III. GENERAL PRINCIPLES OF ANESTHESIA
LEGAL ISSUES
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QUESTIONS
QUESTIONS
QUESTIONS
QUESTIONS
QUESTIONS
QUESTIONS
Advanced Healthcare Directives
- A patient’s designation of “Do Not Resuscitate” is often lifted during the perioperative period because the cause of the untimely death is viewed as a result of anesthesia and the outcome of resuscitation in this setting is often better managed than elsewhere. There is no simple explanation to what can be done when a patient has DNR orders on the chart and intervention is required perioperatively. The provider and patient/family should address their exact wishes and what those entail
REFERENCE: Barash Clinical Anesthesia 9th edition, pages 84, 1588-1589.
- Breach of duty is when the provider fails to get a surgical consent prior to surgery when doing a preoperative evaluation of a patient.
- Informed consent of anesthesia:
- Proposed technique
- Potential substantial risks
- Possible complications
- Expected benefits
- Alternative techniques and risks
- Obtaining informed consent for obstetrics has unique issues.
- The main issue is that the patient is in pain and may have been given pain medication. The latest studies show that recall of this interaction is like other patients.
- Competence to make a legal and/or health decision in the US is 18 years of age. Exceptions: emancipated minors
- Pregnancy does not ALWAYS constitute emancipation and it is best to include the legal guardians. Local/state/federal guidelines
- Informing the patient of risks should include those that are common/reasonable risk.
- Signature, date, and time
REFERENCE: Nagelhout 7th edition Nurse Anesthesia, page 1186.
The most common cause of malpractice against anesthesia providers is tooth damage.
The most common lawsuit incident is inadequate ventilation/inadequate oxygenation
- Documentation of a critical incident should include:
- What happened
- Which drugs were used
- Which procedures were used
- Time sequence
- Who was present
- In the event of an error that caused an injury, documentation and communication should be kept strictly objective.
REFERENCE: Barash Clinical Anesthesia 9th edition, pages 83-84
Res ipsa loquitur – a doctrine that allows circumstantial evidence to prove negligence.
Captain of the ship– once the surgeon enters the OR and assumes control, the surgeon is responsible for everything, including negligence.
Borrowed servant– a doctor may be held liable for the negligence of a hospital employee who is subject to the doctor’s control.
- The doctrine of res ipsa loquitur depends on three things:
- (1) the injury must occur under circumstances such that in the ordinary course of events the injury would not have occurred if someone had not been negligent,
- (2) the injury must be caused by something within the exclusive control of the defendant
- (3) the injury must not have been due to any voluntary action or contribution on the part of the plaintiff.
- The Statute of Limitations defines the maximum amount of time in which parties involved in a dispute must initiate legal proceedings. The Statue of Limitations may vary amongst states and between circumstances and/or nature of the case.
- The Statute of Limitations places a time constraint on the plaintiff to file action.
- The 2 exceptions to the Statute of Limitations for filing a lawsuit claiming negligence—
- The plaintiff is under a disability which keeps the plaintiff from bringing the suit (e.g. children, persons under legal guardianship).
- The plaintiff may not have been able to discover that there was an injury caused by negligence before the Statute of Limitations expired.
Summons and complaint is a written document delivered to a party in person or by certified mail that notifies them that a legal complaint has been filed against them.
- The four elements that must be proven in a malpractice case are:
- Duty– the plaintiff must prove that the defendant had a duty to the plaintiff
- Breach of duty– the plaintiff must prove that the defendant failed to fulfill the duty owed to the defendant.
- Causation– a reasonably close relationship must be proven to exist between the breach of duty by the defendant and the injury that resulted.
- Damages– the plaintiff must also prove that some injury occurred due to the breach in duty.
- Negligence involves the failure to provide a certain level of care that is accustomed to that position. In anesthesia, dental trauma is the number 1 claim.
- Informed consent is the agreement to do something or to allow something to happen only after all the relevant facts are known. To help show that the patient/family have been informed, it is helpful to list the family members that are present, as well as the anesthetic risks, death, and anesthetic options (especially if the patient chooses one).
- Implied consent is consent when surrounding circumstances exist which would lead a reasonable person to believe that this consent had been given, although no direct, express or explicit words of agreement have been spoken.
- Emancipated minor -freeing a minor child from the control of parents and allowing the minor to live on his/her own or under the control of others. It usually applies to adolescents who leave the parents’ household by agreement or demand.
