AANA/ASA Awareness brochure - unethical

nursesrock! · Aug 16, 2005

Can you explain exactly what your experience was during the incident? I feel that sometimes information like your brochure example may be misleading, but on the upside, your experience could help make the information correct/accurate. Just trying to be objective...

Mana_Tangata · Aug 16, 2005

Hi,

I don't think that this forum encourages patients to go into our personal experiences, sorry. I think that my experience was not unusual.

My feeling is the point of the brochure is not education but to placate patients. If it was labeled "Why your anesthesia providor thinks you don't need to worry about awareness" I'd be okay with it.

I doubt that those that crafted the brochure were unaware of the studies that show how many patients develop PTSD, how many patients are traumatized by the experience, how many patients feel pain during awareness.

NCgirl · Aug 16, 2005

Hi,
I don't think that this forum encourages patients to go into our personal experiences, sorry. I think that my experience was not unusual.
My feeling is the point of the brochure is not education but to placate patients. If it was labeled "Why your anesthesia providor thinks you don't need to worry about awareness" I'd be okay with it.
I doubt that those that crafted the brochure were unaware of the studies that show how many patients develop PTSD, how many patients are traumatized by the experience, how many patients feel pain during awareness.

Intubation does not occur during maintenance, it's part of induction.

heartICU · Aug 16, 2005

Before I reply to this, I want you to know that I am sorry for your experience. It is a traumatic thing to go through, and I hope that you have sought appropriate resources to help you cope. That being said, I have a few comments to what you wrote.

I've posted before - I'm a patient who had anesthesia awarenss. I've just seen the AANA/ASA patient brochure on awarness and I think that it is a shining example of misinformation and a true disservice to patients and patient safety. The brochure is at http://www.aana.com/news/pdfs/awareness_brochure0705.pdf
It's more the whole tone of the thing, the way the whole thing seems to be designed to placate and present the information in such a skewed way that a patient is discouraged from participating in their anesthesia choices, such as the use of relaxants, BIS or amnesiacs. I know you may be sick of people coming to you scared out of their wits by a sensationalist news article, but this type of skewed wordsmithing exercise is not justified or ethical in my book.

I know that current healthcare embraces patient decision making in their own care, but there are some decisions that a patient cannot make. For example, when you talk about patients making a choice about relaxants or amnestics - that is not always a "I can either have it or not, depends on what I want." Some procedures absolutely require it, and some prohibit it. You can't always do a case without muscle relaxant - it's not safe. The muscle relaxant isn't what causes awareness. Same thing with the amnestic drugs. Some procedures permit patients to have them, others not. Lack of use of midazolam or comparable agents does not cause awareness - otherwise we would have a lot more people complaining of awareness.

The BIS is controversial as you have read in previous posts. Having one or not having one does not prevent or cause you to have awareness. Just as an aside, with limited information about your case, if you had the vital signs you described, and you had a BIS on, no matter what the number was, I would have ignored it. I do not believe it is right to treat a BIS number - everything else we treat in anesthesia has a verifiable backup. For example, if your heart rate reads 110, and I want to double check it, I can check your pulse with my finger and manually count it. If your O2 sat is low, I can send a gas and check it. If your end tidal CO2 is low or high, I can send a gas and check it. With the BIS, I have no backup. Therefore, I would never treat anything on a number alone. So I think providing a patient with the option of a brain monitor provides them with a false sense of security.

Section on "Why does it happen?"
Patient condition mentioned first, pt varied reaction to anesthesia 2nd, "In rare instances, technical failure of human error" Is this so? I've read (I think in closed claims) that technical failure was #1, human error #2, patient condition #3, but since this was closed claims I assume it would be biased. I don't know, but I doubt the validity that technical failure plus human error would be the cause of, say, less than 10%.

I think this will depend on the patient population. For example, in awareness among trauma patients, it is probably patient condition first, but that is just a guess.

