3. ”MAN CAN BUT ACHIEVE TRANSITORY
SLEEP WHILE LORD CAN PUT HIM TO
ETERNAL SLEEP” -Dr. Graham pearce.
-Anaesthesia improved quality of all surgical
procedures.
-Certain agents and techniques are source of
morbidity and mortality.
-Any intervention does carry an element of risk.
4. 1987 confidential enquiry into perioperative
deaths.
Anaesthesia as sole cause of death 0.1%.
Contributory factor 14% of cases.
Practice of anaesthesia has many interfaces
with law.
State has the responsibility to protect the
citizens.
State has a role to regulate the behaviour of
physicians and hospitals
5. New technologies always emerge and are
applied in practice of medicine and may create
new interfaces between medicine and
jurisprudence.
New technologies may change the practice of
anaesthesia practice.
“Nothing is static everything is
changing”.
6. Anesthesiology and per-operative surgery
are unique specialities in view of the fact that
generally, the patients are unconscious, either
for the performance of surgical procedures or
in the intensive care units.
This brings forward ethical issues that are
unique to these specialties.
7. Anesthesia has long been considered
to be a“behind the screen” specialty,
and patients as well as
anesthesiologists’ colleagues in the
hospital seem to be unaware of the
widespread role of the speciality.
8. Malpractice is defined by Columbia
Encyclopedia as the “…failure to provide
professional services with the skill usually
exhibited by responsible and careful members
of the profession, resulting in injury, loss, or
damage to the party contracting those services”
Medical malpractice tort system as intended to
“minimize patient injury, maximize patient
safety and compensate injured patient”.
Most common cause of medical malpractice is
medical negligence. Negligence occurs when a
physician’s failure to meet the standard of care
directly leads to patient’s injury.
9. “Negligence is one type of tort
(a wrongfull act) and
malpractice is one type of
negligence”
10. A) Germination of a lawsuit
B) Risk management strategies
C) Notification of a lawsuit
D) Discovery
E) Deposition testimony
F) Expert witnesses
11. All patients may be considered as potentially
litigious.
There is subset of patients who are more likely
to sue than others.eg….
- Pt who is currently involved in a malpractice
lawsuit
- Those who have had an adverse outcome from
previous care.
- Who appears hostile to physician
- Degree of injury
12. The prevention of a lawsuit in the
face of an adverse outcome is a
function of risk management .
2. Risk management strategies
13. 1) Improve the physician patient relationship
2) Adhere to a “standard of care”
3) Keep good records
4) Respond appropriately when an incident
occurs
5) Recognize malpractice prodromes
6) Avoid vicarious liability
14. Communication with the patient requires
both talking and listening, with a
willingness to listen being the more
important.
Give patients the opportunity to ask
questions and to make sure that their
consent to proceed is as fully informed as
possible
15. Why Anaesthesiologist are more
likely to be sued than primary
care physicians for several
reasons??????
16. Most significant is that the patient is
unaware of us for most of the time we
are caring for them
Except for paediatric surgery there is
very little, if any involvement with the
patients family so anaesthesiologist is not
always recognized as a dedicated
physician
17. It is much easier to blame the
anaesthesiologist for less than perfect
outcome than to blame the surgeon who
may have spent hours at the patients
bedside and offered consolation to a
worried family
Obvious solution would be to extend our
involvement with the patient and family.
18. Anaesthesiologist should be sensitive to the
needs of patients who seem anxious, ill or
prone to specific complications
Spouses and family members may be informed
seperately of risks when patients clearly
request not to be informed
But from a legal point of view in informing a
spouse or family member anaesthesiologist is
not relieved from the burden of informing the
patient unless he or she is the patients legal
guardian
19. The anaesthesiologist who gives the
impression of being unconcerned or
uninterested when a complication that
may be related to anaesthesia occurs may
suffer a law suit.
