Radiology resident consenting for general anesthesia

[Dumpstarrian]

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- Thanks for the responses.

 

[B-Bone]

This is not good. First off, I would imagine that radiologists are not credentialed to perform general anesthesia at your institution, and if they are, I (as an anesthesiologist) would not work at this institution. Regarding liability, you are responsible for all sedation that you direct. As I understand it, you should only be directing nurses, not CRNAs. CRNAs would either practice under their own license (opt-out state, an unlikely scenario at an academic institution) or under the direction of an anesthesiologist. I guess there could be "proceduralist direction" of a CRNA in a non opt-out state, but again this would be unusual at an academic center.

If you "moderately sedate" someone and call me in halfway through to either bail out some emergency or provide GA to get the procedure done, I am going to be pretty pissed off. In the case of an emergency, I would help manage the emergency (airway, etc), and promptly do my damnedest to get your sedation priviliges revoked. In the case of "we need more sedation to get this done" (usually after like 10 mg versed and 500 mcg fentanyl, with probably some benadryl/atarax/demerol/whatever thrown in for good measure), I would tell you to F off and do it another day when I can consent the patient for anesthesia. Your "consent" for my procedure doesn't mean ^%&* to me.

 

[Dumpstarrian]

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[jwk]

So I assume at this same institution that the anesthesiologist does the radiology consent for all arteriograms?

A radiologist can't give INFORMED consent for general anesthesia.

 

[Psai]

Wtf?

 

[IlDestriero]

Your system doesn't make sense, you're not capable of giving informed consent for anesthesia. You could for sedation that you direct, and take responsibility for.
Our surgical consent has a generic anesthesia consent paragraph on it, but we document our own consent at the time of the procedure or by phone with a witness.

 

[urge]

I don't see any issues with it. Paper consents are useless. I don't imagine you would have more or less liability by getting the consent signed. It is interesting how that happened in your institution.

There are only two things that matter: 1 the anesthesia team getting good rapport with the patient/family, 2 not having a bad outcome.

The consent doesn't really play much role in anesthesia liability.

 

[pgg]

The consent doesn't really play much role in anesthesia liability.

Probably not.

But, given a settlement or jury award (especially a jury award), consent issues absolutely can play a role in the size of the check.

Consent is always, always going to be attacked by the plaintiff. You'd be insane to give them an easy target with some half-ass UNinformed consent from an unqualified 3rd party.

Unless you think you'll never be sued for anything, ever.

 

[2ndyear]

Through some interesting hospital dynamics, Radiology consents for all general anesthesia and moderate sedation for MRI (peds and adult), and places sedation medication orders for moderate sedation. This usually ends up being 6-8 consents a day. I would assume this is atypical? Just a few questions as I'm not overly familiar with informed consent of general anesthesia:

If an unwanted outcome of anesthesia occurs, is the consenter, the anesthesiologist, or are both held lawfully accountable?

Information I've read on general anesthesia consent comments on including or excluding <1% events, are there standardized guidelines in place?

I have been asked to follow the order sets for medications in moderate sedation. I would assume I am legally responsible for the CRNA / ICU Nurse's actions based on my orders?

Perhaps I am just overthinking this a bit, any input is appreciated.

I'll go out on a limb here and guess that you're seeing some paperwork anomoly at your hospital. As a radiologist it would be in your realm to obtain consent and order moderate sedation for the appropriate patients and procedures. For those patients having an anesthesiologist present, you might still have a generic consent form stating general or monitored anesthesia care, or moderate sedation, but in those cases you should leave the consent and any pre/post anesthesia orders blank.

 

[urge]

Probably not.

But, given a settlement or jury award (especially a jury award), consent issues absolutely can play a role in the size of the check.

Consent is always, always going to be attacked by the plaintiff. You'd be insane to give them an easy target with some half-ass UNinformed consent from an unqualified 3rd party.

Unless you think you'll never be sued for anything, ever.

Have you ever heard of any anesthesiologist being liable for consent issues (other than battery, ie patient refusing regional and you doing a spinal after some sedation)? Never.

