C Srinath, G Thomas
C Srinath, G Thomas. Audit on Consent to Anaesthesia. The Internet Journal of Anesthesiology. 2009 Volume 26 Number 1.
Patient has a fundamental right to know what he is undergoing and it is the duty of the anaesthetist taking care of the patient to provide the necessary information and seek an informed consent.
The Association of Anaesthetists of Great Britain and Irelands ‘Information and Consent to Anaesthesia’ clearly explains the legal, professional and ethical responsibilities of the anaesthesit in providing information and obtaining consent.
It is highly recommended to document the details of discussion between the patient and the anaesthetist. Documentation is an important feature of risk management in order to defend against claims of clinical negligence2.
Previous audits of consent have been undertaken in other medical disciplines but these did not address anaesthetic consent in any detail. As a result, the action plan from the last audit of consent stressed the need for a separate audit of anaesthetic consent to be undertaken.
The standards selected were from the trust policy and they were:
1. 100% of patients should give either verbal or written consent to anaesthesia.
2. Written consent should be obtained in 100% of cases where anaesthesia represents a significant risk to the patient.
3. Where verbal consent is given, details of the discussion with and agreement of the patient (including details of the anaesthetic techniques, risks involved etc.) should be documented in the anaesthetic record.
A list of all procedures during one month was obtained from information services and all procedures known to be performed without anaesthetic or using only local anaesthetic were removed. A sample was obtained by randomly selecting 50 cases from the list using a random number generator. Any cases that did not meet the inclusion criteria when reviewed were replaced with another randomly selected set of case notes.
Data was collected and analysed with the assistance of the audit department.
A Trust ‘Consent to Anaesthesia’ form was found in only one case but verbal consent was documented on the anaesthetic record in a further 35 cases. In 1 case, there was documentation on the anaesthetic record, which confirmed that the patient was unable to consent. These cases all met standard one.
In 13 cases no evidence was found to suggest that the patient had consented to anaesthesia.
A significant anaesthetic risk was identified in only one case and this patient gave written consent to anaesthesia.
The criterion regarding details of the anaesthetic technique was met if the checkbox ‘Technique explained’ on the anaesthetic record was ticked or if there were written details regarding anaesthetic technique in any notes made by the anaesthetist. Similarly for risks explained, there is a checkbox. The criterion regarding documentation of risks however, was only met if the risks of anaesthesia were listed in the anaesthetic notes/on the anaesthetic record
The chart below shows the proportion of the 35 patients who gave verbal consent, in which each criterion was met. The last column of the chart shows the percentage of cases in which all 3 criteria were met.
Additional information obtained from the audit
Documentation of Type of Anaesthesia
Grade of Anaesthetist
Documentation of Procedure
Under common law, patient has the right to give or withhold consent (except in special circumstances) and failure to recognize this right amounts to negligence.
Verbal consent for anaesthesia is acceptable and a formal written consent for anaesthesia and anaesthetic related procedures is not necessary13.
The guidelines, produced by a working party of the Association of Anaesthetists of Great Britain and Ireland(AAGBI) has emphasized that written and patient signed consent for anaesthesia should not be a formal requirement1.
Primary therapeutic interventional procedures may need a signed consent in accordance with local policies1.
There is no acceptable place or time to provide information to the patients and there are no acceptable standards or guidelines regarding the amount and nature of information to be provided to the patients, however relevant and reasonable information which can help the patient to come to a decision should be given24.
There is no uniform opinion regarding obtaining and documenting consent and can vary between different hospitals and between different anaesthetists in the same hospital.
Surveys have shown that to comply with the CNST requirements and ensure a uniform approach was being followed some of the departments had their own local guidelines and separate trust consent forms5.Studies have shown that use of formatted pre-printed standardized records improved the quality of documentation67.
In the world of ever increasing cases of litigation it is essential to ensure that consent is recorded properly in the notes and especially for procedures which carry significant risks.
Accurate and clear documentation is not only good medical practice but would also create an impression of professional competence. Proper documentation of the conversation between the anaesthetist and the patient will help to protect the anaesthetist from later disputes, legal complications and would prove invaluable in defending claim of negligence.
The audit has shown incomplete documentation of anaesthetic consent.
Action plan to improve documentation of consent in anaesthetic records included:
Modifying the anaesthetic record by adding tick boxes and using ink stamps/preprinted stickers.
Increasing education and awareness among the anaesthetists.
Use of trust consent form in high risk patients and consenting patients in preassessment clinics.
Doing a re-audit to monitor continuing compliance with standards and to assess whether implementation of the action plan has improved practice.
I would like to thank the staff in the audit department and Scunthorpe General Hospital for their support during the audit.