ASRA Pain Medicine Update

Shared Decision-Making in Regional Anesthesia

Jul 24, 2018

Daniel Abraham, MD, and Melanie Donnelly, MD

Consider this all too common scenario: You meet a patient scheduled for a total joint arthroplasty. This is your first time meeting the patient, and he has not spoken with anyone from anesthesia before today. You believe this patient is a perfect candidate for a spinal anesthetic, but the patient is nervous and instead opts for a general anesthetic. He tells you that he is afraid of being paralyzed and/or he knows someone who had a bad experience with a spinal. As an anesthesiologist you wonder if this patients’ reluctance could have been avoided with a preoperative meeting on another day, before the day of surgery and separated from the stress of the preoperative holding area. And if so, how might preoperative anesthesia education affect his decision?

Anesthetic choice on the day of surgery can be influenced by multiple factors: patients’ comorbidities, coagulation status, body mass index, culture of the institution, surgeon preference, and also the comfort level of the anesthesiologist.1–4 But how does patient preference factor into this decision? This is an important question, especially in the era of the perioperative surgical home (PSH) where patient satisfaction with surgical care is highlighted. With this in mind, how can we, as anesthesiologists and perioperative physicians, involve patients more concretely in decision-making for their anesthetic in a timely and meaningful way? The first step along this road is making sure the patient is appropriately informed and educated, and that often means preoperative education regarding anesthetic options.

Patient Education and How It Can Affect Anesthesia

Preoperative patient education is certainly not a new concept. In fact, patient education forms the underpinnings of the informed consent process. Ideally, the informed consent process includes enough information for patients to make educated decisions about their health care. When it comes to anesthesia, throughput pressures in the operating room can influence the consenting process when it occurs immediately preoperatively. This situation is especially evident when there are several anesthetic options to choose from, as is the case when offering blocks to patients for pain control or as an anesthetic. Patients are often not sure about the different anesthetic options available to them when presenting for surgery. It is possible that patients may harbor incorrect assumptions regarding anesthetic management that is derived from a previous occasion, a family member’s experience, or even information researched online.5-6 In a practice with a preoperative clinic, a fully informed dialogue about anesthetic options can be conveyed in a calm environment.7 If a preoperative clinic does not exist, the first interaction that a patient has with an anesthesiologist is often in the preoperative holding area before surgery. This is usually a time when the patient’s anxiety level is high, possibly interfering with his or her ability to process new information, and therefore potentially affecting the patient’s ability to appropriately weigh the anesthetic options presented.8 With this in mind, it is worth considering the utility and merit of introducing information to the patient earlier and in more diverse formats.

Researchers at the University of Pennsylvania examined the impact of incorporating anesthetic information into a preoperative education course for patients scheduled to undergo total knee arthroplasty. They found that patients who had this early education on anesthetic options were more likely to choose a regional anesthetic in the form of neuraxial anesthesia than those who did not have that educational experience.9 This study helps demonstrate that patient education is a crucial step toward fostering an environment for informed decision-making. Brooks et al10 examined similar principles by using an iPad and providing patients with an informational brochure about regional anesthesia options in the preoperative clinic. They discovered that not only did this intervention lead to a 10% increase in their regional anesthesia acceptance rate, but also it reduced delays to operating room. This reduction in delays to the OR reflects a decreased need to exhaust preoperative time discussing the various anesthetic options with patients who are undecided. Groves et al11 also demonstrated a similar principle. They were able to establish that by providing patients with “relevant websites” of anesthesia information and education, the utilization of neuraxial anesthesia increased.

These studies demonstrate that there are a number of ways to educate patients before the day of surgery. These improvements can be further reinforced by creating a service whereby an anesthesiologist is available for questions and concerns that a patient may have by way of telephone calls or e-mails. By introducing this information to patients and educating them before the day of their surgery, we give them the tools necessary to successfully take part and share in the decision regarding their anesthesia.

 

The Concept of Shared Decision-Making

Shared Decision-Making is the model of including patients and their family in the decision-making process (Figure 1). The Agency for Healthcare Research and Quality has published the “SHARE” Approach to this type of process, which includes the following five steps: (1) Seek your patient’s participation, (2) Help your patient explore and compare treatment options, (3) Assess your patient’s values and preferences, (4) Reach a decision with your patient, and (5) Evaluate your patient’s decision.12 The conventional informed consent discussion typically includes a description of the treatment. However, a full explanation of alternatives and an assessment of how this treatment choice fits within the patient’s values and preferences are often lacking. According to Posner et al,13 70% of the informed consent litigation complaints revolve around the risks of treatment. To avoid the pitfalls of using incorrect data, using terms not comprehensible to patients, and avoiding the dissatisfaction that patients express is associated with the paternalistic approach to the consent processes, providers may choose to rely more on the SHARE principles for consent and consider the creation and use of decisions aids.14 This would allow the patient and family, who may have strong beliefs and views, to communicate with the physicians about their medical management and for both to come together to craft a unique and specific plan: a true ideal of patient-centered care.

Shared decision-making has become popular within many specialties across medicine.15–19 These discussions are now starting to populate the field of anesthesia and chronic pain.20 One impact of this process is improved patient satisfaction. Flierler et al14 showed that 94% of patients wanted to be involved in their anesthetic decision-making and that to be involved increased patient satisfaction. Hwang et al21 similarly demonstrated that 88% of patients wanted to be involved in their choice of anesthetic, resulting in patients feeling satisfied and respected.

The field of regional anesthesia is rapidly growing and can help serve as the face of this movement toward patient education and shared decision-making, owing to the frequent existence of multiple analgesic or anesthetic options and the nuanced decision making that accompanies these options.

