anesthesiologist to patient communication: a systematic review
TRANSCRIPT
Original Investigation | Anesthesiology
Anesthesiologist to Patient CommunicationA Systematic ReviewMichael J. Tylee, MD; Gordon D. Rubenfeld, MD, MSc; Duminda Wijeysundera, MD, PhD; Michael C. Sklar, MD; Sajid Hussain, MD; Neill K. J. Adhikari, MD, MSc
Abstract
IMPORTANCE Many patients are admitted to the intensive care unit following surgery, and some ofthem will experience incomplete recovery. For patients in this situation, preoperative discussionsregarding patient values and preferences may direct care decisions. Existing literature shows that itis uncommon for surgeons to have these conversations preoperatively; it is unclear whetheranesthesia professionals engage with patients on this topic prior to surgery.
OBJECTIVE To review the literature on communication between patients and anesthesiaprofessionals, with a focus on discussions related to postoperative critical care.
EVIDENCE REVIEW MEDLINE and Web of Science were searched using specific search criteria fromJanuary 1980 to April 2020. Studies describing encounters between patients and anesthesiaprofessionals were selected, and data regarding study objectives, study design, methodology,measures, outcomes, patient characteristics, and clinical setting were extracted and collated. ThePreferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelinewas followed.
FINDINGS A total of 12 studies including 1284 individual patient encounters were eligible forinclusion in the review. These studies demonstrated that communication between patients andanesthesia professionals related to postoperative care is rare: only 2 studies reported communicationregarding adverse postoperative events, and this communication behavior was reported in only 46of 1284 consultations (3.6%) across all studies. Additional findings were that communication duringthese encounters is dominated by anesthetic planning and perioperative logistics, with variablediscussion of perioperative risks vs benefits and infrequent elicitation of patient values andpreferences. Some data suggest that patients wish to be involved in perioperative decision-makingbut are often limited by an incomplete understanding of risks and benefits.
CONCLUSIONS AND RELEVANCE This systematic review found that communication in anesthesiais dominated by anesthetic planning and discussion of preoperative logistics, whereas postoperativecritical care is rarely discussed. Most patients who are admitted to an intensive care unit after a majoroperation will not have had a discussion regarding goals of care specific to protracted recovery orprolonged intensive care with their anesthesiologist.
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503
Introduction
Communication with patients about therapeutic options and care plans is a critical component ofshared decision-making and is particularly important when a decision may result in a major orpermanent change in a patient’s health status. This situation is relatively common for patientsundergoing major surgery. Surgeons and anesthesiologists are the principal clinicians with the
Key PointsQuestion Do anesthesiologists or other
anesthesia professionals engage in
discussions with patients regarding
decisions with implications beyond the
operating room?
Findings In this systematic review of
the literature on communication
between patients and anesthesia
professionals, limited data were found
on communication regarding
perioperative decisions with
implications that reach beyond the
operating room. These data suggest that
communication between patients and
anesthesia professionals during
preoperative encounters is dominated
by discussion of anesthetic planning and
perioperative logistics, with variable
discussion of risks vs benefits and
infrequent discussion of postoperative
care or elicitation of patient values and
preferences.
Meaning These findings suggest that
patients who become critically ill
following scheduled surgical
interventions are unlikely to have had
discussions with their anesthesiologist
regarding values and preferences for
navigating complex postoperative care
decisions, such as prolonged invasive
ventilation, protracted hospital stay with
incomplete recovery, or end-of-life care.
+ Invited Commentary
+ Supplemental content
Author affiliations and article information arelisted at the end of this article.
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 1/15
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opportunity and, arguably, the responsibility to elicit values and preferences about postoperativecare from surgical patients to inform care decisions if patients become critically ill and lose decisionalcapacity postoperatively. Previous work suggests that surgeons uncommonly elicit patientpreferences regarding postoperative critical illness preoperatively, even for high-risk patients.1,2
Anesthesiologists also have the opportunity to elicit patient values and preferences preoperatively,and some members of the specialty have an interest in expanding anesthesiologists’ role inperioperative medicine.3-5 Knowledge and communication of medical and surgical complicationsafter surgery, as opposed to complications of the anesthetic, are essential to this role. However, theextent of anesthesiologists’ responsibility and their ability to perform this role is not clear, and thereare likely variable professional expectations for patient-anesthesiologist communication in differenthealth care systems and settings.
There are few data on communication during anesthesia consultations. Although studies onanesthesiologist-patient communication have been narratively reviewed,6,7 there is no systematicreview on this topic. In this review, a systematic search strategy was used to extract and collate dataon communication between anesthesia professionals and patients, and the methodological qualityof existing studies was assessed. A synthesis of the data focused on communication aboutpostoperative critical illness is presented.
Methods
A systematic review of the literature on communication between anesthesia professionals andpatients was performed to address the following question: in preoperative anesthetic encounters,what are the patterns and content of communication between anesthesia professionals and patientsas evaluated by qualitative or mixed methods? Reporting is consistent with the Preferred ReportingItems for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.8
Information Sources and SearchA MEDLINE search was performed (from 1980 to April 2020) to retrieve any studies with a focus oncommunication between patients and anesthesia professionals (eAppendix 1 in the Supplement). A1-generation, forward-and-backward search on Web of Science was then performed using each of theincluded studies from the MEDLINE search to identify additional relevant studies.
Study Eligibility, Selection, and Data ExtractionOnly studies with data describing specific encounters between patients and anesthesia professionalswere included. Studies with a primary focus other than communication, studies on communicationduring anesthesia procedures, and studies examining communication with children were excluded(see eAppendix 2 and eAppendix 3 in the Supplement). In addition, studies that developed orevaluated communication interventions were excluded because these studies prescribedcommunication strategies instead of evaluating established communication practices. The searchwas limited to studies published in English, which generally gives a sufficient assessment of a giventopic,9,10 and to studies published after 1980. Three reviewers (M.J.T., S.H., and M.C.S.) performedtitle screening, and 1 reviewer (M.J.T.) retrieved the full text of relevant titles, selected studies, andextracted data.
Methodological Quality ReviewOne reviewer (M.J.T) assessed the quality of all studies using the previously validated CriticalAppraisal Skills Program (CASP) tool for Qualitative Studies.11 A second reviewer (N.K.J.A.) verifiedthese assessments.
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 2/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
Statistical AnalysisIndividual study results and quality reviews are presented, and overall results are synthesizeddescriptively. Variables and outcomes extracted from individual studies were too diverse forquantitative synthesis. Continuous data are expressed as means with SDs or as medians withinterquartile ranges (IQR). No statistical testing was conducted.
Results
Search and Study SelectionThe Figure shows an overview of study selection. Thirty full-text articles from the search werereviewed, of which 20 studies were excluded (see eAppendix 4 in the Supplement). Seventeen ofthese studies were excluded because they did not include any data about anesthesiologist-patientcommunication during routine encounters. Three studies were excluded because they were aboutcommunication during procedures. The remaining 10 studies were included, and the Web of Sciencesearch returned 2 more studies, resulting in 12 studies for review.12-23
Study CharacteristicsStudy characteristics are summarized in Table 1. All studies included descriptive statistics, and 5studies13-15,20,23 performed some statistical modeling. Ten studies collected raw communication dataon clinical encounters by audiotaping,15,17-20,22,23 videotaping,16 or direct observation with anexperienced observer.12,13 One study collected data using questionnaires only,14 and another used
Figure. Study Selection
3316 Total MEDLINE results
910 Included for abstract review
30 Included for full-text review
10 Included
12 Included for data extraction
2406 Excluded in manual title review
880 Excluded245 No data
23 About consent for research
287 Not about communication22 About subpopulation
74 Not about anesthesia professionals
41 Not English language
71 About communication adjuncts78 Not about communication with patients
15 Reflections on practice
2 Duplicate studies
14 About patient needs8 Not available
20 Excluded10 Communication intervention7 About patient experiences3 About procedures
2 Included from Web of Science search
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 3/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
Tabl
e1.
