Patient Preference vs Standard Practice - Where is the line?

[Spinach Dip]

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Was shadowing in the hospital the other day and heard this interesting conversation:

(Keep in mind the patient is a 20-something male of normal height and weight, non-diabetic, non-smoker, ASA 1. He is here for a surgery that will take ~4 hours. He has been sedated before, but never for something this long.)



Anesthesiologist: Hi there, Patient, I'm going to take you to the OR.
Patient: Hi there.

Then comes a standard exam. Bend your head back and forward. Open your mouth. Have any pain? Etc. etc.

P: Before we go, I have 2 questions... er... requests.
A: Shoot.
P: Could we do a mask induction?
A: (confused) Why?
P: Because I've had propofol inductions before and don't really like it. I thought I might prefer a mask induction.
A: ...No. Because you already have an IV in place, it would be much easier to just do propofol.
P: Oh...

After a couple more innocuous questions:

P: My second request... Could you leave the breathing tube IN for a few minutes extra?
A: Why?
P: Because I have motion sickness and acid reflux sometimes--in fact, I had a bad case last night--and I don't want to aspirate anything while I'm waking up and delirious.
A: We generally don't do that unless there is some kind of complication and you have to be sent to the ICU.
P: Really? I'm just asking for you to leave it in for a couple extra minutes. Until I'm actually awake. Can't you do that?
A: I'll pull it out when I feel the risk of aspiration is zero, okay?
P: Fine.
(Result: tube is pulled deep. Luckily, there is no aspiration.)



Now, I understand that an anesthesiologist's job is to care for the patient while they're under and to ensure they feel the least discomfort possible. But where do patient requests come in? As long as there is no increased risk involved, do you honor these kind of requests?



What do you guys think about this?

 

[G0S2]

I would explain that he could aspirate during mask induction thus RSI and then let him wake up and stand there until he pulls out his own tube while coughing, bucking and tearing.

 

[IlDestriero]

I would explain that he could aspirate during mask induction thus RSI and then let him wake up and stand there until he pulls out his own tube while coughing, bucking and tearing.

This.

 

[pgg]

Heh, so this guy is so worried about aspiration that he wants the tube in until he's wide awake, but wants a mask induction? 🙄

I'd do a mask induction for him, why not, and tell him I'd pull the tube when he's awake, but that he probably wouldn't remember it. 😉

 

[Idiopathic]

why does it matter? you can do all of these things safely, and a patient who feels like he has some input into his care will likely be happier with the experience

 

[deleted126335]

I always try to honor patient requests. People have a right to be stupid up to a point. I would point out the contradictory arguments he is making with regard to his anesthetic care. As long as he didn't have clinically significant GERD and I informed him how miserable some patients find being "awake" and intubated...and he still wanted this, sure, why not?

 

[lane]

awake NGT. reduce that aspiration risk. 😀

 

[Precedex]

Patients and surgeons have all sort of silly inane requests which if I don't think are too too stupid I don't have a problem accommodating. Keeps things interesting I suppose.

 

[excalibur]

What if patient requests retrograde wire?

 

[imfrankie]

"Sure thing, you can go home with the tube in if you want"

 

[Spinach Dip]

why does it matter? you can do all of these things safely, and a patient who feels like he has some input into his care will likely be happier with the experience

QFT



I spoke with someone who's been an attending at a teaching hospital for 20+ years about this very case. The 3 take-aways:

1. An anesthesiologists job outside the OR is to keep the patient as comfortable as possible. This means listening to them, talking to them, etc. etc. Any special requests should be considered if they do not cause an increased risk in complications for the patient.

2. Why not mask induction? Pre-oxygenate. "I'm going to turn the gas on now." Crank the sevo. Cricoid pressure. Have suction ready. No problem.

3. Waking patients up while still intubated happens all the time. In fact, if they know ahead of time that they're going to wake up with a tube in their throat (or if they are one of the 0.001% who request it), they seem to be much calmer than those patients who didn't expect it. Make sure you communicate with them so they don't feel lost. Take the tube out when they're awake. Maybe a little Versed or Fentanyl when you give your anti-emitic of choice. No problem.

 

[IlDestriero]

The patient admitted to "bad gastric" reflux, including just last night. And he's afraid of aspiration and asks to keep the tube in for a few minutes to avoid it.
That alone means that a mask induction is off the table. If he doesn't want propofol, he can get a RSI with something else.

 

[Idiopathic]

I feel confident that i can do a mask induction with one or two breaths in just as much time if not quicker than with a big dose of propofol, no bagging, they drift off to sleep. Id have to add a sedative to the sux probably, but they go to sleep with volatile and maybe thats what matters to them (maybe they hated propofol like some people hat etomidate or pentothal?)

regardless, i always temper it with "we will try" but make no promises.

 

[Spinach Dip]

"Sure thing, you can go home with the tube in if you want"

I like your flexibility, sir! 👍

What if patient requests retrograde wire?

