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Some practices require mandatory preoperative laboratory testing for select patients presenting for anesthesia and surgery. Such mandatory preanesthesia laboratory testing has significant ethical implications related to informed consent and patient autonomy. Assumptions that a patient provides "presumed consent" by merely presenting for a test are flawed because such consents are often not informed and do not acknowledge patient autonomy. By placing a condition on access to a medical treatment, mandatory preanesthesia testing may not be ethically justifiable. Not all laboratory tests are "ethically equal"; several raise specific questions regarding informed consent, related to their potential to cause significant harm., Competing Interests: Disclosures All authors assert that they have no commercial or financial interests concerning this publication and have received no funding., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Because modern surgical and medical care have advanced, patients increasingly present for procedural and surgical intervention with life-limiting diagnoses and/or advanced care goals such as "do not resuscitate." Anesthesiologists now care for these patients across the complete perioperative setting and frequently find themselves at the crossroads of these mounting pressures. As the boundaries and capabilities of anesthetic care and critical care anesthesiology expand so too do the specialty's needs for support in ethical decision-making. Herein, we review the role of the ethics consultation in anesthesia practice and special ethic issues encountered by the anesthesiologist., Competing Interests: Disclosure Dr A.P. Notarianni reports no relevant commercial or financial disclosures relevant to the topic., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Facing ethical dilemmas is challenging and sometimes becomes a real burden for anesthesiologists, particularly because they rarely have previous or long-standing patient relationships that help inform clinical decision-making. Although there is no ideal algorithm that can fit all clinical situations, some basic moral and ethical principles, which should be part of every clinician's armamentarium, can guide the decision-making process. Dealing with conflicting views among providers and/or patients can be distressing but can lead to meaningful professional and personal growth for each clinician., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Children commonly refuse induction of anesthesia. Anesthesia providers must then decide whether to honor the child's dissent or to proceed over objection. In some circumstances, a forced induction involves restraining the child, incurring both practical and ethical harms to the patient-provider encounter. This educational review explores the practical dilemma encountered when a child dissents to induction of anesthesia. In the course of exploring this dilemma, dissent and associated terms are defined and compared, and the prominent ethical underpinnings regarding pediatric decision-making are described to clarify dissent as an ethical and practical concept. Important legal and professional standards are summarized, and practice trends are discussed to depict the current state of practice, including novel approaches to honoring pediatric dissent for elective surgeries. This information is then used to invite providers to consider where they ethically situate themselves within a legally and professionally defined space of acceptable practice. Finally, these considerations are synthesized to discuss important nuances regarding pediatric refusal, and some key questions are presented for clinicians to ponder as they consider their practice of choosing whether to honor pediatric dissent at induction., (© 2024 John Wiley & Sons Ltd.)

Purpose of Review: This review explores the intricacies of ethical anesthesia, exploring the necessity for precision anesthesia and its impact on patient-reported outcomes. The primary objective is to advocate for a defined aim, promoting the implementation of rules and feedback systems. The ultimate goal is to enhance precision anesthesia care, ensuring patient safety through the implementation of a teamwork and the integration of feedback mechanisms., Recent Findings: Recent strategies in the field of anesthesia have evolved from intraoperative monitorization to a wider perioperative patient-centered precision care. Nonetheless, implementing this approach encounters significant obstacles. The article explores the evidence supporting the need for a defined aim and applicable rules for precision anesthesia's effectiveness. The implementation of the safety culture is underlined. The review delves into the teamwork description with structured feedback systems., Summary: Anesthesia is a multifaceted discipline that involves various stakeholders. The primary focus is delivering personalized precision care. This review underscores the importance of establishing clear aims, defined rules, and fostering effective and well tolerated teamwork with accurate feedback for improving patient-reported outcomes. The Safe Brain Initiative approach, emphasizing algorithmic monitoring and systematic follow-up, is crucial in implementing a fundamental and standardized reporting approach within patient-centered anesthesia care practice., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

