Informed Consent in Patients With Frailty Syndrome.

Frailty is present in more than 30% of individuals older than 65 years of age presenting for anesthesia and surgery, and poses a number of unique issues in the informed consent process. Much attention has been directed at the increased incidence of poor outcomes in these individuals, including postoperative mortality, complications, and prolonged length of stay. These material risks are not generally factored into conventional risk predictors, so it is likely that individuals with frailty are never fully informed of the true risk for procedures undertaken in the hospital setting. While the term "frailty" has the advantage of alerting to risk and allowing appropriate care and interventions, the term has the social disadvantage of encouraging objectivity to ageism. This may encourage paternalistic behavior from carers and family encroaching on self-determination and, in extreme cases, manifesting as coercion and compromising autonomy. There is a high prevalence of neurocognitive disorder in frail elderly patients, and care must be taken to identify those without capacity to provide informed consent; equally important is to not exclude those with capacity from providing consent. Obtaining consent for research adds an extra onus to that of clinical consent. The informed consent process in the frail elderly poses unique challenges to the busy clinical anesthesiologist. At the very least, an increased time commitment should be recognized. The gap between theoretical goals and actual practice of informed consent should be acknowledged.

Facing internet fake-medicine and web para-pharmacy in the total absence of official recommendations from medical societies.

PURPOSE: Internet fake information, parapharmacy and counterfeit drugs are a market of hundreds of billion dollars. Misleading internet data decrease patients' compliance to medical care, promote use of questionable and detrimental practices, and jeopardize patient outcome. This is particularly harmful among cancer patients, especially when pain and nutritional aspects are considered. Provision of Web recommendations for the general audience (patients, relatives, general population) from official medical-providers might be useful to outweigh the detrimental internet information produced by non-medical providers. METHODS: 370 oncology and anesthesiology related societies were analyzed. Our objective was to evaluate the magnitude of web-recommendation for cancer cachexia and cancer pain for the general audience provided by official medical organizations' web sites at global level. RESULTS: Magnitude of web-recommendations at global level was surprisingly scant both for coverage and consistency. Seven official medical societies provided updated web-recommendation for cancer cachexia to their patients/family members, and 15 for cancer pain. Scantiness was unrelated by continent, developmental index, oncology tradition, economic-geographic area and society type scrutinized. CONCLUSIONS: Patients need expert advice when exposed to fake internet information largely dominated by paramedical market profits. In this era of "new media" the patients' net-education represents a new major educational challenge for medical societies.

Value-Based Payment in Ambulatory Anesthesia: MACRA, MIPS, and More.

Congress passed the Medicare Access and Chip Reauthorization Act of 2015 to replace the flawed sustainable growth rate system and it consolidates all pay-for-performance programs. These programs are intended to reduce health care costs but do not address the lack of funding for the social networks that (in all other developed countries) support better health and lower health care use and cost. These programs require reporting by providers about performance on quality, cost, and other metrics, leading to bonuses for those who exceed Centers for Medicare & Medicaid Services-determined metrics and financial penalties for those who do not.

The future of nonoperating room anesthesia in the 21st century: emphasis on quality and safety.

PURPOSE OF REVIEW: Nonoperating room anesthesia (NORA) has grown from an insignificant percentage of total anesthesia cases into a major percentage of anesthesia workload over the past 30 years. This trend evidences no signs of abating. RECENT FINDINGS: With the rapid development of novel interventional techniques in cardiology, radiology, gastroenterology and pulmonary medicine and other areas, the core responsibilities of the anesthesia provider will no longer be confined to delivering care in traditional operating rooms. This change presents challenges for the profession on several fronts. Efficient staffing of multiple locations poses challenges. The demand for anesthesia services continues to increase, but underutilization is a major problem. Each clinical area presents unique patient care issues. New interventional techniques are continually developed with which anesthesiologists need to be familiar in each specific area. NORA patients are older and medically complex, yet many are treated on an outpatient basis. Consequently, anesthetic management for NORA will of necessity require techniques that allow patients to recover quickly. SUMMARY: It may be anticipated that in the next decade that NORA cases will constitute over 50% of the number of cases performed with anesthesia involvement. As the last century belonged to invasive surgery, the next century will belong to interventionalists. There is also an increasing national emphasis on quality measurement and metrics reporting. Future anesthesia payment models under Medicare Access and CHIP Reauthorization Act, such as merit-based incentive payment system (MIPS), emphasize various process and outcomes measures. Anesthesiologists will be evaluated based on a composite performance score consisting of four components: quality, resource use, clinical practice improvement activities and meaningful use of certified electronic health record technology.

