The ‘Catch-22’ of Patient-shared Decisions in Anesthesia

Shared decision-making expands on conventional informed consent, requiring not just detailed disclosure of the pertinent clinical options and their risks, but also encouraging patients to form preferences about these options and collaborating with the provider in the selection of options.

While involving patients in shared decision-making is now widely considered a critical dimension of optimal patient care, the preoperative anesthesia consultation involves unique features and challenges compared to other healthcare providers’ patient encounters.  Shared decision-making with patients in the anesthetic realm may be limited by external factors, not least of which may be the risk of increasing preoperative anxiety.

A small qualitative study just published in the journal Anesthesiology examined how preoperative consultations with patients about to undergo primary knee arthroplasty led to decisions regarding primary anesthesia.

The study authors analyzed anesthesia consultations of 36 primary knee arthroplasty patients, and also interviewed the patients, thus capturing and then characterizing the perceptions of patients and anesthesia providers as well as their interactions in the consultation.

Patient expectations, provider goals

Among the unique features of preoperative anesthesia consultation versus other clinical patient encounters is that, typically, patients have no prior relationship with the anesthesia provider. In addition, the consultation sometimes occurs directly before an operation. Regardless, studies show that patients rank preoperative communication as an important part of undergoing surgery, further amping the challenge for anesthesia providers to align preoperative consultations with shared decision-making principles.

The authors found that the providers’ objectives of the consultation ranged from those who saw it as chiefly an educational opportunity (informing the patient about the anesthetic plan most medically suitable to instill comfort), to those who perceived their role as presenting options to the patient (educating them on each, and facilitating a choice between the options, and ultimately arriving at a plan that met with the patient’s desires).

Among the latter group, providers had varied approaches about how to meet that collaborative outcome, with some attempting to present the anesthetic options in neutral terms and allowing the patient to choose provided there were no contraindications for a specific anesthesia type. Other conversations revealed an ambivalence between making a neutral presentation and their desire to swing the patient toward a particular anesthetic option preferred by the provider without overly overruling the patient’s preference.

Patients’ responses

The patient side likewise reflected a range of reactions to the consultation, from those who expected not only to be informed about the details of the anesthetic procedure and be actively involved in the process of anesthesia type selection, to those patients who had no expectations or desires to contribute to choosing the anesthetic approach “as they did not feel qualified, comfortable, or interested in doing so.”

The consult results

Of the conversations analyzed in the study, in only 2 instances did the provider present the consultation as a choice, maintaining neutral throughout, and ultimately deferring to the patient’s preference for a specific anesthesia type.  In 6 of the consultations, the anesthesia provider flatly told the patient that they were contraindicated for spinal anesthesia and would have to undergo general anesthesia.

The remainder of the consultations fell in the range between the collaborative and the directive approaches. Some characterized the operation to the patient as appropriate for either anesthesia type, but expressed a preference for one, and the patient quickly agreed to the provider’s preferred method. In 12 instances, the provider presented anesthetic options and expressed preferences, but the patients did not quickly agree to the clinical recommendation. In response, the providers continued to justify their preference by describing its advantages and/or easing the patient’s discomfort with it until the patient consented to its use.

Finally, in 1 consultation, the provider presented options and conveyed a preference which the patient was disinclined to pursue.  In this case, the clinician’s brief attempt to persuade the patient failed.

Worthy, but impractical in anesthesia?

While a thoroughgoing anesthesia education, discussion, and collaborative decision-making session with patients may seem beneficial in the abstract, its pragmatic application in the aesthetic arena may be constrained by limited preoperative consultation time, lack of a previous patient-provider relationship, and the scheduling of the encounters often just prior to the surgical procedure.

“As such,” the authors write, “the potential benefit of behavioral interventions designed to enhance patient involvement in decisions should be carefully considered alongside their potential effect on the other functions accomplished by preoperative consultation.”

Most importantly, the authors express concern that the consultation’s “use for these objectives may result in less attention being devoted to important humanistic aspects of preoperative communication observed in this study, such as lessening anxiety.”

Read more about navigating the anesthesia-specific patient decision-making challenges in “Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty” at https://pubmed.ncbi.nlm.nih.gov/33891695/