AbstractObjective: We performed this study to examine patients' choices to permit or refuse medical student pelvic examinations under anesthesia (EUAs) during planned gynecologic procedures., Design: We conducted an exploratory retrospective chart review of electronic consent forms at a single academic medical center using contingency tables, logistic regression, and nonparametric tests to explore relationships between patient and physician characteristics and consent., Results: We identified and downloaded electronic consent forms for a census of 4,000 patients undergoing gynecologic surgery from September 2020 through calendar year 2022. Forms were linked to anonymized medical record information. Of the 4,000 patients, 142 (3.6%) were removed from analysis because consent forms were incomplete. Of 3,858 patients, 308 (8.0%) were asked for EUA consent more than once, 46 of whom were not consistent. Overall, 3,308 (85.7%) patients consented every time asked, and 550 (14.2%) refused or limited EUA consent at least once. Nine patients limited their consent to female students, and two patients refused medical student participation at all. We performed exploratory multiple logistic regression analyses exploring differences in rates of consent across patient and physician demographic groups., Conclusions: We find that some patients are more likely than others to refuse a pelvic EUA, magnifying the dignitary harm from a nonconsensual invasion of intimate bodily integrity and perpetuating historic wrongs visited upon vulnerable people of color and religious minorities. Patients' rights to respect and control over their bodies require that physicians take seriously the ethical obligation to inform their patients and ask them for permission.

The changing ethical and legal landscape in the UK means that anaesthetists should routinely be discussing the risk of death during the consent process. To do this effectively means expanding anaesthetic preassessment services for children and young people, something that has been recognised as a priority, but which still needs investment and an appreciation of its value at the trust level., (Copyright © 2024 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Many of our elderly have now signed advance directives or physicians' order sets of life-sustaining treatment forms. Frequently, choices have been made for no life-sustaining interventions at the end of life or do-not-resuscitate (DNR) orders. As the proportion of elderly grows and more patients seek surgical intervention for comfort or to improve their quality of life, the medical and ethical issues of DNR orders in the perioperative setting become increasingly more complex. Many health care providers neither recognize the complexity and significance of the DNR order during the perioperative period nor have hospitals established actions toward resolution of this situation. This article will discuss how this complex issue should be explored, definitions established, and positions recommended. [ABSTRACT FROM AUTHOR]

Introduction: This study aims to identify the full spectrum of ethical challenges of all forms of palliative sedation for adults as presented in current clinical practice guidelines (CPGs) and to determine whether CPGs specify ethical challenges of this therapy for patients with cancer and non-cancer and, if so, how exactly they do this. To the best of our knowledge, no studies have yet investigated this topic. The purpose is purely descriptive; our aim is not to make any kind of normative judgements on these challenges. Nor is our aim to assess the quality of the CPGs., Methods and Analysis: We will perform a systematic review of CPGs on palliative sedation for adults via five electronic databases, grey literature search tools, citation tracking and contact with palliative care experts. Current CPGs accredited by an international, national or regional authority, published in English, German, French, Italian or Polish, from 2000 to the date of the search, will be subjected to content analysis at the textual, linguistic and thematic levels., Ethics and Dissemination: This is a protocol for a systematic review and no human will be involved in this research. Therefore, ethics approval and consent to participate are not applicable to this context. This study protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis for Protocols criteria and registered on PROSPERO. Moreover, the integral version of this study protocol is published as a preprint on Research Square. The results of this study will be actively disseminated through peer-reviewed journals and books, international, national and local conference presentations, social media and media in general., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Disclosure E.H. Wilson and C.M. Burkle: None.