Stud
yCh
arac
teris
tics
Sour
ceSe
ttin
gan
dpa
tient
sO
bjec
tive
Stud
yde
sign
and
met
hodo
logy
Data
type
and
anal
ysis
Babi
tuan
dCy
na,1
220
0068
fem
ale
patie
ntse
nrol
led
follo
win
gpr
eane
sthe
sia
asse
ssm
enti
nAu
stra
lia.N
oris
kst
ratif
icat
ion
data
ofpa
tient
spro
vide
d.
Dete
rmin
ew
heth
erpa
tient
sund
erst
ood
tech
nica
lter
msu
sed
inpr
eane
sthe
sia
asse
ssm
ent.
Obs
erva
tiona
lstu
dyw
ithst
anda
rdiz
edpa
tient
ques
tionn
aire
.Di
rect
obse
rvat
ion
with
expe
rtob
serv
ers.
Num
bero
fte
chni
calt
erm
suse
dpe
rcon
sulta
tion.
Num
bera
ndna
ture
ofte
chni
calt
erm
snot
unde
rsto
odby
patie
nts.
Desc
riptiv
est
atis
tics.
Barn
esch
ieta
l,13
2002
Preo
pera
tive
asse
ssm
ents
of27
2pa
tient
sfor
elec
tive
gene
rals
urge
ryin
Ital
y.Pa
tient
sfor
elec
tive
surg
ery;
mos
tlyAS
Acl
assI
orII
(n=
224)
with
som
eAS
Acl
assI
IIpa
tient
s(n
=31
).
Dete
rmin
eho
wm
any
patie
ntsr
ecei
ved
info
rmat
ion
abou
tris
ksof
anes
thes
iadu
ring
preo
pera
tive
cons
ulta
tions
with
and
with
out
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ing
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gan
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rmat
ion
pam
phle
t.
Obs
erva
tiona
lstu
dyw
ithst
anda
rdiz
edpa
tient
ques
tionn
aire
s.Di
rect
obse
rvat
ion
with
expe
rienc
edob
serv
ers.
Num
bero
fane
sthe
sia
com
plic
atio
nsdi
scus
sed
preo
pera
tivel
y.De
scrip
tive
stat
istic
s.
Flie
rler
etal
,14
2013
197
Preo
pera
tive
patie
ntsu
nder
goin
gel
ectiv
esu
rger
yw
ithop
tions
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nest
hesi
a(ie
,ge
nera
lorr
egio
nal)
inSw
itzer
land
.Mos
tlyAS
Acl
assI
orII
(n=
177)
with
som
eAS
Acl
ass
IIIpa
tient
s(n
=20
).
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ssco
ngru
ence
betw
een
patie
ntan
dhe
alth
care
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essi
onal
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eptio
nof
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ntpr
efer
ence
sand
com
paris
onto
anes
thet
icop
tion
ultim
atel
ych
osen
.
Qua
ntita
tive
obse
rvat
iona
lstu
dy.S
urve
y-ba
sed
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yin
ade
fined
popu
latio
nse
lect
edba
sed
onco
nven
ienc
e.
Surv
eysc
ores
.Mul
tiple
regr
essi
onm
odel
for
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rmin
ing
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ciat
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icfa
ctor
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red
leve
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nvol
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enti
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ons.
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ryet
al,1
520
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ldre
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oing
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tive
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ardi
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rger
y.N
oris
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icat
ion
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vely
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acte
rize
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rmed
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entd
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ssio
n.Q
uant
itativ
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atio
nals
tudy
.Aud
io-
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ngof
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terv
iew
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patie
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alth
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essi
onal
s.
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ore
cord
ing
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nsen
tcon
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atio
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ithsu
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uent
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ngan
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icat
ion
ofsp
ecifi
cel
emen
ts.S
urve
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ting
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ogra
phic
char
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ectiv
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ctio
nle
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atio
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men
tsan
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rent
alre
call.
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lere
tal,1
620
0557
Patie
nten
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ters
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eadm
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oncl
inic
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itzer
land
.No
risk
stra
tific
atio
nda
taof
patie
ntsp
rovi
ded.
Desc
ribe
the
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reof
the
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nt-a
nest
hetis
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tera
ctio
n.Se
miq
ualit
ativ
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serv
atio
nals
tudy
.Vi
deot
apin
gof
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ntin
terv
iew
swith
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ntsa
ndhe
alth
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essi
onal
sm
aske
dto
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yai
ms.
Raw
data
vide
ofo
otag
eof
inte
ract
ions
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eran
ces
from
the
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ntan
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esth
etis
twer
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ga
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ious
lyva
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edco
ding
tool
.Ass
ocia
tion
offr
eque
ncy
ofsp
ecifi
cut
tera
nces
with
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ntin
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emen
tass
esse
dby
Pear
son
prod
uct-
mom
ent
corr
elat
ion.
Laga
naet
al,1
720
1291
Patie
ntsa
ndth
eirp
aren
tsor
guar
dian
son
the
day
ofsu
rger
yin
Aust
ralia
.Mos
tly
ASA
clas
sIor
II(n
=88
)with
som
eAS
Acl
assI
IIpa
tient
s(n
=12
).N
ote
that
nota
llpa
tient
enro
lled
had
com
plet
eda
tafo
rana
lysi
s.
Obs
erve
and
iden
tify
the
num
bera
ndna
ture
ofan
esth
esia
risks
cons
ider
edan
dco
mm
unic
ated
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rent
s/gu
ardi
ans.
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iqua
litat
ive
obse
rvat
iona
lstu
dy.A
udio
-ta
ping
ofre
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tient
inte
rvie
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tient
sand
heal
thca
repr
ofes
sion
als
mas
ked
tost
udy
aim
s.
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o-re
cord
edtr
ansc
ripts
.Num
bero
fris
ksan
ddi
scus
sion
ofris
ksid
entif
ied
from
tran
scrip
tsby
2se
para
tere
sear
cher
s.De
scrip
tive
stat
istic
s.
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blin
get
al,1
820
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Patie
nten
coun
ters
inpr
eadm
issi
oncl
inic
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itzer
land
.No
risk
stra
tific
atio
nda
taof
patie
ntsp
rovi
ded.
Obs
erve
the
asso
ciat
ion
betw
een
phys
icia
ns’
reas
surin
gut
tera
nces
with
ava
riety
ofpa
tient
utte
ranc
es.
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iqua
litat
ive
obse
rvat
iona
lstu
dy.A
udio
-ta
ping
ofre
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tient
inte
rvie
ws.
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o-re
cord
edtr
ansc
ripts
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eran
cesf
rom
the
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ntan
dan
esth
etis
twer
eco
ded
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ga
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ious
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edco
ding
tool
.Ass
essm
ento
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lity
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ring
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omth
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ysic
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don
prio
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eran
cesb
yth
epa
tient
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ndbe
rget
al,1
920
0826
Cons
ulta
tions
inpr
eope
rativ
ecl
inic
inth
eUn
ited
Stat
es.N
oris
kst
ratif
icat
ion
data
ofpa
tient
spro
vide
d.
Qua
ntify
the
amou
ntof
info
rmat
ion
give
nby
anes
thes
iacl
inic
ians
durin
gpr
eane
sthe
ticin
terv
iew
s.
Sem
iqua
ntita
tive
obse
rvat
iona
lstu
dy.
Audi
o-re
cord
edtr
ansc
ripts
.Des
crip
tive
stat
istic
s.
Stub
enro
uch
etal
,20
2017
80Pa
tient
sund
ergo
ing
elec
tive
proc
edur
esw
ithat
leas
t3op
tions
fora
nest
hesi
a(g
ener
al,
neur
axia
l,re
gion
al).