Quality organization and risk in anaesthesia: the French perspective.

PURPOSE OF REVIEW: Ensuring the quality and safety of anaesthesia in the face of budgetary restrictions and changing demographics is challenging. In France, the environment is regulated by the legislation, and it is often necessary to find solutions that seize opportunities to break with the traditional organization. RECENT FINDINGS: Postoperative mortality remains excessively high. The move towards ambulatory care is being adequately integrated into all the stages of patient management in the context of a single therapeutic plan that is mutually agreed upon by all caregivers. The French National Health Authority, which provides certification for healthcare establishments, encourages this 'seamless' approach between private practice and the hospital setting, based on teamwork and interdisciplinary consultation. By daring to break with traditional organizational structures, and by taking account of human factors and staged strategies, it is possible to deliver appropriate care, with a level of quality and safety that meets users' demands. SUMMARY: The management of a patient undergoing surgery with anaesthesia is a seamless spectrum from the patient's home to the hospital and back to home. Decision-making must be multidisciplinary. Increased use of ambulatory care, breaks with traditional organizational structures, and efforts to reduce postoperative mortality represents opportunities to improve overall system performance. Demographic and economic constraints are potential threats to be identified.

Ethical and legal duty of anesthesiologists regarding Jehovah's Witness patient: care protocol / Dever ético e legal do anestesiologista frente ao paciente testemunha de Jeová: protocolo de atendimento

Abstract Background and objectives: Jehovah's Witnesses patients refuse blood transfusions for religious reasons. Anesthesiologists must master specific legal knowledge to provide care to these patients. Understanding how the Law and the Federal Council of Medicine treat this issue is critical to know how to act in this context. The aim of this paper was to establish a treatment protocol for the Jehovah's Witness patient with emphasis on ethical and legal duty of the anesthesiologist. Content: The article analyzes the Constitution, Criminal Code, resolutions of the Federal Council of Medicine, opinions, and jurisprudence to understand the limits of the conflict between the autonomy of will of Jehovah's Witnesses to refuse transfusion and the physician's duty to provide the transfusion. Based on this evidence, a care protocol is suggested. Conclusions: The Federal Council of Medicine resolution 1021/1980, the penal code Article 135, which classifies denial of care as a crime and the Supreme Court decision on the HC 268,459/SP process imposes on the physician the obligation of blood transfusion when life is threatened. The patient's or guardian's consent is not necessary, as the autonomy of will manifestation of the Jehovah's Witness patient refusing blood transfusion for himself and relatives, even in emergencies, is no not forbidden.

Resumo Justificativa e objetivos: Os pacientes testemunhas de Jeová recusam transfusão sanguínea por motivos religiosos. O anestesiologista deve dominar conhecimentos jurídicos específicos para atender esses pacientes. Entender como o direito e o Conselho Federal de Medicina tratam essa questão é fundamental para saber agir dentro desse contexto. O objetivo deste artigo foi estabelecer um protocolo de atendimento do paciente testemunha de Jeová com ênfase no dever ético e legal do anestesiologista. Conteúdo: O artigo analisa a Constituição, o Código Penal, resoluções do Conselho Federal de Medicina (CFM), pareceres e jurisprudência para entender os limites do conflito entre a autonomia de vontade da testemunha de Jeová em recusar transfusão e a obrigação do médico em transfundir. Baseado nessas evidências um protocolo de atendimento é sugerido. Conclusões: A resolução do CFM 1021/1980, o Código Penal no artigo 135, que classifica como crime a omissão de socorro, e a decisão do Supremo Tribunal de Justiça sobre o processo HC 268.459/SP impõem ao médico a obrigação de transfusão quando houver risco de vida. Não é necessário concordância do paciente ou de seu responsável, pois não é proibida a manifestação de vontade do paciente testemunha de Jeová ao recusar transfusão sanguínea para si e seus dependentes, mesmo em emergências.

Insurance statements related to regional anaesthesia: A French database analysis.