Sounds like a rather extreme request, and I think the appropriate answer is to ask WHY?

Does the patient have a cervical halo and extremely limited mandible movement? Do they have some sort of bizarre pharyngeal tumor?

If they have a legit reason, I might suggest a tracheostomy for ease of future airway management.

If the person fails to have a legit reason for wanting a retrograde intubation, I don't see any reason to honor the request. It carries a number of risks, with no clear benefit. I'd probably tell them that I'd try it "the normal way", but would keep retrograde in my range of options if the first try failed.



Anyway, I'm not trying to lecture an attending. Just explaining the way I would reason through such an odd request.

 

[Spinach Dip]

Okay, this has been open for a week. I must admit 4/0/7/5 was about what I was expecting. Thanks for all the replies and votes.



Now, I have a bit of a confession to make--I was not shadowing on this case.

I was the patient. (But then again, maybe some of you already assumed that.) And I have a bit more to add to the background of these two requests...

First, I dislike propofol. It's hard to explain why. And it's not a deep-seated HATE, I would just prefer something else for induction of general anesthesia. (Propofol is okay for procedural sedation as it allows me to wake up rather quick.) I asked for a mask induction because I thought I might prefer it... or at least have something to compare propofol induction to for the next time I need general anesthesia.

And yes, I do know that mask induction is more likely to result in aspiration during induction. That was something I forgot in the stress of the moment. My bad.

My problem with the way the anesthesiologist handled it--he didn't seem willing to discuss it at all. He had a stick of propofol in his scrub shirt ahead of time and seemed determined to use it. He shot my request out of the sky without a second thought. He didn't even discuss the danger of aspiration (if he had, I would have been more agreeable to his induction plan). But he just declined my request without a second thought and moved on.



Second, I'm not afraid of being intubated. I have seen dozens of people intubated and extubated. I have personally intubated a couple pigs that were used for trauma experiments. And I have observed/assisted with the intubation and extubation of dozens of other animals. I am not afraid of it in the least. I am not afraid of waking up with a tube in my throat.

I am FAR more afraid of my duodenal contents finding their way into my bronchi. And as mentioned above, I have a "clinically significant" case of GERD.

The anesthesiologist swore he would remove the tube as soon as he "felt it was safe". Apparently, that meant "as soon as you are breathing spontaneously".

So I woke up with... guess what?... a bit of nausea! (what a surprise!) And as I am coming out of my sevo-induced nap, I am hoping I can turn my head to the side fast enough if I throw up... while simultaneously wondering if I can sue my anesthesiologist if I can't.

Again, it's like he just ignored whatever I had to say and went forward with his own plan.



So, sorry if this turned into a little bit of a rant. I guess my point is that I was a bit disappointed with my first general anesthesia. But I certainly did learn a lot from it.

So please, anesthesiologists of the world, listen to your patients. And if they have special requests, at least consider them. (Some of us do know what we're talking about!)



TY

 

[Trisomy13]

Skip propofol because patient doesn't like it. Induce with succinylcholine because of GERD. As patient is tearing during intubation, whisper in ear "don't tell me how to do my job". Clean out desk, apply for license in different state. Everyone's happy.

 

[Spinach Dip]

Skip propofol because patient doesn't like it. Induce with succinylcholine because of GERD. As patient is tearing during intubation, whisper in ear "don't tell me how to do my job". Clean out desk, apply for license in different state. Everyone's happy.

Thanks for the incredibly enlightening and mature answer.



I pray that some day my patient skills will match (or, dare I say, exceed) your own.

 

[B-Bone]

Thanks for the incredibly enlightening and mature answer.



I pray that some day my patient skills will match (or, dare I say, exceed) your own.

Relax man. He's just saying what everybody else is thinking. When somebody comes into the OR for surgery, they (or somebody) are paying for my expertise in the area of anesthesia. My number one priority is to get the patient safely through surgery. Other priorities are patient comfort, surgeon preferences, etc, but they are all well below safety on the priority list. In general, I will go along with what others (i.e. the surgeon and the patient) want as long as it doesn't compromise priority #1. Want a general instead of a block for your wrist ORIF? Fine. Want a spinal instead of a general for your total knee? Great! Want spinal for your wrist ORIF? Go f%^$ yourself!

Reading through this thread, it's obvious that you are not an anesthesiologist and don't have the expertise to evaluate what is and is not a good idea for an anesthetic. That's why you paid an anesthesiologist to get you through surgery. If you have specific requests, go ahead and let the professional know what your goals are. That expert will figure out if your goals are tenable and safe and make an anesthetic plan. If you don't like it, you can find another anesthesiologist.

Also, a bit of life skills advice: when you come to strangers for help/advice, try not to misrepresent yourself then insinuate that your layperson ideas are on par/superior to the expertise that they've spent years/decades developing. Sticks in one's craw a bit.