It is important to project a professional
image to patients
Appearance at the bedside are major
contributors
20. If patients and their families have the
initial impression that the physician is
sloopy, careless or poorly informed they
are not likely to be forgiving of a less
than perfect outcome
It is important to guard against careless
conversation in the hospital, corridoors
and operating rooms
21. It is not feasible to know what the
standard is? , this requires that one keeps
current in knowledge and provide
medical care consistent with this
knowledge
One should be aware of accepted
guidelines for the provision of
anaesthesia care
22. Standard of care requires that the
choice of agents and techniques
is appropriate
It is necessary to know the
contraindications to the use of
drugs and anaesthetic agents
23. Uses a barbituirate to induce anaesthesia
in patients with acute porphyria
Gives suxamethonium to a burned
patient or to a quadriplegic patient
Uses halothane in the presence of
elevated hepatic enzymes following the
previous use of the agent
24. It is of little benefit in legal terms to have
delivered good anaesthesia care if it is
impossible to identify each component of
an anaesthetic agent and when it was
performed.
The record may have to be defended
years after the case was completed, and
case has been forgotten.
26. Facts should be documented
Avoid using terms such as inadvertently
that convey message of guilt or
negligence
Simply record the relavant facts about
the incident like auscultatory findings,
spinal level of somatic block
27. A frequent complaint is that there is no time to
write notes while responding to a emergency
situation
The solution is to write a perioperative note as
soon as possible making reference to the
approximate times of the events
such records are invaluable in distinguishing
between a known complication and actual
negligence
28. The anaesthesiologist should continue to
maintain professional contact with the
patient during hospitalization after any
incident that might be ralated to
anaesthesia.
Failure to do so might be interpret as a
rejecting the patient.
29. Receiving letters from a previous patient
Getting request for medical record from
attorneys.
Response should not be hostile & goals are to
explain why there is no liability for the claim
to reduce the chance of a lawsuit being filed.
Direct correspondence with the patient should
be kept to a minimum.
Best to work through the insurer or attorney.
30. If anaesthesiologist supervising anyone who is
incompetent, supervision must be very close
such as double checking preoperative findings,
being present in the operating room during the
entire case.
Do not agree to supervise more simultaneous
cases than you can safely handle.
Issues of inadequate supervision and pt
abandonment are hard to defend.
31. Strategies to reduce bad outcomes:
1) CMES:
Have regular CMES,
Share the knowledge
Frame guide lines and protocols for various
procedures.
2)Believe your monitors:
Don’t find fault with the monitors
Try to find something wrong with the patient.
USE multiple monitors for cross checking and
whenever any doubt assess clinicaly.
3) Lab values and clinical condition must correlate
32. ISA & ASA guidelines:
The associations will be providing the members
materials which contains standards, guide lines
and malpractice claims. Anaesthesiologist must
be thorough with this information and follow.
33. Policies and procedures:
The policies formed to cover all the problems.
They must be practicable and practicable. If not
violation is proved by the lawyers.
The policies must be reviewed regularly and
amended if necessary.
34. An anaesthesiologist may receive a notice of
intent to sue within a spicified period of time
or may receive a summons.
There is finite period of time for a response to
the summons and an assistance of an attorneys
will be required.
Failure to respond within time will result in a
directed decision for the plaintiff.
35. Anaesthesiologist should avoid from
discussing the case with anyone other
than the attorney, as certain statements
may be discoverable and used by the
plaintiff during the trial.
36. Access to the patient’s medical records is
permissible, but the temptation to add
notes must be avoided.
plaintiff’s attorney has already obtained
a copy of the medical record, and any
alteration after the notification of a
lawsuit will be introduced as evidence of
negligence.
37. After the complaint is answered,
both sides begin the process knows
as ‘discovery’.
The purpose of discovery is to
ascertain the “facts” of the case in
preparation for trial.
38. It is the responsibility of the jury to
decide which facts to believe.