- Examples:
- Married
- Minors who become parents
- Military
- Economically independent
- Examples:
- Amicus curiae– “friend of the court”; a person or group who is not involved in the case but is allowed to give expert testimony.
The key difference between expert witnesses and factual witnesses is that expert witnesses can give their opinion on a matter and can therefore testify speculation rather than fact.
Torts
A medical tort is a civil wrong that occurs when a medical professional’s actions or omissions cause injury to a patient. Medical torts are also known as medical malpractice.
- The four elements that must be proven in a malpractice case are:
- Duty– the plaintiff must prove that the defendant had a duty to the plaintiff; reasonable and prudent
- Breach of duty– the plaintiff must prove that the defendant failed to fulfill the duty owed to the defendant.
- Causation– a reasonably close relationship must be proven to exist between the breach of duty by the defendant and the injury that resulted; proximate cause; res ipsa loquitur may apply.
- Damages– the plaintiff must also prove that some injury occurred due to the breach in duty.
- Types:
- General
- Special
- Punitive
- Types:
The leading injuries in malpractice claims for adverse events from 2005-2014 were death, nerve damage, permanent brain damage, and airway injury.
- 5 things to do if sued:
- Do not discuss with anyone
- Never alter records
- Gather all pertinent records
- Make notes about the event in question
- Cooperate fully with attorney
REFERENCE: Barash Clinical Anesthesia 9th edition, pages 87-89
Scope of Practice
- 4 areas of practice roles:
- Clinical practice
- Administrative
- Education
- Research.
The American Association of Nurse Anesthesia (AANA) describes the professional roles, functions, and responsibilities as defined by the profession, while the individual CRNA’s scope of practice is based on his/her personal education, licensure, expertise, and skills.
Preoperative | Intraoperative | Postoperative | Pain mgmt. | Other services |
Provide patient education and counseling | Implement a patient-specific plan, which may involve general, regional, and local anesthesia, sedation, and multimodal pain mgmt. | Facilitate emergence and recovery from anesthesia | Provide comprehensive patient-centered pain mgmt. to optimize recovery
| Prescribe meds |
Perform a comprehensive H/P, assessment, and evaluation | Select, order, prescribe, and administer anesthetics, including controlled substances, adjuvants, fluids, accessory drugs, and blood products | Select, order, prescribe, and administer postanesthetic meds | Provide acute pain services, including multimodal pain mgmt. and opioid-sparing techniques | Provide emergency, critical care, and resuscitation services |
Conduct a preanesthesia assessment and evaluation | Select and insert invasive and noninvasive monitoring modalities | Conduct postanesthesia evaluation | Provide anesthesia and analgesia using regional techniques for OB and other acute pain mgmt. | Perform advanced airway mgmt. |
Develop a comprehensive patient-specific plan for anesthesia, analgesia, multimodal pain mgmt., and recovery |
| Educate the patient related to recovery, regional anesthesia, and continued multimodal pain mgmt. | Provide advanced pain mgmt., including acute, chronic, and interventional pain mgmt. | Perform point-of-care testing
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Obtain informed consent for anesthesia and pain mgmt |
| Discharge from PACU or facility |
| Order, evaluate, and interpret diagnostic labs and radiologic studies |
Select, order, prescribe, and administer preanesthetic meds |
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| Use and supervise the use of ultrasound, fluoroscopy, and other diagnostic tools |
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| Provide sedation and pain mgmt. for palliative care |
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| Order consults, treatments, or services |
STANDARD 9 | Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the procedure and anesthetic technique. When a physiologic monitoring device is used, variable pitch and threshold alarms are turned on and audible. Document blood pressure, heart rate, and respiration at least every 5 minutes for all anesthetics. |
1 Patient’s Rights | Respect the patient’s autonomy, dignity, and privacy, and support the patient’s needs and safety. |
2 Preanesthesia Patient Assessment and Evaluation | Perform and document or verify documentation of a preanesthesia evaluation of the patient’s general health, allergies, medication history, preexisting conditions, anesthesia history, and any relevant diagnostic tests. Perform and document or verify documentation of an anesthesia-focused physical assessment to form the anesthesia plan of care. |
3 Plan for Anesthesia Care | After the patient has had the opportunity to consider anesthesia care options and address his/her concerns, formulate a patient-specific plan for anesthesia care. When indicated, the anesthesia care plan can be formulated with members of the healthcare team and the patient’s legal representative. |
