It is important that healthcare providers refer the patient back to the anesthesiologist for evaluation. Dismissing reports of awareness as merely dreaming because of disprovable elements may contribute to preventable psychological stress and harm. It is equally important to refrain from offering opinions that someone must have done something wrong for this to have occurred. A low incidence of awareness under general anesthesia is unavoidable with current medications and technology. Moreover, intraoperative conditions may arise that increase the risk for intraoperative awareness. If cardiac instability or hemorrhage occurs during surgery, compromising the ability of the patient to tolerate general anesthesia, an anesthesiologist may choose to reduce the anesthesia during resuscitation and risk awareness rather than allowing hypotension to persist, risking death. The anesthesiologist who provided the anesthetic is in the best position to perform the evaluation of the patient reporting intraoperative awareness.
In managing a case of suspected awareness, the American Society of Anesthesiologists (ASA) Task Force on Intraoperative Awareness recommends that patients reporting possible intraoperative awareness be interviewed to obtain a detailed account of the patient’s experience and an explanation offered to the patient as to reasons why this may have occurred. Patients should be offered counseling and psychological support, and if awareness is suspected, an occurrence report should be generated for quality management.[20] The Joint Commission, which offers accreditation for healthcare organizations in the United States, offers the same recommendations as the ASA. Additionally, the Joint Commission suggests that an apology be offered to the patient if awareness has occurred and that the patient be reassured that their account is believed by the physician. The Joint Commission recommends that each Anesthesiology Department maintain a policy on intraoperative awareness and that all members of the perioperative team including surgeons, nurses, and other key personnel be educated about intraoperative awareness and how to manage it.[21] The Anesthesiology Department should also establish a relationship with specific counselors and psychiatric support teams that are experienced in cases of awareness.
Although apologies to patients over undesirable clinical outcomes have been demonstrated to reduce subsequent litigation, many physicians are still reluctant to offer apologies. Many fear that apologies may be construed as admission of malpractice and could be introduced as evidence of guilt during subsequent civil litigation. Previously, spontaneous apologies have been admissible as evidence in civil litigation as an exception to the hearsay rule. Recognizing that this has an inhibiting effect of disclosure of adverse healthcare events, many states now shield healthcare providers with the creation of “apology laws.” The first apology law was enacted in Massachusetts in 1986 and states:
“Statements, writings or benevolent gestures expressing sympathy or a general sense of benevolence relating to the pain, suffering or death of a person involved in an accident and made to such person or to the family of such person shall be inadmissible as evidence of an admission of liability in a civil action.”[22]
Most states have now created their own apology laws. An apology does not need to acknowledge error if none has occurred. An effective apology may merely be an empathetic acknowledgement of the patient’s distress. Statements such as “I’m sorry this happened to you” may suffice. However, some studies have shown that apologies that go beyond mere expressions of sympathy and accept responsibility for the outcome may have a greater effect in reducing litigation.[23]
Psychological support and counseling is prudent for the intraoperative awareness patient and should be offered to all patients troubled by the experience. Individuals experiencing Michigan Awareness Class 3 or greater should be particularly encouraged to enroll in counseling and offered appropriate follow-up care.
References
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