decision-making model (4). Under the paternalistic model, the physician employs his expertise in service of what he perceives to be the patient’s best interest. The patient’s role is passive, and the physician decides on the best course of action. The informed decision-making model involves the physician providing relevant technical information to the patient (e.g., risks, benefits, clinical effectiveness, alternatives), and then allowing the patient to decide for themselves based on their own values and preferences. Following this transfer of information, the physician’s role is passive (so as to avoid encroaching on the patient’s autonomy), and the patient decides on the best course of action.
Communicating with patients about the risks and benefits of possible interventions
Eliciting patients’ goals, values, and concerns
Assisting patients in how to conceptualize the risks and benefits/how to approach the decision
planning. For example, in a study of over 1,000 preoperative patients, 8% could not identify their diagnosis, 10% could not identify their procedure, and 7% reported that they did not know the risks and benefits of different options (14). Other studies have suggested even lower rates of understanding/recall. Only 48% of vascular surgery patients were able to demonstrate knowledge of risks and potential complications and orthopedic surgery patients’ recall of specific potential complications ranged from 37% to 61% (15,16).
State the decision the patient is facing.
Communicate evidence-based information regarding the underlying medical condition as well as the management options, including risks, benefits, and areas of uncertainty.
Assist the patient in making a decision by describing risks and benefits in such a way that patients can (a) imagine the possible physical and emotional effects of surgery and (b) consider what matters most to them (23).
Identifying, communicating, and minimizing patient-specific risks using evidencebased protocols (e.g., medical optimization with beta blockers and statins)
Educating patients prior to surgery to diminish anxiety and optimize recovery
Developing plans for individualized postoperative pain management
Structure (knowledge of procedure and risks/benefits)
Process (patient comfort with the extent of discussion about the decision)
Outcome (patient certainty that the decision is right for them)
Figure 16.2 Conceptual model for measuring quality of preoperative decision making. ACP, advanced care planning.
concurrent sedation. The guidelines are not applicable to laboring women or patients undergoing emergency surgery (i.e., to prevent loss of limb or life). It is important to note that patients with an increased risk of aspiration (see Table 16.3) may require additional evaluation and modification of the anesthetic plan to prevent aspiration. Therefore, a thorough preoperative screening history and examination should be obtained for every patient anticipating anesthesia in order to identify these characteristics. The following ASA NPO guidelines apply to both pediatric and adult populations.
gastric pH; however, obesity without any comorbidity has not been demonstrated in our current literature to consistently increase a patient’s risk for aspiration. It is important to note that obesity can be associated with other risk factors for aspiration, such as diabetes mellitus. In our current practice, morbid obesity (BMI >40) is considered a risk factor for aspiration. Patients at risk of aspiration who also have concurrent pulmonary disease predisposing them to worsened respiratory complications should be given special consideration during the preoperative evaluation process.
TABLE 16.2 Fasting Guidelines