P12

A SWIFT SURVEY: RISK DISCUSSIONS IN PAEDIATRIC ANAESTHESIA

C. E. D. Leahy¹, H. Lewis², J. McArdle³

¹Broomfield Hospital, UK

²Evelina London Childrens' Hospital, UK

³Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK

Introduction/Aims:

This survey explored current anaesthetic practice regarding routine risk discussion in the paediatric population in the United Kingdom and Ireland, in patients undergoing general anaesthesia for elective procedures.  These discussions pose a specific challenge in paediatric anaesthesia; balancing clinical considerations and the ethical and legal principles specific to paediatric practice, while also developing rapport with both the patient and carer.

Methods:

The Swift survey was disseminated electronically at the APAGBI 2023 Annual Scientific Meeting. The response rate from UK delegates was 53% (197/372); predominantly consultant anaesthetists (n=169), with the majority being paediatric anaesthetists (n=113). Questions explored their routine practice in the context of elective paediatric ASA 1 day case patients.

Results:

Timing of risk discussions varied; most anaesthetists (85%) routinely only have risk discussions at the pre-operative visit. When risk discussion takes place at pre-assessment clinic, this is most frequently anaesthetist-led. A minority of anaesthetists (4%) do not routinely discuss risk.

Most anaesthetists (94%) verbally present information, with 54% presenting some form of written information. This includes leaflets produced by professional bodies (n=62) and locally produced written information (n=41). Online resources are referred to by just 6.5% of respondents. 40% of anaesthetists routinely check whether prior information regarding risks has been received, with 22% also exploring understanding.

Regarding documentation practices; 47% document the discussion, while 46% list the individual risks. Table 1 demonstrates the differing practices regarding which specific risk factors are discussed. 2% use separate anaesthetic consent forms, while 3% do not document risk discussions.

While 38% routinely hold risk discussions with the child present, a small minority (5%) of anaesthetists do not routinely have the child present. The majority of anaesthetists (59%) make a case-by-case decision regarding child presence.

Discussion and Conclusion:

There is considerable variability amongst anaesthetists regarding risk discussion documentation, content, location, timing and paediatric patient presence. This highlights a lack of consensus amongst clinicians, regarding an important topic within paediatric anaesthesia, despite existing national guidance from the RCoA and other bodies. Discussion of risk of death remains a controversial topic, with the RCOA/APAGBI clarification statement highlighting the anxiety felt amongst many anaesthetists. This is reflected in our results, where only 14% of respondents routinely discuss death.

Timing of risk discussion remains most commonly on the day of surgery, contrary to the current best practice guidance and NAP 7 recommendations to provide information on risk as early as possible. Whilst many anaesthetists are using written information provided by professional bodies to guide risk discussion, its earlier provision could further enhance shared-decision making.

There is also a question of whether current consent practices remain valid in paediatric anaesthesia, where increasingly complex patient cohorts mean that general anaesthesia can potentially incur greater risk than the surgical procedure.

References:

1. Yentis SM, Hartle AJ, Barker IR, Barker P, Bogod DG, Clutton-Brock TH, Ruck Keene A, Leifer S, Naughton A, Plunkett E. AAGBI: Consent for anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2017 Jan;72(1):93-105. doi: 10.1111/anae.13762. PMID: 27988961; PMCID: PMC6680217.General Medical Council. Consent: patients and doctors making decisions together. London: GMC, 2008. http://www.gmc-uk. org/guidance/ethical_guidance/consent_guidance_contents.asp (accessed 20/10/2016)
2. Montgomery v Lanarkshire Health Board [2015] UKSC 11
3. Clarification statement on consent and risk of death in children. The Royal College of Anaesthetists. (n.d.). Retrieved March 31, 2023, from https://www.rcoa.ac.uk/news/clarification-statement-consent-risk-death-children
4. Soar, J. and Cook, T. (eds.) NAP 7 At the Heart of the Matter Report and findings of the 7th National Audit Project of the Royal College of Anaesthetists (2023); Perioperative Cardiac Arrest, Royal College of Anaesthetists.