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

Christopher Boorse is very skeptical of there being a pathocentric internal morality of medicine. Boorse argues that doctors have always engaged in activities other than healing, and so no internal morality of medicine can provide objections to euthanasia, contraception, sterilization, and other practices not aimed at fighting pathologies. Objections to these activities have to come from outside of medicine. I first argue that Boorse fails to appreciate that such widespread practices are compatible with medicine being essentially pathocentric. Then I contend that the pathocentric essence, properly understood, does not prohibit physicians from engaging in actions that are not aimed at combating pathologies, but rather supports an internal morality of medicine that allows medical providers to refuse without penalty to engage in practices that promote pathologies., (© The Author(s) 2019. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Animal-derived constituents are frequently used in anaesthesia and surgery, and patients are seldom informed of this. This is problematic for a growing minority of patients who may have religious or secular concerns about their use in their care. It is not currently common practice to inform patients about the use of animal-derived constituents, yet what little empirical data does exist indicates that many patients want the opportunity to give their informed consent., Discussion: First we review the nature and scale of the problem by looking at the groups who may have concerns about the use of animal-derived constituents in their care. We then summarise some of the products used in anaesthesia and surgery that can contain such constituents, such as anaesthetic drugs, surgical implants and dressings. Finally, we explore the problem of animal-derived constituents and consent using Beauchamp and Childress' four principles approach, examining issues of autonomy, beneficence, nonmaleficence and justice. Disclosing the use of animal-derived constituents in anaesthesia and surgery is warranted under Beauchamp and Childress' four principles approach to the problem. Although there exist systemic and practical challenges to implementing this in practice, the ethical case for doing so is strong. The Montgomery ruling presents additional legal reason for disclosure because it entails that patients must be made aware of risks associated with their treatment that they attach significance to.

Introduction: Informed consent is an active process of the doctor-patient relationship, based on ethical and legal principles. The anesthetic act has inherent risks, which should be subject of specific consent. The aim of this study was to evaluate the degree of implementation of written specific informed consent for anesthesia in the context of elective surgery., Material and Methods: An observational prospective study, at a tertiary university hospital, in 230 patients aged 60 years or older, undergoing elective surgery between May and July 2017. Eligible patients who consented to participate were interviewed clinically on the day before surgery. In the postoperative period, the anesthetic technique and the existence of the written informed consent for the anesthetic and surgical procedures were assessed. Patients who were unable to give informed consent or those admitted in the Intensive Care Unit after surgery were excluded., Results: Written informed consent for the surgical procedure was obtained for 225 (97.8%), while it was obtained in just 96 (41.7%) patients for the anesthetic act. There was a higher prevalence of stroke, anemia, and higher Charlson and physical American Society of Anesthesiologists scores in patients without written informed consent for the anesthetic act., Discussion: We identified a low implementation of written informed consent for anesthesia. This situation may have important implications in the context of disciplinary, civil or criminal liability., Conclusion: Despite its importance, the practice of written informed consent for anesthesia in this institution is not yet implemented on a regular basis.

Previous guidelines on consent for anaesthesia were issued by the Association of Anaesthetists of Great Britain and Ireland in 1999 and revised in 2006. The following guidelines have been produced in response to the changing ethical and legal background against which anaesthetists, and also intensivists and pain specialists, currently work, while retaining the key principles of respect for patients' autonomy and the need to provide adequate information. The main points of difference between the relevant legal frameworks in England and Wales and Scotland, Northern Ireland and the Republic of Ireland are also highlighted., (© 2016 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists of Great Britain and Ireland.)

Background and Objectives: Jehovah's Witnesses patients refuse blood transfusions for religious reasons. Anesthesiologists must master specific legal knowledge to provide care to these patients. Understanding how the Law and the Federal Council of Medicine treat this issue is critical to know how to act in this context. The aim of this paper was to establish a treatment protocol for the Jehovah's Witness patient with emphasis on ethical and legal duty of the anesthesiologist., Content: The article analyzes the Constitution, Criminal Code, resolutions of the Federal Council of Medicine, opinions, and jurisprudence to understand the limits of the conflict between the autonomy of will of Jehovah's Witnesses to refuse transfusion and the physician's duty to provide the transfusion. Based on this evidence, a care protocol is suggested., Conclusions: The Federal Council of Medicine resolution 1021/1980, the penal code Article 135, which classifies denial of care as a crime and the Supreme Court decision on the HC 268,459/SP process imposes on the physician the obligation of blood transfusion when life is threatened. The patient's or guardian's consent is not necessary, as the autonomy of will manifestation of the Jehovah's Witness patient refusing blood transfusion for himself and relatives, even in emergencies, is no not forbidden., (Copyright © 2016 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