Section on "How can awareness be prevented"
Zero JCAHO suggestions. Patients advised to give prior anesthesia history, current meds. I know this board is sick of the JCAHO recommendations, but still as a patient I expect them to mentioned, or at least referenced in an educational document so I can make an informed decision.

With all due respect, the brochure did mention a few JCAHO recommendations. They just specifically did not mention the word JCAHO. The recommendations can be found here: http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_32.htm

These recommendations are for anesthesia providers, and are not geared towards patients. The brochure mentioned a few things the patient can do for themselves: give prior anesthesia history, discuss current meds. The rest is the responsibility of the anesthesia provider.

3. Awareness can vary from brief, hazy recollections to some specific awareness...Patients may dream, have memories of before or after, [which is not necessarily awareness.] To me, another rendition of "It's all in your head".

Some patients do dream. I have found that doing outpatient plastics cases that young men, especially teens and twenties, often have very vivid dreams when using propofol, none of which were true. They are often very upset when they wake up - not because they had awareness, but because the dream was so good they didn't want to wake up yet. (The dreams usually involved women..hehehe.)

Seriously though, I didn't get the same impression you did from the brochure, Mana Tangata. I took it to be a brief informational pamphlet, which is supposed to be a starting point for discussions with your anesthesia provider. You have to remember that when writing educational handouts such as these, you have to write for all education levels. A highly educated PhD researcher may very well understand the results of a retrospective analysis of anesthesia awareness, while another patient will not.

Wanted to mention recommendation #10 (and possibly the most important one): Patients should talk with their anesthesia professional before surgery to discuss all of their concerns, including the remote possibility of awareness.

jewelcutt · Aug 16, 2005

I have to agree with heartICU,

It is never the intention of any anesthesia provider to have a patient with recall, in fact we often give additional amnestics just incase in certain situations. The truth of the matter remains, there may be recall in some instances (i.e trauma, urgent c-section, and possibly any emergent case), however, as anesthesia providers we always try to 1)keep the patient alive 2) provide pain relief, and 3) give as many drugs as the patient can tolerate. It is very hard to write a brochure in laymans terms to relieve the public's anxiety. I always tell my patients they may hear talking as they're going to sleep, and that at the end of the case we will be trying to wake you up so you will remember things and you will hear things. Patients are groggy when waking up, there are many drugs still on board and they can't quite comprehend things accurately, that's why we talk to them and let them know what's going on. As for those that have true recall during maintenance I feel extremely sorry for. We monitor every body function succeed at preventing this most of the time, unfortunately there are a very rare few who do recall. That's why we are continually working on making the system better, because we care for our patients and don't want them to experience this. The data has showed, however, that most recall happens on induction, emergence, and during emergent(trauma) procedures. It is very scary to lose control of your body, but I still believe that anesthesia is the best part of having surgery.

Mana_Tangata · Aug 16, 2005

I have to agree with heartICU,
...." It is very hard to write a brochure in laymans terms to relieve the public's anxiety".... QUOTE]
I think that we agree about the point of the brochure - it is a brochure written to relieve the public's anxiety. That is my problem with it, it has that aim, and not a balanced educational aim, and is misrepresented as patient education.

sandman1 · Aug 17, 2005

With all due respect, I too am extremely sorry for what you have gone through but am going to have to disagree with your opinions on the pamphlet. All information in that pamphlet is accurate and can be found in any anesthesia text. As stated earlier, it is difficult to put that kind of information in lay persons terms, so considering the amount of research you have no doubt done after your experience, the brochure may seem insufficient to YOU, but not to the general public. The purpose of the brochure is for both patient education AND to allay anxiety. That is actually the purpose of most patient education. Countless studies show that educated patients have reduced preop anxiety levels and require less preoperative sedation.

Again, sorry for whatever horrible experience you had but please know that this is accurate information and just because your experience was different from what the brochure says doesn't mean it's full of lies. The brochure describes the usual circumstances, not the exceptions.