So juries are, for this reason ,called
“triers of fact”
A strength is a fact that is favorable and a
weakness is a fact that is unfavorable.
39. The Medical record is the primary
(FIRST) source of the facts.
A trier of the fact will believe what is
written before believing what is said.
The notes were completed before any
adverse outcome was known, so records
are trusted.
40. Second source of facts is the testimony of
those who witnessed the event
Anaesthesiologist may testify that
something that was not recorded was
done or seen.
It is not as believable as medical records
because it relies upon specific recall of
events that may have happened in the
remote past.
41. Third source of facts is the usual
practice pattern of the
anaesthesiologist.
If anaesthesiologist has done
something it must be because that is
part of a routine.
42. It is the expert witness testimony.
Expert are necessary because the subject
of medicine is held to be beyond the
knowledge or understanding of lay
jurors.
Expert will review entire medical record
43. 1) The anaesthesia record and notes
2) The expert’s interpretation
3) Specific recall
4) Usual and customary practice
44. The defendant anaesthesiologist testimony is
conducted by the plaintiff’s attorney.
The plaintiff attorney will attempt to uncover
facts favorable to the plaintiff to ascertain the
defense position on the issues in question.
Prior to the deposition, the defense attorney
should meet the anaesthesiologist to explain
the conduct of the procedure, what to bring.
45. There will be a series of questions .
There is need to speak slowly and clearly,
understanding the questions, and waiting
untill the question is fully asked before
answering .
Answer should be brief and to the point.
It helps to have a familiar with the dates of
training, licence, and certifications.
46. Courts demand that witnesses be called
so that the jury can benefit from the
expertise and opinions of uninvolved
parties.
Witnesses who are allowed to give
opinions are called expert witness.
47. Some lawsuits may begin informally by a
request from a potential plaintiff's attorney to
review records or to discuss a case. An attorney
should be consulted before engaging in these
actions to ensure that proper procedure is
followed.
Lawsuits officially begin with a document
called a Summons and Complaint,
which is a notification to respond to allegations
by the plaintiff.
48. An attorney should be consulted before
engaging in these actions to ensure.
Exchange of documents and a deposition
Before the deposition, the physician should
inform the attorney about his or her
relationship with the plaintiff and any
problems that may have occurred.
A fully informed attorney is the best advocate.
50. Medical negligence:- Breech of a duty of a
standard of care causing harm
Wrongful death:- One that occurs earlier
that it would have otherwise. If
negligence causes death, survivors may
sue for damages
51. Lack of informed consent Obligation to
provide information material to a
reasonable person
Abandonment-- Obligation to provide
continuity of care once a physician
assumes responsibility for the patient
52. Vicarious liability – Obligation for
reasonable oversight of those working
for the physician
Loss of chance of recovery or
survival- The patient must show that
recovery was likely except for the action
of the physician
53. Battery- Touching a person without express
or implied consent. There is no need for the
plaintiff to prove harm in battery cases
Assault -The attempt to touch another
person. There is no need to prove actual harm
54. PREANAESTHESIA EVALUATION
Patient interview
Medical history
Anaesesthesia history
Medication history
Physical examination
Diagnostic data
ASA physical status
Anaesthetic plan (risk and benefits)
55. Patient reevaluation
Check of equipments, drugs and gas
supply
Monitoring
Amounts of drugs used and time of
administration
Amounts of iv fluids, blood and blood
products used and time of administration
56. Estimated blood loss and urine
output
Techniques used
Unusual events – explanation of
recognition of event, treatment and
outcome of event.
Status of the patient at the
conclusion of anaesthesia
57. Patient evaluation on admission and
discharge from the post anasethesia care
unit
Time based record of vital signs and
level of consciousness
Drugs administered- time, doses, routes
of administration
IV fluids, blood and blood products.
Any unusual events
Post anaesthesia visits
58. It is defined as “voluntary agreement, compliance
or permission for a specified act or purpose”.
