ETHICAL CONSIDERATIONS

III. GENERAL PRINCIPLES OF ANESTHESIA

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AUTONOMY, BENEFICENCE, NONMALFEASANCE

RESEARCH ETHICS

QUESTIONS

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Autonomy, Beneficence, Nonmalfeasance

Negligence

- Patient has a latex allergy and the CRNA fails to follow latex allergy protocol.

The basis of the law of negligence is fault.

- The first element in negligence is duty.
  - The plaintiff must prove that a duty to exercise reasonable care existed between the plaintiff and the defendant, in this case the anesthetist. Anytime an anesthetist undertakes patient care, he or she must exercise reasonable care.
- The second element involves breach of the anesthetist’s duty to exercise reasonable care with the patient.
  - This is the negligent act, error, or omission part of the formula. The anesthetist must act within the appropriate standard of care in providing anesthesia services to the patient.

In all instances, the breach must have caused physical injury to the plaintiff, or the plaintiff’s decedent, as the case may be.

- This represents the third element of negligence, causation.
  - The anesthetist may have negligently administered the anesthetic, but the patient had no injury.

Negligence is a type of tort defined as a failure to act with the prudence that a reasonable person would exercise under the same circumstances.

Malpractice refers to any professional misconduct, but usually refers to negligence on the part of a professional such as a CRNA, doctor, or lawyer.

Other than damage to teeth or dentures, the top 3 anesthesia-related injuries that lead to malpractice (negligence) claims are death, nerve damage, and brain damage.

Libel
- Writing on patient’s chart with HIV that he/she has AIDS.

Slander- defamation of another person by verbal means.

Breach of duty
- May be an error in the performance of an act during the administration of anesthesia care.
- Such an error is an error of commission or omission.

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Research Ethics

Research is a process based on 4 concepts:
- It has many forms, must be valid (both internal and external), must be reliable, and must be systematic.
- Internal validity- examines the extent to which the research study establishes a cause-and-effect relationship between the independent and dependent variables.
- External validity- the extent to which the findings can be generalized to other situations.
- Reliable- how consistently a method measures something.
- Systematic- elements include:
  - Problem ID; gathering of information and critical review; data collection; analysis of the data; and conclusion development.
- 8 stages:
  - ID the problem
  - Review the relevant knowledge and literature
  - Form the hypothesis or research question
  - Develop the approach for hypothesis testing
  - Execute the research plan
  - Analyze and interpret the data
  - Disseminate the findings
  - Evaluate the research
- Research methods:
  - Quantitative vs qualitative
  - Blinding- an effort to control obvious and hidden bias.
    - Single blind- the patients are unaware
    - Double blind- both the researchers and patients are unaware
  - Operationalization- defining a given variable, condition, or process so that it may be replicated in the future. This process clearly designates performable and observable acts or procedures so that it can be replicated.
  - Randomized controlled trials (RCT) are the gold standard of clinical experimental research. These RCTs are relied heavily on for evidence-based practice.
  - Levels of measurement

CATEGORY	CHARACTERISTICS	EXAMPLES
Nominal	Identifies	Gender Diagnosis
Ordinal	Identifies Orders	ASA class Order of finish
Interval	Identifies Orders Equal intervals	Intelligence Calendar years Fahrenheit or Celsius
Ratio	Identifies Orders Equals intervals Has a true zero	Blood pressure Reaction time Weight Distance

Descriptive statistics
- Mean- average
- Median- halfway point of the measurements
- Mode- most frequently occurring value
- Range- difference from the highest to lowest point
- Variance- square of the sum of all the deviations divided by the number of scores
- Standard deviation- positive square root of the variance

Statistical tests

TEST	GOAL
t-test, independent groups	To test the difference between the means of two independent groups
t-test, dependent samples	To test for the difference between dependent, paired samples
Analysis of variance	To test the difference among the means of more than two independent groups of more than one independent variable
Chi-squared	To evaluate the difference between observed and expected frequencies
Correlation coefficient	To test whether a relationship exists between two variables
Simple linear regression	Used when one independent variable (x) is used to predict a dependent variable (y)
Multiple linear regression	To understand the effects of two or more independent variables on a dependent measure
Analysis of covariance	To test for differences between group means after adjustment of the scores on the dependent variable to eliminate the effects of the covariate
Factor analysis	To reduce a large set of variables into a smaller, more manageable set of measures
Canonical correlation	To analyze the relationship between two or more independent variables and two or more dependent variables
Discriminant analysis	To make predictions regarding memberships in categories or groups, in contrast to using interval- or ratio-level measures

The process of evidence-based clinical practice
- Ask a question that deserves an answer
  - PICO
    - Patient, Intervention (or cause), Comparison, and Outcome
  - Search for relevant evidence
  - What is it worth?
    - 3 study designs that produce the most valuable empirical evidence:
      - RCTs
      - Systematic review
      - Meta-analysis.
  - Applying evidence to your patient
  - Evaluate the effect (outcome) of the evidence-based interventio

REFERENCE: Nagelhout Nurse Anesthesia 7^th edition, pages 32-54