Bringing It All Back Home: How Patient Involvement Is Part of The PSH

The evolving medical landscape is being guided by the “Triple Aim” set out by the Institute of Healthcare Improvement. These aims include improving the individual experience of care, improving the health of populations, and reducing per capita costs.22 These goals require a collaborative effort for success, and anesthesiologists are counting on the PSH to be that collaborative effort.23 The principles of the PSH lend themselves to the use of shared decision-making tools as part of the perioperative process, as well as anesthetic discussions taking place before the day of surgery. This allows patients to have their values and preferences regarding their anesthetic choices taken into consideration with ample time before the day of surgery. Brooks et al10 found that by moving the patient consent process to the preoperative assessment clinic, their practices were more consistent with the triple aim of health care improvement.

As our care evolves to meet the triple aim and to accomplish patient-centered care, we need to also upgrade the tools we use to accomplish this care. Our processes for preoperative evaluation need to grow to allow for patient participation in decisions about their anesthetic. This may result in the creation and use of shared decision-making tools, as well as improved preoperative patient education in using multiple modalities. By leading the charge to educate our patients preoperatively and involve them in their care, we are leading the perioperative field into the future. And bringing them into our home: the PSH.

References

1. Fleischut PM, Eskreis-Winkler JM, Gaber-Baylis LK, et al. Variability in anesthetic care for total knee arthroplasty: an analysis from the anesthesia quality institute. Am J Med Qual 2015;30(2):172–179.

2. O’Sullivan CT, Dexter F. Assigning surgical cases with regional anesthetic blocks to anesthetists and operating rooms based on operating room efficiency. AANA J 2006;74(3):213–218.

3. McCartney CJ, Choi S. Does anaesthetic technique really matter for total knee arthroplasty? Br J Anaesth 2013;111(3):331–333.

4. Salam AA, Afshan G. Patient refusal for regional anesthesia in elderly orthopedic population: a cross-sectional survey at a tertiary care hospital. J Anaesthesiol Clin Pharmacol 2016;32(1):94–98.

5. De Oliveira GS, Jung M, Mccaffery KJ, McCarthy RJ, Wolf MS. Readability evaluation of internet-based patient education materials related to the anesthesiology field. J Clin Anesth 2015;27(5):401–405.

6. Roughead T, Sewell D, Ryerson CJ, Fisher JH, Flexman AM. Internet-based resources frequently provide inaccurate and out-of-date recommendations on preoperative fasting: a systematic review. Anesth Analg 2016;123(6):1463– 1468.

7. Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology 1996;85(1):196–206.

8. Mitchell M. Patient anxiety and modern elective surgery: a literature review. J Clin Nurs 2003;12(6):806–815.

9. Abraham D, Elkassabany N. Does preoperative patient education affect anesthetic choice for total knee arthroplasty? Poster session presented at: 41st Annual Regional Anesthesiology and Acute Pain Medicine Meeting; March 21– April 2, 2016; New Orleans, Louisiana.

10. Brooks BS, Barman J, Ponce BA, Sides A, Vetter TR. An electronic surgical order, undertaking patient education, and obtaining informed consent for regional analgesia before the day of surgery reduce block-related delays. Local Reg Anesth 2016;9:59–64.

11. Groves ND, Humphreys HW, Williams AJ, Jones A. Effect of informational internet web pages on patients’ decision-making: randomised controlled trial regarding choice of spinal or general anaesthesia for orthopaedic surgery. Anaesthesia 2010;65(3):277–282.

12. The SHARE Approach. Last reviewed September 2016. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/ professionals/education/curriculum-tools/shareddecisionmaking/index.html. Accessed April 12, 2017.

13. Posner KL, Severson J, Domino KB. The role of informed consent in patient complaints: reducing hidden health system costs and improving patient engagement through shared decision making. J Healthc Risk Manag 2015;35(2):38–45.

14. Flierler WJ, Nubling M, Kasper J, Heidegger T. Implementation of shared decision making in anaesthesia and its influence on patient satisfaction. Anaesthesia 2013;68(7):713–722.

15. Kumar R, Korthuis PT, Saha S, et al. Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors. J Gen Intern Med 2010;25(6):517–523.

16. Mazur DJ, Hickam DH, Mazur MD, Mazur MD. The role of doctor’s opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures? Health Expect 2005;8(2):97–102.

17. Charles CA, Whelan T, Gafni A, Willan A, Farrell S. Shared treatment decision making: what does it mean to physicians? J Clin Oncol 2003;21(5):932–936.

18. Sheridan SL, Harris RP, Woolf SH, Shared Decision-Making Workgroup of the U.S. Preventive Services Task Force. Shared decision making about screening and chemoprevention: a suggested approach from the U.S. Preventive Services Task Force. Am J Prev Med 2004;26(1):56–66.

19. Adam JA, Khaw FM, Thomson RG, Gregg PJ, Llewellyn-Thomas HA. Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons. Ann R Coll Surg Engl 2008;90(3):198–207.

20. Spies CD, Schulz CM, Weiss-Gerlach E, et al. Preferences for shared decision making in chronic pain patients compared with patients during a premedication visit. Acta Anaesthesiol Scand 2006;50(8):1019–1026.

21. Hwang SM, Lee JJ, Jang JS, Gim GH, Kim MC, Lim SY. Patient preference and satisfaction with their involvement in the selection of an anesthetic method for surgery. J Korean Med Sci 2014;29(2):287–291.

22. The IHI Triple Aim Initiative. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. Available at: www.IHI.org. Accessed April 12, 2017.

23. Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Pittet JF. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg 2014;118(5):1131–1136.

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