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• W2940770797 abstract "Editor—Informed consent is a fundamental principle of anaesthesia care and is a medicolegal requirement.1Association of Anaesthetists of Great Britain and Ireland AAGBI: consent for anaesthesia 2017.Anaesthesia. 2017; 72: 93-105Crossref PubMed Scopus (71) Google Scholar, 2Australian and New Zealand College of Anaesthetists PS26 Guidelines on consent for anaesthesia and sedation.2005http://www.anzca.edu.au/documents/ps26-2005-guidelines-on-consent-for-anaesthesia-or.pdfDate accessed: September 30, 2018Google Scholar Recent guidance from the Australia and New Zealand College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland relating to the conduct of informed consent for anaesthesia include a number of recommended risks that anaesthetists should discuss when obtaining informed consent. Although the consent process is generally considered benign, recent research on the nocebo effect suggests that some elements of the risk discussion may potentially harm patients by increasing anxiety or increase the likelihood of an adverse perceptual experience such as nausea or pain. It is not uncommon to obtain informed consent for anaesthesia on the day of the procedure from a patient who is already fasted and consented for surgery. In addition, anxious paediatric patients are particularly vulnerable to the effects of suggestion, both positive and negative (nocebo communications).4Krauss B.S. “This may hurt”: predictions in procedural disclosure may do harm.BMJ. 2015; 350: h649Crossref PubMed Scopus (16) Google Scholar We conducted a qualitative, structured interview-based study that aimed to determine the risks of anaesthesia that parents of children presenting for anaesthesia were already aware of, and to identify the risks of anaesthesia that parents wanted to discuss (if any). In addition, we asked parents which risks might affect the decision to proceed with their child's surgery. After ethics approval by the Women's and Children's Hospital Network Ethics Committee (HREC/17/WCHN/168) and written informed consent from study participants, parents were surveyed in the largest tertiary paediatric referral centre in South Australia between January and August 2018. Standard practice in our institution involves a pre-anaesthetic assessment on the day of surgery. We questioned parents before their contact with the anaesthetist. Of the 213 parents approached, 211 agreed to participate (99%). Four parent participants declined to see the list of potential risks, expressing concerns that this might increase their anxiety. All patients were undergoing day of surgery admission for non-emergent surgery. The average age of the children involved was 6.55 yr (range 0–17 yr), and 101 children had previously undergone anaesthesia. When shown the list of risks, participants were most familiar with postoperative nausea and vomiting (94%), and least familiar with the risk of eye damage (9.7%). One hundred and ninety-four participants (92%) reported that none of the specific risks of anaesthesia presented would affect their decision to consent for anaesthesia. In the remaining population, the most common risk potentially affecting the decision to proceed was the risk of death (n=17, 5.7%). However, despite some reservations, every parent surveyed decided to proceed with their child's surgery. A key finding was that 107 participants (49%) preferred no further risk discussion on the day of surgery; these parents were equally divided amongst patients who had previously undergone anaesthesia (n=53) and those who had not (n=54). A small subgroup of parents (<10%) wanted 10 or more risks discussed. Whilst previous studies have examined the number of risks discussed and recall of risks,5Feinstein M. Pannunzio A. Lobell S. Kodish E. Informed consent in paediatric anesthesia: a narrative review.Anesth Analg. 2018; 127: 1398-1405Google Scholar this is the first study to explore how knowledge of anaesthesia risks may affect a parent's decision to proceed with their child's anaesthesia. We discovered parents had diverse opinions regarding their wish to discuss these risks, varying from no risk discussion to a discussion encompassing every possible risk. This highlights a particular challenge faced by anaesthetists when attempting to gain informed consent whilst still respecting patient autonomy and avoiding potential harms from nocebo communications. Children are particularly vulnerable to the effects of suggestion and nocebo communication. Tailoring the risk discussion in a way that takes into account both the needs of the parent and child is important. In particular, it is important to recognise the child's need for a sense of control and a growing level of autonomy. Depending on the age and maturity of the child, their wishes for a discussion of anaesthesia risks need to be both considered and tailored to what is meaningful to them. Although risks such as death were reported to affect some parents' decision to proceed, all parents allowed their child to have their planned surgery. Current guidance suggests that the ethical principle of beneficence is secondary to the medicolegal requirements.1Association of Anaesthetists of Great Britain and Ireland AAGBI: consent for anaesthesia 2017.Anaesthesia. 2017; 72: 93-105Crossref PubMed Scopus (71) Google Scholar, 2Australian and New Zealand College of Anaesthetists PS26 Guidelines on consent for anaesthesia and sedation.2005http://www.anzca.edu.au/documents/ps26-2005-guidelines-on-consent-for-anaesthesia-or.pdfDate accessed: September 30, 2018Google Scholar A full disclosure of recommended potential risks of anaesthesia for some parents and children will deny them the autonomy to decline such a discussion, especially as some components of the risk discussion involve potentially harming patients by mechanism of the nocebo effect.3Dutt-Gupta J. Bown T. Cyna A. Effect of communication on pain during intravenous cannulation: a randomized controlled trial.Br J Anaesth. 2007; 99: 871-875Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar The concept of informing patients in a way that is likely to be helpful rather than harmful has been challenging. Our findings suggest that for many parents and children, a risk discussion needs to be individualised and take into account patient concerns and their individual needs for information. Informed consent cannot be standardised, nor should it be. Acting within current practice advisory statements may not accomplish the stated goals of a respect for patient autonomy or the avoidance of patient harms.1Association of Anaesthetists of Great Britain and Ireland AAGBI: consent for anaesthesia 2017.Anaesthesia. 2017; 72: 93-105Crossref PubMed Scopus (71) Google Scholar, 2Australian and New Zealand College of Anaesthetists PS26 Guidelines on consent for anaesthesia and sedation.2005http://www.anzca.edu.au/documents/ps26-2005-guidelines-on-consent-for-anaesthesia-or.pdfDate accessed: September 30, 2018Google Scholar The authors declare that they have no conflicts of interest." @default.
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• W2940770797 title "Parental understanding of their child's risk of anaesthesia" @default.
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• W2940770797 doi "https://doi.org/10.1016/j.bja.2019.03.039" @default.
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