BACKGROUND: Adverse events in the perioperative period remain frequent, occurring in about 30% of the hospital admission and may be avoidable in nearly 50% of cases. Improving safety needs a continuous assessment of the risk level. MATERIAL AND METHODS: Data from the MACSF-Sou medical insurance company, including all the statements declared by anaesthesiologists and intensivists, were analyzed retrospectively by three experts, senior anaesthesiologists, of the SFAR, the French society of anesthesia and intensive care (Société française d'anesthésie réanimation) to describe the risk associated with regional anaesthesia. RESULTS: One hundred and sixty-four events were analyzed, involving young patients (mean age of 48.3±15years; sex ratio: 0.57). The most involved surgical specialties were: orthopaedic surgery (61%) and obstetric surgery (13.4%). Reported events were predominantly peripheral nerve injury (64.6%). Mechanical complications of puncture (pneumothorax, haemothorax, complications of axial punctures) accounted for approximately 15% of events, infection for 11%. The revelation was predominant in the postoperative course (137 cases, 83.6%), particularly after the release of the operating room in over 47% of cases, including 39 cases (22%) after discharge from the hospital. CONCLUSION: Collaboration with insurance companies allows a relevant approach of the perioperative risk. In most cases, liability related to regional anaesthesia involved young patients in the perioperative course of scheduled surgery. One of the future challenges in managing, the anaesthetic and perioperative risks should be to invest more accurately the postoperative care both in the hospital or ambulatory settings.

[Pharmacogenetics in anesthesia and intensive care medicine : Clinical and legal challenges exemplified by malignant hyperthermia]. / Pharmakogenetik in Anästhesie und Intensivmedizin : Klinische und juristische Herausforderung am Beispiel der Malignen Hyperthermie.

Pharmacotherapy is a key component of anesthesiology and intensive care medicine. The individual genetic profile influences not only the effect of pharmaceuticals but can also completely alter the mode of action. New technologies for genetic screening (e.g. next generation sequencing) and increasing knowledge of molecular pathways foster the disclosure of pharmacogenetic syndromes, which are classified as rare diseases. Taking into account the high genetic variability in humans and over 8000 known rare diseases, up to 20 % of the population may be affected. In summary, rare diseases are not rare. Most pharmacogenetic syndromes lead to a weakening or loss of pharmacological action. In contrast, malignant hyperthermia (MH), which is the most relevant pharmacogenetic syndrome for anesthesia, is characterized by a pharmacologically induced overactivation of calcium metabolism in skeletal muscle. Volatile anesthetic agents and succinylcholine trigger life-threatening hypermetabolic crises. Emergency treatment is based on inhibition of the calcium release channel of the sarcoplasmic reticulum by dantrolene. After an adverse pharmacological event patients must be informed and a clarification consultation must be carried out during which the hereditory character of MH is explained. The patient should be referred to a specialist MH center where a predisposition can be diagnosed by the functional in vitro contracture test from a muscle biopsy. Additional molecular genetic investigations can yield mutations in the genes for calcium-regulating proteins in skeletal muscle, e.g. ryanodine receptor 1 (RyR1) and calcium voltage-gated channel subunit alpha 1S (CACNA1S). Currently, an association to MH has only been shown for 35 mutations out of more than 400 known and probably hundreds of unknown genetic variations. Furthermore, MH predisposition is not excluded by negative mutation screening. For anesthesiological patient safety it is crucial to identify individuals at risk and warn genetic relatives; however, the legal requirements of the Patients Rights Act and the Human Genetic Examination Act must be strictly adhered to. Specific features of insurance and employment law must be respected under consideration of the Human Genetic Examination Act.

[Legal characteristics of expert opinions of anaesthetic cases of the North German Arbitration Board]. / Gutachtenfälle - Juristische Besonderheiten bei der Begutachtung anästhesiologischer Fälle der Norddeutschen Schlichtungsstelle.

The Arbitration Board for Medical Liability Issues of the State Medical Councils of Northern Germany in Hannover (North German Arbitration Board, NGAB) settles about 100 cases in the area of anaesthesiology per year. In these proceedings the patient carries the burden of proof. I. e. the patient has to prove that its health damage was caused by a medical error. Nevertheless, for individual cases the NGAB examines also whether facilitation of the burden of proof can be granted to the patient. This article exemplifies cases, for which the NGAB recognized such facilitation of the burden of proof. In each of these cases, the NGAB asserted the damage claim.

[Selected medical closed claims in the field of regional anaesthesia]. / Gutachtenfälle - Gutachtenbeispiele aus der Regionalanästhesie.

Legal malpractice cases in regional anaesthesia comprise a significant number of all cases before the expert commissions and arbitration boards of the state medical associations. One reason for this is the increasing use of neuraxial and peripheral regional blocks in orthopaedics and traumatology. Only in about one fourth of the reviewed cases could either a causal relationship between substandard performance and patient injury or an inadequate obtaining of informed consent be established. In the great majority of cases patients' claims were unfounded, since the patients' injuries were adjudged to be unavoidable and adequate consent had been abtained prior to performance of the blocks.

[Expert Opinion Cases - What documentation is necessary from a legal perspective?]. / Gutachtenfälle - Welche Dokumentation ist aus juristischer Sicht notwendig?

