Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty

Abstract

Background Calls to better involve patients in decisions about anesthesia—e.g., through shared decision-making—are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia. Methods This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia. Results The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences. Conclusions Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists’ attention away from important humanistic aspects of communication such as decreasing patients’ anxiety. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Anesthesiologists and Community Engagement: A Scoping Review of the Literature

“…25 A study characterizing how preoperative consultations for primary knee arthroplasty arrived at decisions about anesthesia found that most physicians presented the available options, recommended their preference, provided an opportunity for patients to voice their concerns, and ultimately, persuaded hesitant patient to accept their choice. 26…”

“…26,35 Patients pointed to feeling unqualified or uninterested as reasons for having a more minor role in their medical care. 26 Instead, patients viewed consultations and decision aids as tools to prepare their expectations for anesthesia and ease their fears, but do not feel that the information influences their treatment decisions. 26,35 In our scoping review, a thorough search of the literature only resulted in 23 articles that exemplified community engagement among anesthesiologists.…”

“…46,47 In our review, 2 papers on SDM revealed that some patients do not desire greater involvement in their anesthesia care. 26,35 Patients pointed to feeling unqualified or uninterested as reasons for having a more minor role in their medical care. 26 Instead, patients viewed consultations and decision aids as tools to prepare their expectations for anesthesia and ease their fears, but do not feel that the information influences their treatment decisions.…”

“…25 A study characterizing how preoperative consultations for primary knee arthroplasty arrived at decisions about anesthesia found that most physicians presented the available options, recommended their preference, provided an opportunity for patients to voice their concerns, and ultimately, persuaded hesitant patient to accept their choice. 26 Two of the studies in this category sought public feedback on patient involvement in research. Inam et al 28 conducted community consultations to determine the willingness of individuals to have themselves or family members enrolled in a trial comparing 2 types of anesthetic care in emergency endovascular thrombectomy under an Exception from Informed Consent (EFIC) protocol.…”

Comparative Effectiveness Research on Spinal versus General Anesthesia for Surgery in Older Adults

“…79 Administration of spinal anesthesia without intraoperative sedation is uncommon in Western countries, 21 likely due to the desire of many patients to receive some degree of sedation or anxiolysis during surgery. 80 Notably, the Li et al 25 trial incorporated a protocol for neuraxial anesthesia in which no sedation was permitted to be administered during surgery. 47 No difference was found between this regimen and general anesthesia in postoperative delirium incidence or severity or other outcomes.…”