No
risk
stra
tific
atio
nda
taof
patie
ntsp
rovi
ded.
Dete
rmin
eth
ele
velo
fsha
red
deci
sion
-m
akin
gin
anes
thes
iaco
nsul
tatio
ns.
Qua
ntita
tive
obse
rvat
iona
lstu
dy.S
hare
dde
cisi
on-m
akin
gm
easu
red
byO
PTIO
Nsc
ore;
patie
ntan
dph
ysic
ian
subj
ectiv
eas
sess
men
tsw
ithSD
M-Q
-9su
rvey
.
Surv
eysc
ores
.Des
crip
tive
stat
istic
s.M
ultip
lere
gres
sion
mod
elst
ode
term
ine
asso
ciat
ions
betw
een
degr
eeof
shar
edde
cisi
on-m
akin
gan
dsa
tisfa
ctio
nw
ithca
re.
Tait
etal
,21
2011
263
Pare
ntsi
nter
view
edw
hile
thei
rchi
ldw
asin
surg
ery
inM
ichi
gan.
No
risk
stra
tific
atio
nda
taof
patie
ntsp
rovi
ded.
Exam
ine
the
info
rmat
ion
that
pare
ntss
eek
rega
rdin
gth
eirc
hild
’san
esth
esia
,wha
tthe
yar
eto
ld,w
hoto
ldth
em,a
ndho
wm
uch
ofth
ein
form
atio
nth
eyre
call.
Mix
edqu
antit
ativ
ean
dqu
alita
tive
obse
rvat
iona
lstu
dy.
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istr
uctu
red
inte
rvie
wpl
ussu
rvey
.Des
crip
tive
stat
istic
sand
χ2te
stto
dete
rmin
eth
eas
soci
atio
n,if
any,
betw
een
who
and
whe
nco
nsen
twas
take
n,an
dvo
lum
eof
info
rmat
ion
reca
lled.
Trum
ble
etal
,22
2015
14Pa
tient
shav
ing
epid
ural
cath
eter
sins
erte
din
Aust
ralia
.No
risk
stra
tific
atio
nda
taof
patie
ntsp
rovi
ded.
Desc
ribe
and
quan
tify
the
risks
and
bene
fits
ofep
idur
alan
esth
esia
durin
gth
eco
nsen
tpr
oces
s.
Qua
litat
ive
obse
rvat
iona
lstu
dy.
Audi
o-re
cord
edtr
ansc
ripts
.Des
crip
tive
stat
istic
s.
Zollo
etal
,23
2009
27In
terv
iew
swith
stan
dard
ized
patie
ntsi
npr
eane
sthe
sia
clin
icin
New
York
.No
risk
stra
tific
atio
nda
taof
stan
dard
ized
patie
nts
prov
ided
.
Obs
erve
and
desc
ribe
the
patt
erns
ofco
mm
unic
atio
nin
the
prea
nest
hesi
acl
inic
with
2ty
peso
fsta
ndar
dize
dpa
tient
s.
Qua
ntita
tive
obse
rvat
iona
lstu
dyw
ithst
anda
rdiz
edpa
tient
s.Au
dio-
reco
rded
tran
scrip
ts.D
escr
iptiv
est
atis
tics.
Abbr
evia
tions
:ASA
,Am
eric
anSo
ciet
yof
Anes
thes
iolo
gist
s;O
PTIO
N,O
bser
ving
Patie
ntIn
volv
emen
tSco
res;
SDM
-Q-9
,9-it
emSh
ared
Dec
ision
-Mak
ing
Que
stio
nnai
re.
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 4/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
semistructured interviews.21 Of the studies that performed qualitative analyses, only 1 study15
specified a qualitative analysis approach and framework24 for data coding.
Methodological QualityThe summary of the methodological quality is shown in Table 2. Only 4 studies14,16,18,20 usedpreviously validated tools to collect or code data, and 1 study21 created and validated a survey. Eightstudies12,15-20,22 used 2 or more assessors to code recorded data. Eleven studies12,13,15-23 wereevaluated on all CASP criteria, with a median (IQR) score of 4 of 5 (3-5). One study14 was onlyevaluated on 4 of the CASP criteria and scored 3 of 4. Methodological issues and assessment ofquantitative analyses for studies that conducted statistical modeling are shown in Table 3.
Description of Content of CommunicationOnly 2 studies reported communication regarding adverse postoperative medical events, and thiscommunication behavior was reported in only 46 of 1284 consultations (3.6%) across all studies. Ana priori decision was made to specifically evaluate papers for communication data in the followingcategories: (1) discussion of therapeutic options including informed consent, patient comprehension,and risks/benefits, (2) elicitation of values and preferences, (3) shared decision-making, and (4)communication about postoperative care. These categories were chosen because they highlightcommunication that is central to patient-physician consultations around major interventions.Because of the broad types of data found in the review, the second and third categories werecollapsed into a single category, and other data was added as a category to capture data that did notfit into previously defined categories. Study results are summarized in Table 4.
Informed Consent and Patient ComprehensionTen studies12,13,15-17,19-23 included data on these topics. Two studies16,23 examined communication ingeneral without a specific focus. One study of patient and anesthesiologist utterances duringconsultations16 identified a mean of 23% of utterances as being related to patient counseling (exactproportion not provided); however, the coding method used suggests that most utterances coded ascounseling were likely related to technical and logistical aspects of care. A similar result was seen ina study of anesthesia consultations with standardized patients,23 which used mock patient scenarios
Table 2. Critical Appraisal Skills Program Tool Scoring and Quality of Evidence
Source Clear objective Appropriate methodologyData collectionappropriate Validated tools Multiple assessors
Quality ofevidencea
Babitu and Cyna,12 2000 Yes Yes No No Yes (not during datacoding)
4
Barneschi et al,13 2002 Multiple Objectives Only for descriptiveobjectives
Yes No No 4
Flierler et al,14 2013 No clear primaryobjective
Only for descriptiveobjectives
Yes Yes NA 3
Gentry et al,15 2017 Yes Only for descriptiveobjectives
Yes No Yes 4
Kindler et al,16 2005 Yes Yes Yes Yes Yes 4
Lagana et al,17 2012 Yes Yes Yes No Yes 4
Nuebling et al,18 2004 Yes Yes Yes Yes Yes 4
Sandberg et al,19 2008 Yes Yes Yes No Yes 4
Stubenrouch et al,20 2017 Yes Only for descriptiveobjectives
Yes Yes Yes 4
Tait et al,21 2011 No clear primaryobjective
No Yes Validated during study(data not shown)
Not clear 4
Trumble et al,22 2015 Yes Yes Yes No Yes 4
Zollo et al,23 2009 Yes Yes Yes No Not clear 4
Abbreviation: NA, not applicable.a Quality of evidence follows rating scheme from Oxford Centre for Evidence Based
Medicine.
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
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and 2 different standardized patients. In this study, only a mean of less than 1 minute was spentmaking a plan in each encounter.23
Seven studies13,15-17,20,22,23 contained data about risk and benefit discussions; 3 studies13,17,22
specifically evaluated communication of risks. One study17 found that during 91 clinical encounterswith parents of children undergoing anesthesia, in 27 consultations (29.6%) no risks were discussed,and in a further 23 consultations (25.3%), only a general statement of risk was included. Serious riskswere only discussed in 4 encounters (4.4%). In adults undergoing elective surgery, another study13
found that during 40 routine encounters, only 31 preoperative consultations (77.5%) includeddiscussion of at least 1 risk. Where risk was part of consultations (n = 151), patients were almostalways satisfied and not distressed by the discussion (146 of 151 consultations [96.7%]). Conversely,in consultations where no risks were discussed (n = 115), most patients (96 [83.5%]) believed thatthere was no risk to anesthesia at all.13 A small study on epidural insertion22 found a similar degree ofvariability, where the number of risks discussed in consent conversations varied from 0 to 11 perencounter. In studies with a focus other than risk communication that had ancillary data about riskdiscussions, there was a similar degree of variability.15,16,20,23 Most risks specifically evaluated inthese studies were minor, short-term risks. Global assessment of informed consent was evaluated inonly 1 study,15 which found that in conversations with parents of children undergoing anesthesia, theminimum requirements for informed consent were included in 68 of 97 cases (70.1%). Only aminority of conversations (12%, exact proportion not provided) included all 7 aspects of fullyinformed consent as defined by the authors.