Doctors are obliged by professional code and civil law (630 f German Civil Code [BGB] §) to document their medical activities in relation to patients. The documentation serves as proof of executed measures and thus for backing up medical/therapeutic issues. Documentation shall be made immediately after or during the treatment and if the original content remains recognizable, can be supplemented/modified. The patient record may be kept in paper form or in electronic form. Medical records are to be stored at least for 10 years. Some special laws (eg. laws governing X rays, Transfusion Act) require that documents be stored for longer periods. Documentation errors are - unlike patient information errors/medical malpractice - no basis for damages claims by the patient, but may result in medical malpractice process with the burden of proof in favor of the patient (§ 630 h BGB). The patient has, in principle, the right to inspect the medical documents relating to him.

The liability of the anaesthesiologist in ambulatory surgery.

With the development of ambulatory surgery, there may be questions about the legal risk of this procedure. Indeed, the discharge of the patient from the hospital on the same day as the medical treatment raises the problem of monitoring and supervising potential complications, with a substantial delay in medical care, and the anaesthesiologists can be confronted with new areas of liability. This article specifies the French statutory and legal framework of the ambulatory surgery, and shows how the responsibility of the anaesthesiologist can be involved during patient care at all steps. The analysis of judicial precedent shows that the legal risk for the anaesthesiologist also exists in outpatient surgery. Surgery and anaesthesia are medical procedures involving a relatively high risk of damage for the patient. The damage can be attributed to malpractice from one or several health care professionals or to a medical complication (abnormal damage not related to malpractice and independent of past medical history of the patient). In the light of the ongoing and significant development in ambulatory surgery, there may be questions about the legal risk of this procedure. Indeed, the discharge of the patient from the hospital on the same day as the medical treatment raises the problem of monitoring and supervising potential complications, with a substantial delay in medical care. If the patient suffers any damage, the surgeon, the anaesthesiologist and in some cases, the hospital will have to answer in courts: the surgeon for the surgical procedure, the anaesthesiologist for the medical care and the hospital as the liable institution. After having specified the statutory framework of ambulatory surgery, we will see how the responsibility of the anaesthesiologist can be involved during patient care at all steps.

The aging anesthesiologist.

PURPOSE OF REVIEW: The average age of anesthesiologists in the USA is increasing. Advancing age is accompanied by challenges and opportunities to the individual anesthesiologist and his/her colleagues. This article will discuss the science behind policies to assure continued competence among these aging physicians and safety for their patients. RECENT FINDINGS: There is growing evidence that aging anesthesiologists may be advantaged by a lifetime of experience but possibly disadvantaged under certain circumstances by lapses in current medical knowledge contributing to medical errors. Policies and procedures are emerging to assist in evaluating the continued competence of aging physicians. SUMMARY: The average age of practicing anesthesiologists in the USA is increasing. As physicians continue to practice into later years, it is critical that innovative continuing medical education programs and objective evaluations of clinical skills and competence focused upon this group continue to be developed to assure public safety.

Alleged malpractice in anesthesiology: analysis of a series of private insurance claims.

BACKGROUND: Medical malpractice is currently a crucial topic and anesthesia is a key specialty for the improvement of patient safety. However, death and permanent impairment due to anesthesia still occur and studies of insurance analysis data are increasing. We investigated the main features of a major Italian insurance broker's archive in order to identify possible recurrent pitfalls in this critical field of medicine. METHODS: Three hundred seventeen Italian claims were analyzed, filling out a standardized form that recorded information on patient and physician's characteristics, procedures, sequence and location of events and outcomes. The operative setting, the type of anesthesia performed the origin of the multidisciplinary team malpractice hypothesis, the final clinical outcome and the malpractice investigation results were also analyzed. RESULTS: In 225 malpractice claims, the adverse event was surgery-linked, either intraoperatively (114 cases) or postoperatively (111 cases): abdominal surgery (26%), orthopedics (22%), gynecology (20%), heart surgery (11%) and neurosurgery (9.5%) were the most frequently involved surgical specialties. In 92 cases, the claim was unlinked to a surgeon's activity, with dental damage in oral intubation procedures as the greatest contributor (42.3%). Anesthetists' malpractice was technically ascertained in 39% of cases, 74.8% resulting in permanent impairment. CONCLUSIONS: Malpractice was mainly suspected in surgery-linked procedures. Most of the claims were settled for procedural error in performing locoregional anesthesia and oral intubation procedures. 60% of all closed claims resulted in no malpractice ascertained. Confirmed malpractice typically deals with non surgery-linked and non multidisciplinary team cases, causing permanent impairment.