An 81-year-old man with a history of villous adenoma of the duodenum was admitted with new-onset jaundice, abdominal pain, and pruritus, which raised concerns about disease progression and hepatobiliary obstruction. The patient had refused surgical resection of tumor on initial diagnosis 2 years earlier and opted out of it again at the current presentation because of his significant comorbidities. While discussing treatment options with his family, he developed symptoms suggesting myocardial infarction. Therefore, before anesthetizing this patient with escalating cardiac enzyme levels for an urgent noncardiac procedure, it was important to attend to the dynamics of the decision-making process.

It is increasingly common for patients to be scheduled for anaesthesia and surgery with a 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) decision in place. Updated guidelines for the implementation and management of DNACPR decisions were published jointly by the British Medical Association (BMA), the Resuscitation Council (UK) and the Royal College of Nursing (RCN) in 2014 (BMA, RC(UK), RCN 2014). The Association of Anaesthetists of Great Britain and Ireland (AAGBI) published specific guidelines in 2009 to guide the perioperative management of such patients (AAGBI 2009). In this article, we explain these guidelines with a focus on how DNACPR decisions are made and how they can be modified in order to permit appropriate surgery to take place.

Obtaining anesthesia informed consent for a series of repetitive debridements in burn-injured patients requires a significant time investment for anesthesiologists and patient families. A single consent form was introduced that covered multiple related anesthetics in burn patients. The number of consents per patient before and after implementation was analyzed using Welch ANOVA; Tukey-Kramer post hoc test, with 99% confidence intervals for mean differences was used to examine pairwise comparisons. The mean number of consents per patient was 4.5 ± 2.8 and 1.6 ± 0.51 (P < 0.001) before (2010) and after implementation (2013), respectively. The Multiple Related Anesthetics Consent Form in this population resulted in less time spent by anesthesia providers in obtaining consent for patients undergoing multiple related procedures while providing patient- and family-centric care.

Is a painful experience less bad for you if you will not remember it? Do you have less reason to fear it? These questions bear on how we think about medical procedures and surgeries that use an anesthesia regimen that leaves patients conscious - and potentially in pain - but results in complete 'drug-induced amnesia' after the fact. I argue that drug-induced amnesia does not render a painful medical procedure a less fitting object of fear, and thus the prospect of amnesia does not give patients a reason not to fear it. I expose three mistakes in reasoning that might explain our tendency to view pain or discomfort as less fearful in virtue of expected amnesia: a mistaken view of personal identity; a mistaken view of the target of anticipation; and a mistaken method of incorporating past evidence into calculations about future experiences. Ultimately my argument has implications for whether particular procedures are justified and how medical professionals should speak with anxious patients about the prospect of drug-induced amnesia., (© 2012 John Wiley & Sons Ltd.)

The elderly have the ethical and legal equivalence of younger adults, yet are treated differently by society. Numerous recent reports have exposed poor inpatient care resulting in part from institutional ageism, which has moral and legal implications for healthcare providers. Morally, there is an argument for positive 'exceptionalism' in elderly peri-operative care, pursuing quality improvement through use of a dignity agenda. Legally, numerous changes in human rights, equality, consent, capacity, and end-of-life laws and professional guidance have consistently re-emphasised the need for greater communication between doctors, patients, their relatives and carers. This review describes current ethical thinking and legal precedent (in England and Wales), and directs readers to consider areas in which the law might change in the near future, particularly with regard to the end-of-life care of elderly surgical patients., (© 2013 The Association of Anaesthetists of Great Britain and Ireland.)

The psychologic effect of the preoperative visit by an anesthetist has been compared with the effect of pentobarbital for preanesthetic medication. Patients receiving pentobarbital 1 hour before an operation became drowsy but it could not be shown that they became calm. Patients who had received a visit by an anesthetist before operation (informing them about the events which were to occur on the day of operation and about the anesthetic to be administered) were not drowsy but were more likely to be calm on the day of operation. The importance of the preoperative visit probably explains, in part, the difficulties previous investigators have had in showing sedative effects from the barbiturates and narcotics before operation. The tremendous emotional significance to a patient of illness or an operation may explain why physicians are able to exert such influence upon their patients.