4 Informed Consent for Anesthesia Care and Related Services | Obtain and document or verify documentation that the patient or legal representative has given informed consent for planned anesthesia care or related services in accordance with law, accreditation standards, and institutional policy. |
5 Documentation | Communicate anesthesia care data and activities through legible, timely, accurate, and complete documentation in the patient’s healthcare record. |
6 Equipment | Adhere to manufacturer’s operating instructions and other safety precautions to complete a daily anesthesia equipment check. Verify function of anesthesia equipment prior to each anesthetic. Operate equipment to minimize the risk of fire, explosion, electrical shock, and equipment malfunction. |
7 Anesthesia Plan Implementation and Management | Implement and, if needed, modify the anesthesia plan of care by continuously assessing the patient’s response to the anesthetic and surgical or procedural intervention. The CRNA provides anesthesia care until the responsibility has been accepted by another anesthesia professional. |
8 Patient Positioning | Collaborate with the surgical or procedure team to position, assess, and monitor proper body alignment. Use protective measures to maintain perfusion and protect pressure points and nerve plexus. |
9 Monitoring, Alarms | Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the procedure and anesthetic technique. When a physiologic monitoring device is used, variable pitch and threshold alarms are turned on and audible. Document blood pressure, heart rate, and respiration at least every 5 minutes for all anesthetics. |
10 Infection Control and Prevention | Verify and adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to patients, the CRNA, and other healthcare providers. |
11 Transfer of Care | Evaluate the patient’s status and determine when it is appropriate to transfer the responsibility of care to another qualified healthcare provider. Communicate the patient’s condition and essential information for continuity of care. |
12 Quality Improvement Process | Participate in the ongoing review and evaluation of anesthesia care to assess quality and appropriateness to improve outcomes. |
13 Wellness | Is physically and mentally able to perform duties of the role. |
14 A Culture of Safety | Foster a collaborative and cooperative patient care environment through interdisciplinary engagement, open communication, a culture of safety, and supportive leadership. |
Scope and Standards for Nurse Anesthesia Practice, 2019. American Association of Nurse Anesthesiology.
- Council on Accreditation of Nurse Anesthesia Educational Programs (COA) accredits nurse anesthesia programs as recognized by the US Department of Education. These educational programs are required to adhere to the Standards and Accreditation Policies and Procedures set forth by the COA.
PARAMETER | MODIFIER |
OXYGENATION | Continuously monitor oxygenation by clinical observation and pulse oximetry. The surgical or procedural team communicates and collaborates to mitigate the risk of fire. |
VENTILATION | Continuously monitor ventilation by clinical observation and confirmation of continuous expired carbon dioxide during moderate sedation, deep sedation, or general anesthesia. Verify intubation of the trachea or placement of other artificial airway device by auscultation chest excursion, and confirmation of expired carbon dioxide. Use ventilatory monitors as indicated. |
CARDIOVASCULAR | Monitor and evaluate circulation to maintain patient’s hemodynamic status. Continuously monitor heart rate and cardiovascular status. Use invasive monitoring as indicated. |
THERMOREGULATION | When clinically significant changes in body temperature are intended, anticipated, or suspected, monitor body temperature. Use active measures to facilitate normothermia. When malignant hyperthermia (MH) triggering agent are used, monitor temperature and recognize signs and symptoms to immediately initiate appropriate treatment and management of MH. |
NEUROMUSCULAR | When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery. |
Scope and Standards for Nurse Anesthesia Practice, 2019. American Association of Nurse Anesthetists.
AANA Standards for Nurse Anesthesia Practice requires documentation of pertinent anesthesia-related information in the patient’s medical record. Vital signs are required for documentation.
Standard II- obtain an informed consent.
- Assault– unlawful threat of actions by a person intended to inflict, by force, corporal injury.
- Battery– unlawful constraint or physical violence inflicted on a person without his consent. Example- administration of an anesthetic to an unwilling patient. If during the general anesthetic for a case you realize there was no anesthesia consent obtained, then you can be charged with battery.
- Establishing standards of care:
- 1) Expert witness says it is
- 2) Textbook
- 3) Professional journals
- 4) Facility policies and procedures
- 5) Standards of professional organizations
- 6) State or federal statutes
- 7) Prior case law.