Informed Consent in Obstetric Anesthesia

1
Informed Consent in Obstetric Anesthesia

• Dmitry Portnoy
• Anesthesiology Department
• UTMB

2
OB Anesthesia is a High Risk Area

• Many patients are healthy individuals
• High expectations regarding
• outcome in general
• both availability and quality of anesthesia
• Great disappointment if outcome less then perfect
• Misconceptions re anesthesia options and risks

3
OB Anesthesia is a High Risk Area

• High stress and high anxiety environment
• Public influence on role of anesthesia in LD
• Anesthesia care for both fetus and mother
• Problematic process of obtaining consent
• Legal remedies for real or perceived injuries

4
Theories of Liability and Medical Malpractice

• Theories (or causes of action)
• Medical malpractice
• Breach of contractual promises
• Lack of informed consent
• Four elements for proving medical negligence
• Duty
• Breach
• Injury
• Proximate cause

5
What is Informed Consent ?

• Recognized ethical and legal right of every
  patient for self-determination and direction of
  health care
• Elements of full informed consent
• Nature of the procedure
• Reasonable alternatives
• Relevant risk, benefits, and uncertainties of
  each choice
• Assessment of patient understanding
• Acceptance of the intervention by the patient
• Documentation

6
Establishing Lack of Informed Consent

• Failure to inform of material facts
• Patient consented without being aware
• A reasonably prudent patient under the same
  circumstances wouldnt have consented if informed
• The treatment provided was the cause of injury

7
What is Adequate Information?

• No need for full disclosure of all possible risks
• Only risks that are reasonably foreseeable
  required
• Usually one of three approaches
• Reasonable physician standards
• Reasonable patient standard
• Subjective standard
• Shown in court as not significant risk
• 0.75 esophageal perforation during endoscopy
• 1 in 20,000 to 1 in 50,000 is not foreseeable
  risk

8
Is this Patient Able to Make a Decision?

• Premeditated patient
• Patient under stress
• Patient with known mental illness
• The immature patient
• Patient in labor

9
Influence During Informed Consent Process

• Coercion
• Manipulation
• Persuasion

10
Special Situations

• Capacity/incapacity (competence/incompetence)
• Determined by professional judgment or by court
• State laws delineates who is authorized
• Decision is consistent with patients best
  interests
• Minor patient is able to consent
• By state law that permits minor to consent
• By clinical determination
• By judicial determination of emancipation

11
Consent for Labor Analgesia

• No consensus nationwide on signed consent
• Ideally should be discussed before the labor
• Obtaining consent during active labor
• Have a good recall
• Rarely primary basis for verdict
• Considered adequate in court
• Lack of objection and cooperation of the patient