Data related to patient comprehension of information communicated by anesthesiologists wereextracted from 4 studies.12,15,19,21 Among studies with objective measures of patient comprehension,patient understanding of risks and benefits of various anesthetic options was poor. For example, 1study showed that many parents recalled a description of the anesthesia planned for their child(96.2%, exact proportion not provided) and plans for postoperative pain control (81.2%, exactproportion not provided), but follow-up questions suggested very few parents fully understood risks,benefits, and complications (28 of 263 parents [10.6%]).21 In another study, parents frequentlyreported understanding risks, benefits, and the anesthetic plan (88%, 96%, and 96%, respectively;exact proportions not provided).15 However, this study only included self-reported parental
Table 3. Methodological Issues Identified in Included Papers
Source Potential for biasBabitu and Cyna,12 2000 Hawthorne effects: patients primed to think about technical terms by enrollment; presence of observer biases anesthesiologist. May exclude terms
not on standardized list used in the study. Small sample and limited patient population.Barneschi et al,13 2002 Small sample. Tools not validated; data only assessed and coded by 1 person. High chance of Hawthorne effect with a direct observer. Data about
risks discussed was limited to predetermined list of potential risks. Large proportion of patients had previous anesthesia, which may have reducedthe chance the anesthesiologist would discuss risks. Quantitative analysis: no primary outcome, no adjustment for multiple comparisons, noinformation on logistical model variable selection or assessment of modeling assumptions. Full final model not presented in the article.
Flierler et al,14 2013 Not designed around a primary objective. Quantitative analysis: no primary outcome, poor justification for sample size.
Gentry et al,15 2017 Small sample of consecutively enrolled patients. Measures of parental recall and understanding of information in the pediatric preanestheticencounter were based solely on the perspective/opinion of the parent, with no objective assessment. Tools for variable assessment not validated.Quantitative analysis: 2 primary outcomes, no sample size calculation, not clear how clustering by clinician was included into model.
Kindler et al,16 2005 No major sources of bias identified beyond selection bias; Hawthorne effect minimized well.
Lagana et al,17 2012 Substantial potential for Hawthorne effect given the direct proximity of observer and the nature of the research question. Did not use validatedtool for data collection.
Nuebling et al,18 2004 Large potential for Hawthorne effect.
Sandberg et al,19 2008 Likely underreported unexplained medical terms used in consultations, given that this is defined by patient queries and these are likely to be asubset of the medical terms misunderstood by patients.
Stubenrouch et al,20 2017 Large potential selection bias. Quantitative analysis: arbitrary exclusion of physicians with low representation in data set, variable selection inmultivariable model not explained or justified, no assessment of modeling assumptions.
Tait et al,21 2011 Entire data set is from parental recall, thus, high risk of recall bias. Selection bias of parents willing to participate, although enrollment was 89%successful.
Trumble et al,22 2015 Large potential for Hawthorne effect. Selection bias of patient and anesthesiologists willing to participate. Small sample size.
Zollo et al,23 2009 Substantial potential for Hawthorne effect given that the participants knew the interviews were conducted with standardized patients.Standardized patient roles may represent outliers from general population. Quantitative analysis: unclear which specific variables were thedependent variables in multivariable modeling (ie, no clear hypothesis or association under evaluation), no justification of covariates included inmodels, no assessment of modeling assumptions or multicollinearity.
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
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Tabl
e4.
Sum
mar
yof
Stud
yRe
sults
Sour
ceO
bjec
tive
Mea
sure
sCo
nsen
tand
patie
ntco
mpr
ehen
sion
Shar
edde
cisi
on-m
akin
gDi
scus
sion
ofpo
stop
erat
ive
care
Oth
erda
taBa
bitu
and
Cyna
,12
2000
Dete
rmin
ew
heth
erpa
tient
sun
ders
tood
tech
nica
lter
msu
sed
inpr
eane
sthe
sia
asse
ssm
ent.
1.N
o.of
tech
nica
lter
msu
sed
inco
nsul
tatio
ns;
2.N
o.of
tech
nica
lter
msn
otun
ders
tood
bypa
tient
s.
89.9
%of
the
tech
nica
lter
msu
sed
byan
esth
esio
logi
stsw
ere
unde
rsto
odby
patie
nts.
Patie
ntsf
aile
dto
unde
rsta
nd≥1
ofth
ete
rmsu
sed
byth
ean
esth
esio
logi
stin
47%
ofco
nsul
tatio
ns.
No
data
.N
oda
ta.
No
addi
tiona
ldat
a.
Barn
esch
ieta
l,13
2002
Dete
rmin
eho
wm
any
patie
nts
rece
ived
info
rmat
ion
abou
tris
ksof
anes
thes
iadu
ring
preo
pera
tive
cons
ulta
tions
with
and
with
out
prim
ing
usin
gan
info
rmat
ion
pam
phle
t.
1.N
o.an
dty
peof
anes
thet
icris
ksdi
scus
sed;
2.Pa
tient
unde
rsta
ndin
gof
risk;
3.Pa
tient
satis
fact
ion
scor
es.
With
outp
atie
ntpr
imin
g,on
ly44
%of
asse
ssm
ents
incl
uded
disc
losu
rean
ddi
scus
sion
ofan
esth
etic
risks
.Whe
nth
ean
esth
esio
logi
stdi
scus
sed
risks
,>9
5%pa
tient
swer
esa
tisfie
dw
ithth
edi
scus
sion
.Whe
nno
risks
wer
edi
scus
sed,
>80%
ofpa
tient
sbel
ieve
dth
atth
ere
wer
eno
risks
from
anes
thes
ia.A
mon
gth
ose
who
fear
edth
eris
ksof
anes
thes
iaan
dw
ere
give
nno
info
rmat
ion
abou
tris
k,m
ore
than
half
wou
ldha
vepr
efer
red
toha
vea
disc
ussi
onof
risks
.
No
data
.De
ath
orse
vere
perm
anen
tha
rmdi
scus
sed
in20
/272
(7.4
%)a
nd22
/272
(8.1
%)
ofin
terv
iew
s,re
spec
tivel
y.Po
stop
erat
ive
pain
men
tione
din
36in
terv
iew
s(13
.2%
).
Addi
tion
ofa
patie
ntpr
imer
with
aqu
estio
nnai
refo
cuse
don
perio
pera
tive
risks
incr
ease
sthe
chan
ces
that
risks
are
disc
usse
ddu
ring
the
preo
pera
tive
asse
ssm
ent.
Flie
rler
etal
,14
2013
Toas
sess
patie
nts’
pref
eren
ces
onbe
ing
invo
lved
insh
ared
deci
sion
-mak
ing
and
itsin
fluen
ceon
thei
rsat
isfa
ctio
n.
1.Pa
tient
and
heal
thca
repr
ofes
siona
lper
cept
ions
ofid
eala
ndac
tual
leve
lof
patie
ntin
volv
emen
tin
deci
sion-
mak
ing;
2.Pa
tient
and
heal
thca
repr
ofes
siona
lper
cept
ions
that
spec
ifici
tem
son
alis
tof
shar
edde
cisio
n-m
akin
gco
mpo
nent
swer
eco
mpl
eted
durin
gen
coun
ters
;3.
Patie
ntsa
tisfa
ctio
nsc
ores
.
