Consent for anaesthesia: new guidelines meet old constraints

The new consent for anaesthesia guidance from the Association of Anaesthetists provides a welcome update on the subject [1]. Greater clarity on the professional and legal obligations in this domain is particularly helpful, specifically with reference to the timing and content of such discussions. Wider expectations as to how this might be delivered are also useful but, as the Working Party acknowledge, the guidelines “do not evaluate the resource implications that accompany them.” While the authors are to be commended for asserting organisational responsibility in meeting these new guidelines, in the interim, the gap between what is expected of anaesthetists with respect to consent and what can be realistically delivered grows. Anaesthetists are now expected to provide comprehensive, patient-specific information about serious risks in advance of the day of surgery while the infrastructure to achieve this is unlikely to change quickly for most. The gap this creates is not between disclosure and non-disclosure; it is between what is now required and what the system currently supports. There is clearly a mandate for national and local reform, but the tension for now lands with the individual anaesthetist, who must reconcile an unfunded or ‘unacceptable’ professional standard with a clear legal obligation. They may also be left exposed if either the standard or the shortfall in time is later scrutinised in a complaint or claim. Gaps in pre-operative assessment and the discussion of serious but low frequency risks have been previously identified in paediatric practice [2, 3]. An evolution in pre-operative assessment clearly needs to take place. With most pre-assessment services led by a valued team of nurses, empowering these individuals to have these conversations early in the referral process would offer one solution. Support in terms of time, staffing and training would still be a necessary and substantial prerequisite. The team at Great Ormond Street Hospital for Children have demonstrated that this can be achieved with diligence including wide stakeholder involvement and considered cultural change such that the routine disclosure of rare but serious complications, including the risk of death, has become the accepted norm for all patients undergoing anaesthesia at this institution [4]. While there is repeated emphasis on the non-compulsory nature of the information that should be included in such discussions, the list shown in Box 1 of the guidelines [1] may become the de facto clinical and legal standard despite the disclaimer, especially if we are to delegate some of this early discussion to other members of the multidisciplinary team [1]. For patients not reviewed by a consultant pre-operatively, it will then become incumbent upon the anaesthetist on the day of surgery to meet patient-specific materiality and ensure the understanding of previous discussions, while avoiding further bombardment of information and the repetition of risks perhaps non-proportional to the patient and procedure in front of them. The aspirations set out in this new guideline should be applauded; the means of achieving it will require guidance and funding beyond local resolution.