 

[IlDestriero]

(Some of us do know what we're talking about!)

But you don't. Your desired plan was inappropriate for a significant GERD patient. I would have given you an RSI if you or I were worried about aspiration. If you didn't want propofol, I'd probably give you ketamine. Pentothal was great, but it's gone now and I'm not a great fan of etomidate.
It sounds like your anesthesiologist wasn't worried about aspiration though, and your recollection of events and what actually occurred may be very different, particularly regarding your extubation and how awake you were when the tube came out.
As a peds anesthesiologist we get lots of odd requests from parents. I at least pretend to consider them before I decline. It makes everyone happier. You will find control freaks and patients or parents trying to control the uncontrollable. There's only so much you can bend from accepted and appropriate norms of practice.
Some parents read up on all kinds of (nonsensical, Jenny McCarthy type) stuff and ask lots of questions. I'm fine with that. It's part of my job. However, my job doesn't extend to explaining all my reasoning for all my anesthetic decisions beyond generalities. If you want more, come do a fellowship here.

 

[jwk]

So please, anesthesiologists of the world, listen to your patients. And if they have special requests, at least consider them. (Some of us do know what we're talking about!)

Some anesthesiologists have better bedside manner than others. But they generally know what they're talking about. You simply don't. You made a request - the answer was no. If you didn't like the answer, you had the option of leaving or requesting someone else to do your case.

 

[WholeLottaGame7]

Relax man. He's just saying what everybody else is thinking. When somebody comes into the OR for surgery, they (or somebody) are paying for my expertise in the area of anesthesia. My number one priority is to get the patient safely through surgery. Other priorities are patient comfort, surgeon preferences, etc, but they are all well below safety on the priority list. In general, I will go along with what others (i.e. the surgeon and the patient) want as long as it doesn't compromise priority #1. Want a general instead of a block for your wrist ORIF? Fine. Want a spinal instead of a general for your total knee? Great! Want spinal for your wrist ORIF? Go f%^$ yourself!

Reading through this thread, it's obvious that you are not an anesthesiologist and don't have the expertise to evaluate what is and is not a good idea for an anesthetic. That's why you paid an anesthesiologist to get you through surgery. If you have specific requests, go ahead and let the professional know what your goals are. That expert will figure out if your goals are tenable and safe and make an anesthetic plan. If you don't like it, you can find another anesthesiologist.

Also, a bit of life skills advice: when you come to strangers for help/advice, try not to misrepresent yourself then insinuate that your layperson ideas are on par/superior to the expertise that they've spent years/decades developing. Sticks in one's craw a bit.

Well said.

 

[pgg]

So, you had a safe and uncomplicated general anesthetic, but are still upset. Check. 🙂

Obviously I wasn't there so I can't comment on his bedside manner. I believe you when you say he was dismissive and kind of abrupt. No excuse for that.



A couple weeks ago we had a patient in preop who was very upset because he didn't know before the preop chat that he was going to be intubated. (He'd previously worked in EMS and associated intubation with being on death's door. I understood the source of his anxiety, even though it was baseless.) He wasn't a good candidate for an LMA, and two of us explained in detail why, but he was still not happy with the idea, and he nearly cancelled the whole thing.

We spent at least 15 or 20 minutes talking with him preop. The person scheduled to do the case brought in a 2nd person (me) for a "2nd opinion" but I think this was just perceived as us closing ranks to sell something to him. These discussions can be no-win situations. If the primary person hadn't called me, he's being stubborn and denying the patient a 2nd opinion. If he does, he looks unsure (despite making the exact same arguments I did). If we "talk someone into" a plan that they don't really like, and there's any complication at all, related or unrelated to that plan, that patient is sure to be angry and far more likely to sue, even if we acted well within the standard of care.

You wrote it yourself -

while simultaneously wondering if I can sue my anesthesiologist if I can't.

Do you see why we love patients like you? 🙂

Eventually he (unhappily) agreed to go along with our plan. The case went fine. He had a bit of a sore throat afterwards, and I suspect he blamed our unreasonable unwillingness to not use an LMA for that. But he got a good, safe anesthetic.

Good or bad bedside manner aside (and we bent over backwards to politely and patiently address his concerns), there's just no pleasing some people. Often, the more they think they know about medicine, the more difficult it can be.

 

[Spinach Dip]

Thanks for all the opinions, positive and negative. They have given me a lot to think about.



I do know a little about anesthesia. I think I am safe saying that... But perhaps I truly know less than I think I know. I will keep that in mind.



And the anesthesiologist in question was certainly capable--my only true complaint was nausea post-procedure... And after thinking about it some more, I think the real reason I was unsatisfied was because of his poor bedside manner. Sure, he declined both of my requests (the first of which, I admit, was better off declined), but he failed to explain why. With a little more discussion and explanation between us, I would have never made this post because I would have felt that I was part of the decision making process--not as though he was ignoring me.



Thanks for all your input.