No
data
.O
vera
ll,>9
0%of
patie
nts
wis
hed
tobe
invo
lved
inde
cisi
onsa
bout
care
.Goo
dco
ncor
danc
ebe
twee
nan
esth
etis
tsan
dpa
tient
’spe
rcep
tions
ofde
sire
dpa
tient
invo
lvem
enta
ndac
tual
patie
ntin
volv
emen
tin
perio
pera
tive
deci
sion
s.An
esth
etis
tste
nded
toun
dere
stim
ate
patie
nts’
desi
refo
rsha
red
deci
sion
-m
akin
g.Pa
tient
sbel
ieve
dth
atth
eyun
ders
tood
bene
fits
and
draw
back
sto
each
anes
thet
icop
tion
92%
ofth
etim
e,w
hile
anes
thet
ists
belie
ved
this
was
true
only
69%
ofth
etim
e.
No
data
.Pa
tient
satis
fact
ion
scor
esw
ere
wea
kly
corr
elat
edw
ithpa
tient
desi
reto
bein
volv
edin
deci
sion
-m
akin
gbu
twer
eno
taf
fect
edby
conc
orda
nce
betw
een
patie
ntan
dan
esth
esio
logi
stpe
rcep
tion
ofpa
tient
s’de
sire
tobe
invo
lved
inde
cisi
on-
mak
ing.
Ina
mul
tivar
iabl
em
odel
,the
degr
eeof
shar
edde
cisi
on-m
akin
gan
dpa
tient
age
wer
eth
eon
lyva
riabl
esth
atw
ere
asso
ciat
edw
ithpa
tient
satis
fact
ion
scor
es.
Gent
ryet
al,1
520
17Ch
arac
teriz
eth
ein
form
edco
nsen
tdis
cuss
ion.
1.Au
dio-
reco
rdin
gof
cons
ent
conv
ersa
tions
with
subs
eque
ntco
ding
and
quan
tific
atio
nof
spec
ific
elem
ents
;2.
Surv
eyda
taev
alua
ting
dem
ogra
phic
char
acte
ristic
san
dsu
bjec
tive
satis
fact
ion
leve
ls.
Ove
rall,
95%
ofin
form
edco
nsen
tco
nver
satio
nsin
clud
edso
me
disc
ussi
onof
risk,
and
70%
cont
aine
d≥3
elem
ents
ofin
form
edco
nsen
t(r
awda
tano
tpro
vide
d).A
mon
gsu
bset
ofdi
scus
sion
stha
tinc
lude
d≥3
elem
ents
ofin
form
edco
nsen
t,pa
rent
alre
call
rate
sfor
risks
,be
nefit
s,an
dan
esth
etic
plan
wer
e84
%,8
5%,a
nd97
%,r
espe
ctiv
ely
(raw
data
notp
rovi
ded)
.Sel
f-re
port
edpa
rent
alco
mpr
ehen
sion
rate
sfor
thes
eel
emen
tsw
as88
%,
96%
,and
96%
,res
pect
ivel
y(r
awda
tano
tpro
vide
d).
Disc
ussi
onof
unce
rtai
nty
(48%
)and
disc
ussi
onof
patie
ntpr
efer
ence
s(18
%)
wer
em
ostc
omm
only
mis
sing
elem
ents
ofin
form
edco
nsen
t.
No
data
.Pa
rent
alre
call
ofel
emen
tsof
info
rmed
cons
entw
asco
rrel
ated
with
pres
ence
of≥3
elem
ents
ofin
form
edco
nsen
tin
preo
pera
tive
disc
ussi
ons(
ie,r
isks
,be
nefit
s,an
dpl
an).
Mos
tpa
rent
s(85
%,r
awda
tano
tpr
ovid
ed)w
ere
satis
fied
with
info
rmed
cons
ent
conv
ersa
tions
,reg
ardl
ess
ofel
emen
tsin
clud
edin
cons
entp
roce
ss. (c
ontin
ued)
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
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Tabl
e4.
Sum
mar
yof
Stud
yRe
sults
(con
tinue
d)
Sour
ceO
bjec
tive
Mea
sure
sCo
nsen
tand
patie
ntco
mpr
ehen
sion
Shar
edde
cisi
on-m
akin
gDi
scus
sion
ofpo
stop
erat
ive
care
Oth
erda
taKi
ndle
reta
l,16
2005
Desc
ribe
the
natu
reof
the
patie
nt-a
nest
hetis
tint
erac
tion
and
shar
edde
cisi
on-m
akin
g.
1.U
tter
ance
sfro
mth
epa
tient
and
anes
thet
istw
ere
code
dus
ing
2pr
evio
usly
valid
ated
codi
ngto
ols;
2.O
PTIO
Nsc
ores
.
No
spec
ific
data
ondi
scus
sion
ofris
ks.M
ean
of23
%of
utte
ranc
esab
outc
ouns
ellin
g;th
isin
clud
ed18
.7%
ofut
tera
nces
abou
tdes
crib
ing
vario
usan
esth
etic
tech
niqu
es.B
ased
onde
tails
ofut
tera
nce
code
s,on
ly8.
9%of
utte
ranc
esin
clud
eddi
scus
sion
ofbe
nefit
s/ris
ksof
vario
usan
esth
etic
tech
niqu
es.T
here
mai
nder
ofth
eco
unse
lling
utte
ranc
esw
ere
abou
tpat
ient
prep
arat
ion
(exp
lain
ing
tech
niqu
es/l
ogis
ticsa
ndex
pect
atio
nm
anag
emen
t)an
dpa
tient
reas
sura
nce.
Inth
e21
cons
ulta
tions
that
invo
lved
shar
edde
cisi
on-
mak
ing,
mea
nO
PTIO
Nsc
ores
wer
e26
.8(o
f100
).An
esth
esia
prof
essi
onal
sco
mm
only
liste
dch
oice
sfor
anes
thet
icte
chni
ques
(19
of21
visi
ts)b
utra
rely
conf
irmed
patie
ntun
ders
tand
ing
(2of
21vi
sits
).In
addi
tion,
elic
itatio
nof
patie
ntex
pect
atio
ns,
conc
erns
,and
pref
eren
ces
was
rare
inO
PTIO
Nsc
ores
.
Utte
ranc
esab
out
post
oper
ativ
eca
rew
ere
rare
(2.3
%of
all
utte
ranc
es,i
nclu
ding
utte
ranc
esab
outp
ain
cont
rol)
.
Ove
rall,
26%
ofut
tera
nces
byph
ysic
ians
wer
equ
estio
ns,t
hem
inor
ityof
whi
chw
ere
open
ende
d(3
.4%
).Fe
wut
tera
nces
abou
tpsy
chos
ocia
liss
ues
(<0.
1%)o
rem
path
izin
g(0
.5%
).St
atis
tical
lysi
gnifi
cant
asso
ciat
ions
wer
efo
und
betw
een
use
ofop
en-e
nded
ques
tions
,fa
cilit
atin
gst
atem
ents
,and
emot
iona
lsta
tem
ents
byan
esth
etis
tsan
dle
velo
fpa
tient
invo
lvem
ent,
but
the
mag
nitu
deof
thes
eco
rrel
atio
nsw
assm
all.
Laga
naet
al,1
720
12O
bser
vean
did
entif
yth
enu
mbe
ran
dna
ture
ofan
esth
esia
risks
cons
ider
edan
dco
mm
unic
ated
topa
rent
s/gu
ardi
ans.
1.N
o.of
risks
disc
usse
din
preo
pera
tive
inte
rvie
ws.
27/9
1co
nsul
tatio
nsco
ntai
ned
nodi
scus
sion
ofris
k.23
/91
cons
ulta
tions
only
incl
uded
gene
ral
stat
emen
tsw
ithno
elab
orat
ion
ordi
scus
sion
ofm
ater
ialc
onse
quen
ces.