Indian contracts act section 13 states that “two
or more persons said to consent when they
agree upon the same thing in the same
sense”
Consent must be intelligent and informed.
Without consent it amounts to assault and
battery.
59. Consent may be either expressed or implied.
Expressed consent may be written or verbal.
Implied consent is for routine small procedures .
Written consent is a must for specialised
procedures.
Must be taken in the presence of third party.
Informed consent: the procedure is explained
to the patient in his local language and consent
is taken.
60. Legal and moral imperatives for
informed consent are based on the
ethical principle of respect for
patient autonomy.
The goal of informed consent is to
maximize the ability of the patient to
make substantially autonomous
informed decisions.
61. Autonomy refers to the ability to
choose without controlling
interference by others and without
personal limitations that prevent
meaningfull choices, such as
inadequate information or
understanding.
62. In 1914, the case of Schloendorff
Society of Newyork Hospital
established that it was the right of
“every human being of adult years
and sound mind to determine what
shall happen to his own body”.
63. In 1957, the term informed consent was
first used in the case of Salgo Trustees of
Leland Stanford hospital.
Judge clarified that “it is not sufficient for
the physician to simply secure the
consent; physicians have duty to inform
patients about the risks and alternatives
to treatment, in addition to procedure
themselves and their consequences”
64. “Autonomy to make medical decisions
cannot exist in the absence of
competence”.
Patients have right to make bad decisions
if they are competent and have
appropriate information.
65. Can the patient formulate and communicate a
decision?
Can the patient receive and understand the
information relevant to the decision ?
Can the patient understand consequences of
the decision, including risk and benefits ?
Can the patient express a decision and
communicate values regarding the medical
advice.
66. Temporary or permanent.eg are-
Mental illnesses
Dementia
Immaturity
Anxiety
Pain
Effect of medication
67. It is anaesthesiologist’s duty to treat the
reversible condition affecting the competence
of the pt and postpone the elective surgery.
When the surgery is urgent or a pt is impaired
by irreversible condition, anaesthesiologists
may have to rely on surrogate decision maker
or proceed with their best determination of the
pt’s interests in mind.
68. Informed consent process require honest
disclosure of medical information to the patient.
Reasonable person standards- in this physician
must disclose any information that a theoretical
reasonable person would want to know.
The subjective standard recognizes that some
patients may have special needs for specific
information and that when that need is obvious
the information must be disclosed.
Eg: concert violinist
69. In general, legal and ethical standards
now require that
(1) the physician accurately discuss the
therapy and its potential alternatives
(including no therapy)
(2) disclose the common risks (because they
are more likely to happen) and the
serious risks (because the consequences
are severe).
70. It states to avoid discussing risk under
the reasoning that the stress of discussing
risks can harm the patient
psychologically or physically.
It is ethical to risk discussions at the
patient’s request but it is unethical for the
physician to unilaterally decide to do so.
71. 1. Decision making capacity is defined as the
ability to make a particular decision at a
specific time.
2. Voluntariness - a competent patient has a right
to refuse potentially life-sustaining treatment,
even if her decision is considered unwise.
3. Disclosure The goal of disclosure is to provide
information relevant to the decision-maker and
the decision to be made.
72. 4. Recommendation: Anesthesiologists should
offer an opinion about which options are
preferable and the advantages and
disadvantages of each option.
5. Understanding: Patients need to understand
the risks and benefits of the proposed
procedures, the recommendations made, and
why those recommendations were made
6. Decision: When a patient refuses an
anesthesiologist's recommendation or requests
a technique that the anesthesiologist believes is
inappropriate, the focus of conversation moves
from informed consent to informed refusal.
73. When a patient chooses a technique that the
anesthesiologist believes is inappropriate, or
likely to result in harm, anesthesiologists are
not obligated to provide care in nonemergency
situations.
Anesthesiologists may refuse to provide care if
they do not feel qualified to provide the needed
care.