Unlabelled: Spinal muscle atrophy (SMA) is autosomal recessive and one of the most common inherited lethal diseases in childhood. The spectrum of symptoms of SMA is continuous and varies from neonatal death to progressive symmetrical muscle weakness first appearing in adulthood. The disease is produced by degeneration of spinal motor neurons and can be described in three or more categories: SMA I with onset of symptoms before 6 months of age; SMAII with onset between 6 and 18 months and SMA III, which presents later in childhood. Genetics: The disease is in more than 95% of cases caused by a homozygous deletion in survival motor neuron gene 1 (SMN1)., Pathophysiology: The loss of full-length functioning SMN protein leads to a degeneration of anterior spinal motor neurons which causes muscle weakness. Anesthetic risks: Airway: Tracheal intubation can be difficult. Respiration: Infants with SMA I almost always need postoperative respiratory support. Patients with SMA II sometimes need support, while SMA III patients seldom need support. Circulation: Circulatory problems during anesthesia are rare. Anesthetic drugs: Neuromuscular blockers: Patients with SMA may display increased sensitivity to and prolonged effect of nondepolarizing neuromuscular blockers. Intubation without muscle relaxation should be considered. Succinylcholine should be avoided. Opioids: These should be titrated carefully. Anesthetic techniques: All types of anesthetic technique have been used. Although none is absolutely contraindicated, none is perfect: anesthesia must be individualized., Conclusion: The perioperative risks can be considerable and are mainly related to the respiratory system, from respiratory failure to difficult/impossible intubation., (© 2013 John Wiley & Sons Ltd.)

Aims: Patients with central venous catheters who are transferred out of the Intensive Care Unit to the care of an anesthesiology team for an operation or interventional radiology procedure had excessive rates of catheter associated blood stream infection (CABSI)., Methods: We convened a multi-disciplinary team to audit anesthesia practice and to develop countermeasures for those aspects of practice that were thought to be contributing to CABSI's. It was noted that provider behavior changed in the presence of an auditor (Hawthorne effect) and so videorecordings were used, in the hope that this Hawthorne effect would be reduced. Clips were chosen from the hours of video (without audio) recordings that showed medication administration, airway management and touching the anesthesia cart of equipment/supplies., Results: These clips were viewed by three observers and measurements were made to assess intra-rater and inter-rater reliability. The clips were then viewed to quantify differences in practice before and after our bundle of "best practices" was introduced., Conclusions: Although video recording has been used to evaluate adherence to resuscitation protocols in both trauma and in neonatal resuscitation, (Pediatric Emergency Care, 26, 2010, 803; Pediatrics, 117, 2006, 658; Pediatrics, 106, 2000, 654) we believe this is the first time that video has been used to record before and after behaviors for an anesthesia quality improvement initiative., (© 2013 John Wiley & Sons Ltd.)