Mos
tcom
mon
risks
disc
usse
d:na
usea
and
vom
iting
(36%
);so
reth
roat
(35%
);al
lerg
y(2
9%);
hypo
xia
(25%
);an
dem
erge
nce
delir
ium
(19%
).
No
data
.Sp
ecifi
csi
tuat
ions
refle
ctin
gca
rebe
yond
the
OR
rare
lym
entio
ned
(pro
long
edin
tuba
tion,
1in
stan
ce;p
rolo
nged
adm
issi
on,3
inst
ance
s;de
ath,
0in
stan
ces)
.
No
addi
tiona
ldat
a.
Nue
blin
get
al,1
820
04O
bser
veth
eas
soci
atio
nbe
twee
nph
ysic
ians
’rea
ssur
ing
utte
ranc
esan
da
varie
tyof
patie
ntut
tera
nces
.
1.Au
dio
reco
rdin
gof
patie
nten
coun
ters
with
codi
ngan
dca
tego
rizat
ion
ofut
tera
nces
from
patie
ntsa
ndph
ysic
ians
.
No
data
.N
oda
ta.
No
data
.Ph
ysic
ian
reas
surin
gan
d/or
optim
istic
utte
ranc
esw
ere
asso
ciat
edw
ithpa
tient
utte
ranc
esth
atas
ked
for
reas
sura
nces
,exp
ress
edco
ncer
n,or
expr
esse
dop
timis
man
d/or
self-
reas
sura
nce.
Sand
berg
etal
,19
2008
Toqu
antif
yth
eam
ount
ofin
form
atio
ngi
ven
topa
tient
sby
anes
thes
iacl
inic
ians
durin
gpr
eane
sthe
ticin
terv
iew
s.
1.Au
dio
reco
rdin
gsof
prea
nest
hetic
cons
ulta
tions
with
quan
tific
atio
nof
volu
me
ofin
form
atio
nco
nvey
eddu
ring
enco
unte
rs.
No.
ofin
form
atio
nun
itsin
prof
essi
onal
s’co
mm
unic
atio
ngr
eatl
yex
ceed
edpa
tient
s’in
form
atio
nst
orin
gca
paci
ty.N
urse
spr
ovid
edm
ore
info
rmat
iona
luni
tsco
mpa
red
with
phys
icia
ns(m
ean
[SD]
,112
[37]
vs49
[25]
;P<
.001
)O
verw
helm
ing
maj
ority
ofco
mm
unic
atio
nbe
havi
orre
late
dto
info
rmat
iona
luni
ts.
No
data
.N
oda
ta.
No
addi
tiona
ldat
a.
Stub
enro
uch
etal
,20
2017
Dete
rmin
eth
ele
velo
fsha
red
deci
sion
-mak
ing
inan
esth
esia
cons
ulta
tions
.
1.Au
dio
reco
rdin
gof
prea
nest
hetic
enco
unte
rsw
ithsu
bseq
uent
codi
ngof
tran
scrip
ts;
2.O
PTIO
Nsc
ores
;3.
Surv
eyda
taus
ing
SDM
-Q-9
with
patie
ntsa
ndan
esth
esio
logi
sts.
Hea
lth
care
prof
essi
onal
srar
ely
expl
ain
bene
fitsa
ndris
kof
vario
usan
esth
etic
optio
ns.
Hea
lth
care
prof
essi
onal
dono
texp
lain
the
need
tode
liber
ate
and/
orco
nsid
eran
esth
etic
optio
nsin
conj
unct
ion
with
patie
ntpr
efer
ence
s,in
freq
uent
lyel
icit
patie
ntpr
efer
ence
s,an
ddo
notm
ake
adeq
uate
atte
mpt
sto
inte
grat
epa
tient
pref
eren
cesi
nto
deci
sion
-mak
ing.
No
data
.Pe
rcep
tion
ofqu
ality
ofsh
ared
deci
sion
-mak
ing
high
amon
gcl
inic
ians
and
patie
nts,
asm
easu
red
bySD
M-Q
-9an
dSD
M-Q
-Doc
,de
spite
obje
ctiv
em
easu
res
ofad
equa
cyof
shar
edde
cisi
on-m
akin
gbe
ing
very
low
.
(con
tinue
d)
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 8/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
Tabl
e4.
Sum
mar
yof
Stud
yRe
sults
(con
tinue
d)
Sour
ceO
bjec
tive
Mea
sure
sCo
nsen
tand
patie
ntco
mpr
ehen
sion
Shar
edde
cisi
on-m
akin
gDi
scus
sion
ofpo
stop
erat
ive
care
Oth
erda
taTa
itet
al,2
120
11To
exam
ine
the
info
rmat
ion
that
pare
ntss
ough
treg
ardi
ngth
eir
child
’san
esth
esia
,wha
tthe
yar
eto
ld,w
hoto
ldth
em,a
ndho
wm
uch
ofth
ein
form
atio
nth
eyco
uld
reca
ll.
1.Se
mist
ruct
ured
inte
rvie
ws
asse
ssin
gpa
rent
alre
calla
ndco
mpr
ehen
sion
ofin
form
atio
nin
prea
nest
hetic
cons
ulta
tions
and
pare
ntal
pref
eren
cesf
orho
wto
rece
ive
info
rmat
ion;
2.Ti
min
gof
cons
enta
ndro
leof
pers
onob
tain
ing
cons
ent.
Ove
rall,
96%
ofpa
rent
srec
alle
da
desc
riptio
nof
anes
thes
iaat
the
time
ofco
nsen
t,an
d81
%re
calle
da
disc
ussi
onab
outp
osto
pera
tive
pain
cont
rol.
Mor
eth
anha
lfco
uld
reca
lla
disc
ussi
onab
outr
isks
and
bene
fitso
fan
esth
esia
;46.
2%of
pare
nts
repo
rted
havi
nga
com
plet
eun
ders
tand
ing
ofan
esth
esia
,and
42.4
%re
port
edha
ving
aco
mpl
ete
unde
rsta
ndin
gof
pain
man
agem
ent.
Very
few
(11%
)rep
orte
dha
ving
aco
mpl
ete
unde
rsta
ndin
gof
risks
and
bene
fitso
fane
sthe
sia.
No
data
.Po
stop
erat
ive
pain
cont
rol
reca
lled
in81
%of
case
s(n
ora
wda
ta),
but
com
plet
eun
ders
tand
ing
only
in10
1/23
8fo
llow
-up
inte
rvie
ws(
42.4
%).
Mos
tpar
ents
pref
erre
da
com
bina
tion
ofw
ritte
nan
dve
rbal
info
rmat
ion
durin
gth
eco
nsen
tpro
cess
,and
mos
tpre
ferr
edto
have
cons
entd
one
with
ina
wee
kof
surg
ery.
Pare
ntal
reca
llap
pear
edto
bebe
tter
whe
nco
nsen
twas
take
non
the
day
ofsu
rger
yan
dw
hen
cons
entw
asta
ken
byan
anes
thes
iapr
ofes
sion
al.
Trum
ble
etal
,22
2015
Tode
scrib
ean
dqu
antif
yth
eris
ksan
dbe
nefit
sofe
pidu
ral
anes
thes
iadu
ring
the
cons
ent
proc
ess
1.Au
dio
reco
rdin
gof
cons
ent
conv
ersa
tions
prio
rto
epid
ural
plac
emen
twith
codi
ngan
dqu
antif
icat
ion
ofris
ksdi
scus
sed.
No.
ofris
ksdi
scus
sed
prio
rto
proc
edur
eva
ried
from
0to
11,w
itha
med
ian
of7
risks
perd
iscu
ssio
n.Th
em
ostc
omm
only
disc
usse
dris
ksw
ere
faile
dbl
ock,
post
dura
lpun
ctur
ehe
adac
he,n
erve
dam
age,
epid
ural
blee
ding
,and
epid
ural
infe
ctio
n.At
leas
t1ris
kw
asqu
antif
ied
in71
.4%
ofdi
scus
sion
s.Be
nefit
sand
alte
rnat
ives
wer
edi
scus
sed
inon
ly21
.4%
ofca
ses.
