pleas after being medicated and the doctor might be able to assert that the pt was no longer oriented or reliable.

Warning a patient about pain in advance wouldn't cause the patient to forfeit his/her right to request that the procedure be stopped. And pain control and sedation are entirely separate entities.

CrohnieToo · Aug 7, 2006

Yes, I think that that is what these doctors must have been counting on: that the patients would have had enough "sedation" that they wouldn't remember. Obviousy, the crohnies who related their stories DID remember!

These "doctors" and I use the term very loosely here, obviously also count on the patient having received some sedation and analgesia would be a protection for them if the patient did file a complaint, that they could claim that the patient was incompetent to make such a decision due to the sedation and analgesia.

Certainly, barring serious injury, it would not be worth pursuing from a legal standpoint, BUT, I still would file complaints w/the licensing board, hospital, medical associations, etc. that doctor belonged to or was licensed by if one of them ever pulled a stunt like that on me and I remembered it!

It bothers me HOW MANY of these stories I read in the various Crohn's forums that there could be so many gastros, surgeons, etc. out there who would continue after being asked, told, begged to stop a colonoscopy by the patient. It makes me realize how blessed I have been to find my gastro!

GI Jackie · Oct 6, 2006

I have been in GI for seven years. I can remember a few pts ask us to stop. What our doc did was stop what he was doing and wait until adequate sedation was achieved before continuing and I do not see anything wrong with that. I can remember one pt in particular that I gave some 200mg Demerol and 15mg Versed and 100mcg Fentanyl and she was still totally awake and crying. (Of course none of that was bolused just titrated over time to try to achieve moderate sedation) I felt miserable. I felt like I was failing her. The MD finally agreed to stop the procedure and we informed her that the next time she needed this done, she needed an anesthetist so that they could keep her comfy with deep sedation. I saw her afterward and she told me she remembered everything. I was amazed. I thought for sure with all that med we would have at least achieved some level of amnesia. All I could do was apologize and reinforce the idea that she needed stronger medicine than I am allowed to push.

I think the one thing that doc should have allowed in your scenario is a couple of minutes and a little extra med to see if they could keep their pt sedated. It may still not have been possible and in that case, he should have stopped.