 

[deltamed]

Have you ever heard of any anesthesiologist being liable for consent issues (other than battery, ie patient refusing regional and you doing a spinal after some sedation)? Never.

From what I understand from our lawyer it doesn't matter who lays out the patient consent as long as the actual person doing the procedure (presumably the anesthesiologist in this case) asks/ answers any questions the patient has about the consent before the procedure - it's then considered informed.

For example, an MA could read a long scripted consent about all the risks, benefits and alternatives and the patient could look these over. If the surgeon or other provider then comes in later and answers any questions reasonably and documents that, its informed consent.

 

[pgg]

Have you ever heard of any anesthesiologist being liable for consent issues (other than battery, ie patient refusing regional and you doing a spinal after some sedation)? Never.

Is it really so hard to believe that one factor in a patient's decision to sue is the quality of the preop discussion and consent?

Is it really so hard to believe that a jury's award would be inflated if the consent was superficial or poorly documented and the lawyer exploited the sob story of "I never would've agreed to that procedure if I'd only know the risks"?

You can pretend that the quality of consent doesn't influence these things if you want. I'll take my liability carrier's opinion on the matter, over yours.

 

[urge]

Is it really so hard to believe that a jury's award would be inflated if the consent was superficial or poorly documented and the lawyer exploited the sob story of "I never would've agreed to that procedure if I'd only know the risks"?

You are saying that a jury will award, let's say 500k, for maiming somebody, versus 700k for maiming them without you letting them know there was a chance?

Do you think you get a 25% discount on the settlement for disclosure?

Do you believe that?

 

[WholeLottaGame7]

Through some interesting hospital dynamics, Radiology consents for all general anesthesia and moderate sedation for MRI (peds and adult), and places sedation medication orders for moderate sedation. This usually ends up being 6-8 consents a day. I would assume this is atypical? Just a few questions as I'm not overly familiar with informed consent of general anesthesia:

If an unwanted outcome of anesthesia occurs, is the consenter, the anesthesiologist, or are both held lawfully accountable?

Information I've read on general anesthesia consent comments on including or excluding <1% events, are there standardized guidelines in place?

I have been asked to follow the order sets for medications in moderate sedation. I would assume I am legally responsible for the CRNA / ICU Nurse's actions based on my orders?

Perhaps I am just overthinking this a bit, any input is appreciated.

I wouldn't even bother getting consent for general anesthesia. I mean, you can, but no one cares and the anesthesiologist is going to get their own consent, anyway.

You do have to get consent for moderate sedation, and yes, you are on the hook for the RN's actions. (It won't be a CRNA and probably not an ICU RN, either). So make sure you are comfortable with the meds you are ordering and the patients you are ordering them on.

The place I work at now has a peds sedation service in no small part to radiology trying to off a couple kids with sedation. And the place I trained had the radiology residents triaging sedation vs anesthesia based on our ASA PS score. And they were encouraged to call everyone an ASA1 or 2 because anything higher meant anesthesia had to be involved (at least consulted). So yes, I have seen VIR H&Ps on patients with pulmonary hypertension or aortic stenosis being called an ASA2.

Do your best to know who's sick and who's not, and know when you're in over your head and when to ask for help. When you are working with anesthesiologists, ask them their opinions on who they should be consulted on, and what scares them, etc. Residency is the time to learn these things.

 

[pgg]

You are saying that a jury will award, let's say 500k, for maiming somebody, versus 700k for maiming them without you letting them know there was a chance?

Yes!

And my insurer agrees. Or maybe they spend all that money on risk-reduction education that focuses on consent because they're sentimental fools, or just bad at math?

I've attended lectures from a handful of malpractice attorneys over the years, and they too dwell on the importance of thorough and well-documented consent, because it affects the probability of being sued in the first place, and the cost of a settlement or loss.

 

[Planktonmd]

The consent is almost always attacked by lawyers as mentioned above, but the consent never helps decrease your liability or exposure no matter how perfect it is.
In other words if your consent is crappy they might be able to get more money from you but if you have the best consent in the world you can still be sued and accused of negligence.