No
data
.N
oda
ta.
No
data
.
Zollo
etal
,23
2009
Toob
serv
ean
dde
scrib
eth
epa
tter
nsof
com
mun
icat
ion
inth
epr
eane
sthe
sia
clin
icw
ith2
type
sof
stan
dard
ized
patie
nts(
ie,
info
rmat
ion
seek
eran
din
form
atio
nbl
unte
r).
1.Au
dio
reco
rdin
gof
enco
unte
rsw
ithst
anda
rdiz
edpa
tient
swith
quan
tific
atio
nof
time
spen
ton
vario
usas
pect
soft
hein
terv
iew
;2.
Post
enco
unte
rqu
estio
nnai
resa
ndpa
tient
satis
fact
ion
scor
es.
Mea
nof
2m
insp
entd
iscu
ssin
gris
ks,
with
slig
htly
mor
etim
esp
entw
hen
patie
ntis
anin
form
atio
nse
eker
vsin
form
atio
nbl
unte
r(1.
6m
invs
2.4
min
).Sp
ecifi
cris
ksdi
scus
sed
varie
dby
enco
unte
r.N
osp
ecifi
cda
taon
coun
selin
g,re
assu
ranc
e,or
prep
arat
ion.
Mea
nof
<1m
insp
ent
mak
ing
apl
an,2
-3m
insp
ent
desc
ribin
ga
gene
rala
nest
hetic
,and
1.2
min
disc
ussi
ngpo
stop
erat
ive
pain
cont
rol.
Ove
rall,
<1m
insp
ent
obta
inin
gpa
tient
pers
pect
ive
inpr
eope
rativ
een
coun
ters
.In
post
inte
rvie
wpa
tient
ques
tionn
aire
s,re
spon
sest
oth
equ
estio
ns,“
Tow
hat
exte
ntdi
dth
ean
esth
etis
task
abou
tyou
rgoa
lsfo
rthe
anes
thet
ican
dre
cove
ry?”
and
“To
wha
text
entd
idth
ean
esth
etis
tenc
oura
geyo
uto
take
the
role
you
wan
ted
inyo
urow
nca
re”
wer
em
ostly
“alit
tle”
or“n
otat
all,”
indi
catin
gin
freq
uent
elic
itatio
nof
patie
ntpr
efer
ence
s.
Mea
nof
1.2
min
disc
ussi
ngpo
stop
erat
ive
pain
cont
rol.
No
data
ondi
scus
sion
ofbr
oade
rpos
tope
rativ
eca
re.
Impr
oved
satis
fact
ion
scor
esw
ithm
ore
expe
rienc
edan
esth
esia
prof
essi
onal
sin
the
info
rmat
ion
seek
erin
terv
iew
sand
with
thos
ew
hore
port
edha
ving
prev
ious
lyta
ken
any
kind
ofco
mm
unic
atio
nsco
urse
.
Abbr
evia
tions
:OPT
ION
,Obs
ervi
ngPa
tient
Invo
lvem
entS
core
s;SD
M-Q
-9,9
-item
Shar
edD
ecisi
on-M
akin
gQ
uest
ionn
aire
.
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 9/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
comprehension. When considering specific words used in consultations, 1 study12 demonstrated thatalthough patients misunderstood a minority of technical terms used by anesthesiologists (49 of 484terms [10.1%] misunderstood across all encounters), there was at least 1 instance of patientsmisunderstanding in 32 of 68 individual encounters (47.1%).12 Another aspect of communicationrelating to patient comprehension was evaluated by a study that measured the amount ofinformation given to patients preoperatively by anesthesia professionals.19 This study found thatpatients’ information storing capacity was consistently exceeded in preoperative encounters.19
Shared Decision-MakingFive studies14-16,20,23 had data about eliciting patient preferences and shared decision-making. In the2 studies16,23 that evaluated communication generally, elicitation of patient preferences and valueswas uncommon. In 1 study,23 anesthesiologists spent less than 1 minute obtaining patientperspectives during encounters that were a mean (SD) of 15.9 (4.9) minutes long. Another study16
showed no utterances eliciting patient preferences during consultations. Across 21 encounters in thisstudy that required a shared decision, the Observing Patient Involvement Scores (OPTION scores25)were poor, with elicitation of patient input categories receiving the lowest scores.16 There weresimilar findings in a study of informed consent in pediatric anesthesia,15 which showed that elicitationof parental preferences was uncommon (18% of consultations, exact proportion not provided). Twostudies14,20 examined shared decision-making. In 1 study of shared decision about neuraxial vsgeneral anesthesia,20 OPTION scores showed that anesthesia professionals rarely explained thebenefits and risks of anesthetic options and did not elicit or make adequate attempts to integratepatient preferences into decision-making. Another study14 had similar findings: most patients(>90%) wanted to be involved in decisions about their care, and anesthetists tended tounderestimate patients’ desire for shared decision-making.
Discussions About Postoperative CareDiscussions about postoperative care were rare: this type of communication was described in 5studies,13,16,17,21,23 and postoperative pain control dominated these discussions. Only 2 studies13,17
presented data on communication about specific adverse outcomes. In these studies, there were 4instances of communication about postoperative events across 91 interviews (4.4%) in 1 study,17 anddeath or severe permanent harm discussed in 20 of 272 interviews (7.4%) and 22 interviews (8.1%),respectively, in another study.13 None of the studies had any data about elicitation of patientpreferences regarding direction of care in the case of serious adverse events.
Other DataEight studies13-16,18,20,21,23 had some additional data about patient satisfaction or perception of thequality of the encounter following anesthesia consultations. Satisfaction was generally high,regardless of which specific components were included in interviews,15,20 and satisfaction may havea positive association with degree of patient involvement in care decisions14 and with moreexperienced anesthesia professionals.23
Discussion
This systematic review of the literature on communication between anesthesia professionals andpatients found only 12 studies that met inclusion criteria. The studies had an overall moderate levelof methodological quality. The main finding is that communication about postoperative care wasrarely described in preoperative consultations with anesthesia professionals; the literature had nodata describing anesthesiologist-patient communication addressing protracted ICU stay, protractedventilation, and end-of-life care in the setting of postoperative incomplete recovery. These findingsare consistent with a previous narrative review on patient-anesthesiologist communication7;however, this review contributes a more robust summary of the evidence by using a systematic
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 10/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
search strategy, extracting and qualitatively collating data from superior data sources, assessing thequality of each study using an established evaluation tool, and including 11 studies that, to ourknowledge, have not been summarized in any previous review on this topic. These data are alsosimilar to previously published data on surgeon communication, showing little elicitation of values orpreferences regarding these issues in surgical consultations.1,2 Therefore, most patients whoundergo major surgical interventions do not have preoperative discussions about values,preferences, or goals of care that address the scenario of protracted or incomplete recovery fromsurgery. Several other findings emerge from the data. First, informed consent, including discussionof risks and benefits, is highly variable, and patient comprehension of risks, benefits, and therapeuticalternatives is frequently poor when measured objectively. Second, anesthesia professionalsfrequently give patients unmanageable amounts of information, and communication is often focusedon technical and logistical aspects of care. Lastly, anesthesiologists infrequently engage in elicitationof patient values and shared decision-making, despite patients’ apparent desire to be involved indecision-making.