My take on the BIS?........ I think the BIS is dangerous. First off, it is a depth of anesthesia monitor, not an awareness monitor. Most, if not all, studies brag about how much money was saved by monitoring with the BIS because of LESS anesthetic consumption but can never prove less awareness with any statistical significance. Logic makes you wonder how if LESS anesthesia is being given, how can that prevent awareness at the same time? I do not care what a BIS monitor says.......it's ALL about the patient.

I have to agree with heartICU,
...." It is very hard to write a brochure in laymans terms to relieve the public's anxiety".... QUOTE]
I think that we agree about the point of the brochure - it is a brochure written to relieve the public's anxiety. That is my problem with it, it has that aim, and not a balanced educational aim, and is misrepresented as patient education.

jwk · Aug 17, 2005

Okay, so I'm all fired up and don't have my ducks in a row...

You're right - you don't.

"Studies are not conclusive on the frequency of awarenes" Huh? I thought that about .1-.2% is fairly accepted in the community. Sounds like they are hedging to me.

If I thought 1 out of 500 of my patients were awake during anesthesia, I'd quit doing anesthesia. If any practitioner's rate of awareness is that high, they should also quit doing anesthesia. We've all seen the articles - most of them that report awareness rates that high are done by :eek: those with vested interests in "awareness monitors".

"When awareness does occur, it is usually just prior to the anesthetic taking full effect or when the patient is emerging from anesthesia. In a very few instances it may occur during surgery" I thought that most awareness occurs during maintenance, perhaps intubation. They make it sound like you might be a little aware as you are drifting off or waking up. Not really the definition of awareness in my book. I really dislike the statement that "in a very few instances it may occur during surgery" Very few? Like count on one hand? I'd like to know where that comes from.

That statement is absolutely correct, whether that's the one you are looking for or not. I always tell my patients as they're waking up that their surgery is over and they are waking up.

Section on "How can awareness be prevented"
Zero JCAHO suggestions. Patients advised to give prior anesthesia history, current meds. I know this board is sick of the JCAHO recommendations, but still as a patient I expect them to mentioned, or at least referenced in an educational document so I can make an informed decision.
Section on "10 Things you should know about awarness" - summary

1. Awareness is rare, ususally fleeting and not traumatic. Speechless at the word crafting of this one. A shining example of cherry picking study data.

2. Patients usually do not feel pain, some feel pressure. Umm, isn't it something like 30% feel pain? "Pressure", if intense, can be severely traumatic to experience as well. Again, made to sound very benign.

3. Awareness can vary from brief, hazy recollections to some specific awareness...Patients may dream, have memories of before or after, [which is not necessarily awareness.] To me, another rendition of "It's all in your head". Read the full text to get the slant.

JCAHO should NEVER make recommendations for clinical practice for any specialty. This issue of awareness is the first time they have done so. One can't help but wonder how much "influence" the folks at Aspect and other awareness monitor manufacturers have had in this process, because CLEARLY, there are no good objective peer-reviewed studies that give the indication that this is as widespread a problem as they would like you to think.

You had an episode of awareness - I don't doubt that. It happens, RARELY. You will not be happy with any brochure printed by anyone unless it states that "Awareness is a common problem, usually caused by poor practitioners, and the only way to prevent it is to use a BIS monitor." Correct me if I'm wrong.

jsteine1 · Aug 17, 2005

I also had awareness, so much so that I heard the surgeon mention "she has a scar there" at the very moment I felt tremendous burning heat at the site of that scar. Not a dream, not my imagination.

athomas91 · Aug 17, 2005

awareness happens - it is rare - and all anesthesia providers strive for this never to happen - to think otherwise is a delusion to yourself ...

for those that have had awareness (true awareness) we have great empathy for but to comment on awareness with no training in anesthetics (how they work, when to use what and why, and when not to use specific things) it is ridiculous to comment on them.

there are times when awareness has a much higher liklihood than others - this is fact - and to stop this occurance could cost a patient his/her life. therefore - in this instance awareness is our second hand concern - survival of our patient is our first and main concern.

there are certain anesthetics that are not "general" and are not intended to place a patient in a state where "awareness" doesn't happen - that is the purpose.

again, we are all sorry for your experience - and would like to learn from it were all the facts available. however, the brochure is accurate and it seems as if you are commenting out of emotion and not reason.