7. Autonomous authorization: The informed
consent process concludes with the patient
intentionally authorizing the anesthesiologist to
perform a specific procedure.
74. Informed consent is meaningless if the patient
cannot also refuse medical therapy.
1. Request to withhold life-supporting care in the
ICU
2. Do not attempt resucitation (DNAR) orders in
the operating room.
3. Objections to certain forms of therapy
eg.Jehovah’s witness
4. Refusal for preoperative testing
eg.HIV,pregnancy
75. On the surgical consent form - suboptimal
By a handwritten note – acceptable but
impractical and time consuming
By a separate anaesthesia consent form –
best method
76. Negligence related to informed consent process
may occur when anaesthesiologist provide a
disclosure that is insufficient to allow a patient to
make an informed decision and an injury
subsequently occurs even if it occurred in the
absence of treatment error.
If the disclosure did not meet the standard of care,
it may be considered a breach of duty.
Informing a patient about a risk does not eliminate
liability for its occurrence. Liability is depends
mainly on whether the standard of care was met
and whether failure to meet the standard of care
was a proximate cause of the injury.
78. Prescribing narcotics for pain control – risk of
investigations
Drug Enforcement Administration (0.06%)
Controlled substance act
Physicians have been held liable for inadequate
pain control
79. An 85-year-old man was admitted to a medical
center for 5 days in 1998 before his subsequent
death several days later.
He received inadequate pain control during his
admission. Although a medical malpractice
suit was dismissed and the state medical board
did not pursue any action against the
physician, the family won a civil suit against
the physician under the California's Elder
Abuse and Adult Civil Protection Act.
80. Children are an example of persons
who may or may not be
autonomous.
Laws define the age at which
children become legally competent
(usually 18)
81. But many younger children have the
mental and emotional capacity to make
medical decisions.
Forcing such individuals to undergo
treatments that they do not want is
unethical and could be illegal as well.
82. Emancipated minor are patients younger
than 18 who have been given the global
right to make their own health care
decisions.
This status is generally awarded to
patients who are married, pregnant, in
the military, and economically
independent (at least 14 years)
83. For example, in a case in 2007 that
seemed to be on the margin, a judge
ruled that a 14-year-old practicing
Jehovah's witness would be permitted to
refuse transfusion therapy during
treatment for a cancer that had a 70% 5-
year survival rate. The patient
subsequently died.
84. Even though pediatric patients who are
pregnant may be considered emancipated,
many states require some form of parental
involvement, such as parental consent or
notification, before an elective abortion in an
adolescent.
it may be best to consult with hospital counsel
when determining such issues.
85. Patients or families may demand therapies that
clinicians believe are inadvisable because of
burden to the patient, cost, or uncertain benefit.
When such situations become irreconcilable,
the cases may go to court, often not to
determine what therapy should be given but to
determine who should be the decision-maker
for a noncompetent person.
unilateral physician declarations are
insufficiently respectful of patient autonomy
and may be legally risky.
86. Health Insurance Portability and
Accountability Act (HIPAA)
EMERGENCY IN MEDICAL
TREATMENT AND ACTIVE LABOUR
ACT-EMTALA
88. 1) Assess the patient, optimise the patient and
assure the patient before taking up for surgery.
2) Take valid and informed consent
3) Keep the things which are necessary during
and after the operation.
4) Check the equipment and monitors.
5) Label all the drugs
6) Supervise the juniors
7) Avoid critical incidents
89. 8) If there is bad outcome contact the family
members and explain
9) Take opinion of consultants
10) Do all the necessary investigations.
11) Don’t leave the patient unattended
12) Take to a higher center if necessary
13) Have a valid medical insurance coverage.
14) Try to avoid physical assaults by the angry
patients attendants.
90. WHAT to????? WHAT not to?????
HOW to reveal?? WHAT about my
future??
WHERE to go???? WHOM to talk????