Professional society guidelines in anesthesia recommend that “anesthesiologists should includepatients, including minors, in medical decision making that is appropriate to their developmentalcapacity and the medical issues involved.”26 However, there are many barriers to discussions ofpatient values, preferences, and goals of care in the preoperative setting. In many North Americansurgical centers, anesthesiologists only become involved in the care of surgical patients after theyhave made the decision to proceed to the operating room with their surgeon. Therefore, it is likelythat many anesthesiologists focus on getting the patient through the operation and may see this kindof communication and patient value exploration as not a part of their job. Second, there are largefinancial incentives to proceed to the operating room, for surgeons as well as anesthesiologists,putting additional emphasis on moving the patient through the operating room. Third, manyanesthesiologists lack the specific expertise to speak to perioperative issues that reach beyond theoperating room. Lastly, given the volume of patients seen at anesthetic clinics, anesthesiologistslikely feel tremendous time pressure and probably feel they do not have adequate time for (and arenot adequately compensated for) protracted discussion of perioperative values, preferences, andgoals of care. In cases where there are nontrivial risks that may result in a significant change in apatient’s health status or prolonged burdensome care (for example, ventilator dependence after apostoperative stroke), then anesthesia consultations without discussion of postoperative care andelicitation of patient preferences may represent a missed opportunity to raise these issues.Identifying patients at risk for postoperative complications, such as prolonged mechanicalventilation, weakness, and postoperative delirium, can provide an important perspective onperioperative decisions. Literature on communication from outside anesthesiology suggests thatpatients often agree to a plan of care that is inconsistent with their values and preferences, includingundergoing surgery.27 Informed consent for major surgery that explores these factors is oftenpossible in a 20- to 30-minute clinical encounter.28 Therefore, it seems both feasible and valuable foranesthesiologists to engage in balancing risks and benefits in the context of the patient’s valuesduring preoperative consultations, especially when anesthesiologists are involved inpostoperative care.
The 2 other physician specialties that routinely encounter surgical patients, namely surgery andcritical care, have studied communication extensively compared with the findings here. For example,there have been several recent reviews on surgeon-patient communication,1,29,30 including asystematic review1 that only included studies with audiotaped or videotaped interactions and at least1 objective measure of surgeon behavior or communication skills. This review reported data from 21studies and an additional 13 companion reports. If these selection criteria were applied to thissystematic review of anesthesia and patient communication, only 1 study would be included.Similarly, there have been multiple reviews of physician-patient communication in critical caremedicine,31-33 a discipline in which specific types of communication, such as end-of-life
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 11/15
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communication34,35 and communication strategies for difficult decision-making,36-38 have beenbroadly evaluated.
Based on the data in this review, several hypotheses follow regarding strategies to improvepatient-anesthesiologist communication. First, if anesthesia professionals adapt to patients’individual communication needs, patient participation and satisfaction may improve, although thisstrategy has not led to measurable improvement in communication about end-of-life issues in ICU.39
Second, while there is tension between providing too much information (risking informationoverload) and not providing enough information (risking inadequate patient understanding andinformed consent), the data suggest that communication may improve if anesthesia professionalsidentify and emphasize important nontechnical information specific to each individual patient.Lastly, for anesthesiologists involved in perioperative medicine, patients who are at high risk ofincomplete recovery may benefit from elicitation of values and preferences regarding postoperativecare during preoperative consultations. Shifting the focus of anesthetic care to perioperativemedicine and specifically improving preoperative communication about goals of care is likely to be asignificant challenge for the specialty of anesthesiology. Several interventions aimed at perioperativeadvance care planning have been developed and evaluated,40-42 providing some guidance foranesthesiologists expanding their practice into perioperative medicine.
LimitationsThis systematic review has several limitations. First, the search was limited to studies published inEnglish from 1980 to April 2020. Although additional data may have been published earlier orindexed elsewhere, they are not likely to be relevant to current practice. The search only found 12studies with different designs, settings, and outcomes, making synthesis challenging. Commonlimitations for the studies that were reviewed included unavoidable selection bias due to selectiveparticipation; the Hawthorne effect in studies that employed direct observation (2 of 12 studies), andthe infrequent use of validated analysis or coding tools (only 4 of 12 studies used validated tools).The survey-based studies (3 of 12 studies) were limited by recall bias of patients and health careprofessionals. Nine studies implemented mitigation strategies for these biases. Lastly, only 3 studiesprovided data about the risk category of the patients in their analyses, and most patients wereconsidered low risk for complications. Preoperative communication with patients with higher riskmay be substantially different compared with the communication patterns found in this review.These limitations make it difficult to draw concrete conclusions about communication in anesthesiaand implications for patients who have incomplete recovery.
Conclusions
This systematic review of the literature on patient-anesthesiologist communication found thatcommunication in anesthesia rarely includes discussion of postoperative care or patient values andpreferences, but rather is dominated by anesthetic planning and perioperative logistics. Thesefindings, coupled with similar data from surgical literature, suggest that most patients who arrive inthe critical care unit following a major operation have not had a preoperative discussion about values,preferences, and goals of care specific to protracted recovery or prolonged intensive care.
ARTICLE INFORMATIONAccepted for Publication: August 28, 2020.
Published: November 12, 2020. doi:10.1001/jamanetworkopen.2020.23503
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Tylee MJ et al.JAMA Network Open.
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
JAMA Network Open. 2020;3(11):e2023503. doi:10.1001/jamanetworkopen.2020.23503 (Reprinted) November 12, 2020 12/15
Downloaded From: https://jamanetwork.com/ on 01/24/2022
Corresponding Author: Michael J. Tylee, MD, Department of Anesthesia and Pain Management, University HealthNetwork, Toronto General Hospital, 200 Elizabeth St, 3EN-464, Toronto, ON M5G 2C4, Canada ([email protected]).
Author Affiliations: Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario,Canada (Tylee, Rubenfeld, Adhikari); Department of Anesthesia and Pain Management, University HealthNetwork, Toronto General Hospital, Toronto, Ontario, Canada (Tylee); Department of Anesthesia, University ofToronto, Toronto, Ontario, Canada (Tylee, Wijeysundera); Interdepartmental Division of Critical Care, University ofToronto, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada (Rubenfeld, Sklar, Adhikari); Department ofAnesthesia, St Michael’s Hospital, Toronto, Ontario, Canada (Wijeysundera); Department of Intensive CareMedicine, King AbdulAziz Medical City, Riyadh, Saudi Arabia (Hussain).
Author Contributions: Drs Adhikari and Tylee had full access to all of the data in the study and take responsibilityfor the integrity of the data and the accuracy of the data analysis. Drs Rubenfeld and Adhikari contributed equallyin senior authorship positions.
Concept and design: Tylee, Rubenfeld, Sklar, Hussein, Adhikari.
Acquisition, analysis, or interpretation of data: Tylee, Rubenfeld, Wijeysundera, Sklar, Adhikari.
Drafting of the manuscript: Tylee, Rubenfeld, Sklar.
Critical revision of the manuscript for important intellectual content: All authors.
Administrative, technical, or material support: Sklar, Hussein.
Supervision: Rubenfeld, Adhikari.
Conflict of Interest Disclosures: None reported.
Funding/Support: Funded academic time provided for Dr Tylee by the Department of Critical Care Medicine,Sunnybrook Health Sciences Centre, and by the Department of Anesthesia and Pain Management, TorontoGeneral Hospital.
Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; anddecision to submit the manuscript for publication.
Additional Contributions: Henry Lam, MLS (Sunnybrook Health Sciences Centre Library) assisted with theliterature search and was not compensated for this contribution.
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2. Pecanac KE, Kehler JM, Brasel KJ, et al. It’s big surgery: preoperative expressions of risk, responsibility, andcommitment to treatment after high-risk operations. Ann Surg. 2014;259(3):458-463. doi:10.1097/SLA.0000000000000314
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SUPPLEMENT.eAppendix 1. MEDLINE Search StrategyeAppendix 2. Study Inclusion CriteriaeAppendix 3. Study Exclusion CriteriaeAppendix 4. Studies Excluded on Full Text Review
JAMA Network Open | Anesthesiology Anesthesiologist to Patient Communication: A Systematic Review
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