 

[pgg]

The consent is almost always attacked by lawyers as mentioned above, but the consent never helps decrease your liability or exposure no matter how perfect it is.
In other words if your consent is crappy they might be able to get more money from you but if you have the best consent in the world you can still be sued and accused of negligence.

Yes, exactly.

But even beyond that, good consent also reduces the risk of getting sued for a bad outcome in the first place. It's an important part of managing expectations before surgery and building rapport with patients, and those two things have a huge impact on whether a suit gets filed.

All of us have seen faultless bad outcomes result in frivolous lawsuits, and all of us have seen people commit egregious malpractice yet not get sued. It just blows my mind that anyone would argue that consent doesn't matter when it comes to shifting those odds.

No one's arguing that consent is some kind of magical shield. Even if the law didn't require it, one would be stupid not to do it, do it well, and document it well.

 

[urge]

1 The level of evidence for all claims in this thread is hearsay. I believe that you are focusing on what your lawyer tells you based on his overall practice, which is probably surgical suits. The patients need to understand there is 3% chance of impotence, and 10% chance of fustilas.... It's not the same for anesthesia. There should be close to zero % chance of anything from the anesthetic itself. If you are not in this ballpark you are not doing it right.

2 The ASA Closed Claims Database never seems to include consent as relevant.

 

[Mman]

A radiology resident can get someone to sign a piece of paper to consent to something, but legally it wouldn't be valid in terms of general anesthesia since they aren't qualified to discuss risks, benefits, and alternatives. Moderate sedation consent would be valid if their attending radiologist was credentialed to provide moderate sedation.

An anesthesiologist can go back and get their own consent separate from that piece of paper and the consent doesn't have to be written, it can be verbal. Our malpractice carrier is very clear that written consent is not needed. What is needed is the actual discussion of R/B/A and answering of questions to the patient's and/or family's satisfaction. Once they are verbally on board, consent has been granted and the anesthesiologist (or their designee CRNA, resident, AA) should document that consent was obtained (although it need not be a separate consent form or patient signature).

Our process is that for cases with EMR anesthesia chart we click a box that documents consent was obtained. For out of OR cases with paper charting (such as MRI) we simply check a box on the record that indicates consent was obtained.

 

[Mman]

1 The level of evidence for all claims in this thread is hearsay. I believe that you are focusing on what your lawyer tells you based on his overall practice, which is probably surgical suits. The patients need to understand there is 3% chance of impotence, and 10% chance of fustilas.... It's not the same for anesthesia. There should be close to zero % chance of anything from the anesthetic itself. If you are not in this ballpark you are not doing it right.

Chances of a dental injury are not that close to zero. It's not high, but they happen particularly when you have poor areas with lack of dental care.

 

[urge]

Chances of a dental injury are not that close to zero. It's not high, but they happen particularly when you have poor areas with lack of dental care.

The radiologist is not doing the anesthesia pre op evaluation. That discussion and any other risks and expectations can be done at that time. That's were the developing good rapport with the patient comes.

It seems to me that radiology getting the consent signed is a clerical issue in his hospital, not a liability concern.

 

[periopdoc]

Written anesthesia consents are a joke and aren't worth the paper they are written on. If you have a bad outcome, neither the decision to sue nor the amount of the settlement or judgement are going to be influenced by the quality of your consent.

Insurance companies lump us in the same database as surgeons and other proceduralists when they do their studies on consent protection in lawsuits. For surgeons, a good consent can be the difference between a multi-million dollar settlement and a case that doesn't even get filed. Not so much for anesthesiologists.

I've asked my insurance companies to split it out and they can't.

The only possible case I can see for written consent is maybe for neuraxial or peripheral nerve blocks which are not intrinsically necessary to successful completion of the operation. Otherwise, the risks of anesthesia are inherent to the risks of surgery.

Our hospital has a consent form for anesthesia. I let the nurses sign it with the patient. I inform every patient the five major risks (MI, Stroke, seizure, coma, death) and ask if they have questions after I go through the plan and options.

-pod