Mana_Tangata · Aug 17, 2005

"You will not be happy with any brochure printed by anyone unless it states that "Awareness is a common problem, usually caused by poor practitioners, and the only way to prevent it is to use a BIS monitor." Correct me if I'm wrong.

My response -

1. I don't think it's a common problem. I think that it probably has an incidence of .1-.2%.

2. I don't think that it's ususally caused by poor practitioners, don't know where you got that one. As I said, I think, in a closed claims analysis, human error may have been #2 after technical problems. Since this database is from people who sued, I assumed it's biased and said so.

3. The only way to prevent it is to use a BIS monitor. It is my personal belief that the BIS, in high risk of awareness cases, can give a provider a tool that helps to reduce the incidence of awareness. I think the numbers that the clinical trials came up with were a 50% reduction in risk, with a p value giving 95% confidence. Personally, I think that with the numbers so low in the trials, that's too optimistic. In the real world maybe what, 25% reduction? For someone trained and comfortable with using it? That's anyone's guess.

If I had my say with the booklet, here are some changes I'd suggest:

Under 10 things you should know

1. It is quite rare and often fleeting. It it does occur, be sure to tell your provider who can help you deal with any psychological consequences, which can be severe if left untreated.

Why I'd make these changes. Awareness is already grossly under-reported. If you don't know you can't help. The original text only gives one side, the experience is fleeting (not always) and not traumatic (how many patients have psychological consequences? A lot)

2. Patients who experience awareness have a wide variety of experiences, from a pleasant, dream type awareness, feelings of pressure, pain, or anxiety.

Why I'd make these changes - pain may not be "usual" but it isn't "unusual" either. What, about 30%? Saying that patients don't usually feel pain, and then transitioning into "maybe" pressure, is MISLEADING.

3. Patients who experience awareness, or other disturbing recollections before, during of after treatment should always feel free to discuss them with their providor.

Why I'd make these changes - I'm sure that there are a lot of patients who think that have inter-operative awareness who are actually remembering before/after the procedure, but there are also those with awareness. The original text only discusses what true awareness is NOT, leaving it up to the patient to figure things out. I also think that the original text misappropriately discourages the patient to admit awareness. To help show why I think it's skewed, I'll flip things around. I'm not suggesting that a pamphlet has this wording.

Awareness can range from an extended, clear recollection of your surgery to a brief awareness of your surroundings. People who have experienced awareness may may think they have had a dream. Such a recollection does not necessariy represent a dream, but may actually be awareness.

5. Awareness can occur for any patient undergoing GA, but is most likely to occur in high risk surgeries.....

Why I'd make these changes - Aren't the highest number (not risk) of cases of awareness in healthy patients, who are not in for cardio, trauma or childbirth? When the original text states that awareness can occur in a, b and c, it misleadingly leads the reader to conclude that it can ONLY occur in a, b and c.

9. New brain wave monitoring devices currently are available and may prove...

Why I'd make these changes - Saying that monitoring devices are "being tested" makes it sound like they have not been FDA approved, which I think is misleading. (I know that a lot of you hate the BIS, but that's not the point, honesty is) If someone tells me a new cancer drug is being tested, I don't think that it's on the market. If a patient is so freaked out about possible awareness to hunt down a facility that has a monitor, maybe they should have one.

And NO - I don't have ANYTHING to do with Aspect.

Please stay polite, I'm trying to. Actually, I'm kind of having fun. I know that I have such a different point of view than almost anyone else on this board. Please take my comments as they are intended, not as an attack on personal beliefs but as a patient perspective.