Objectives: The anesthesia preoperative screening and evaluation of a patient prior to surgery is a critical element in the safe and effective delivery of anesthesia care. In this era of increased focus on cost containment, many anesthesia practices are looking for ways to maximize productivity while maintaining the quality of the preoperative evaluation process by harnessing and optimizing all available resources. We sought to develop a Nurse Practitioner-assisted Preoperative Anesthesia Screening process using quality improvement methods with the goal of maintaining the quality of the screening process, while at the same time redirecting anesthesiologists time for the provision of nonoperating room (OR) anesthesia. The Nurse practitioner (NP) time (approximately 10 h per week) directed to this project was gained as a result of an earlier resource utilization improvement project within the Department of Anesthesia. The goal of this improvement project was to increase the proportion of patient anesthesia screens conducted by NPs to 50% within 6 months., Methods: After discussion with key stakeholders of the process, a multidisciplinary improvement team identified a set of operational factors (key drivers) believed to be important to the success of the preoperative anesthesia screening process. These included the development of dedicated NP time for daily screening, NP competency and confidence with the screening process, effective mentoring by anesthesiologists, standardization of screening process, and communication with stakeholders of the process, that is, surgeons. These key drivers focused on the development of several interventions such as (i) NP education in the preoperative anesthesia screening for consultation process by a series of didactic lectures conducted by anesthesiologists, and NP's shadowing an anesthesiologist during the screening process, (ii) Anesthesiologist mentoring and assessment of NP screenings using the dual screening process whereby both anesthesiologists and NP conducted the screening process independently and results were compared and discussed, (iii) Examination and re-adjustment of NP schedules to provide time for daily screening while preserving other responsibilities, and (iv) Standardization through the development of guidelines for the preoperative screening process. Measures recorded included the percentage of patient anesthesia screens conducted by NP, the percentage of dual screens with MD and NP agreement regarding the screening decision, and the average times taken for the anesthesiologist and NP screening process., Results: After implementation of these interventions, the percentage of successful NP-assisted anesthesia consultation screenings increased from 0% to 65% over a period of 6 months. The Anesthesiologists' time redirected to non-OR anesthesia averaged at least 8 h a week. The percentage of dual screens with agreement on the screening decision was 96% (goal >95%). The overall average time taken for a NP screen was 8.2 min vs 4.5 min for an anesthesiologist screen. The overall average operating room delays and cancelations for cases on the day of surgery remained the same., Conclusions: By applying quality improvement methods, we identified key drivers for the institution of an NP-assisted preoperative screening process and successfully implemented this process while redirecting anesthesiologists' time for the provision of non-OR anesthesia. This project was instrumental in improving the matching of provider skills with clinical need while maintaining superior outcomes at the lowest possible cost., (© 2013 John Wiley & Sons Ltd.)

Unlabelled: Skepticism toward infant pain characterized much of 20th century research and clinical practice, with infant surgery routinely conducted with minimal or no anesthesia into the 1980s. This paper offers a historical exploration of how this view became common by reviewing and analyzing the experimental infant pain research of the 19th and early 20th centuries that contributed to the development of infant pain denial. These experiments used pinprick and electric shock, and the results were generally interpreted as evidence of infants' underdeveloped pain perception, attributed to their lack of brain maturation. Even clear responses to noxious stimuli were often dismissed as reflex responding. Later these experimental findings were used by anesthesiologists to support the lessened use of anesthesia for infants. Based on the reviewed literature, this paper suggests that 4 interrelated causes contributed to the denial of infant pain: the Darwinian view of the child as a lower being, extreme experimental caution, the mechanistic behaviorist perspective, and an increasing emphasis on brain and nervous system development. Ultimately this history can be read as a caution to modern researchers to be aware of their own biases, the risks of null hypothesis testing, and a purely mechanistic view of infants., Perspective: This article reviews the history of 19th and early 20th century infant pain research, tracing how the widely accepted belief that infants could not feel pain developed in the period prior to the growing acceptance of infant pain. Four interrelated causes are posited to help explain the tolerance of infant pain denial until recent times., (Copyright © 2013 American Pain Society. Published by Elsevier Inc. All rights reserved.)

In contemporary clinical practice, the issue of requesting patient consent to perform therapeutic treatment plays an important role. The conscious consent of a patient as an expression of one's will greatly strengthens the legality of medical procedures performed by a physician, regardless of the medical field. However, obtaining consent to treatment in the intensive care unit (ICU) often poses enormous difficulties in daily clinical work, and has in recent decades been the cause of much dispute between doctors and lawyers. The correct interpretation of the provisions under the relevant laws determines the safety and comfort of the medical practice in the ICU. This study compared the current rules of normative acts of Polish common law relating to medical practice in intensive care units and issued on the basis of the judgments of the common court of law over the past ten years. On the basis of those provisions, the authors conclude that the patient should be informed by the anaesthesiologist during the visit as to the possibility of postoperative therapy in the ICU. The extent of such information depends on the likelihood of having treatment in the ICU. The consent of the patient for hospitalisation in the ICU should be mandatory in the case of treatments which are very likely to necessitate such hospitalisation. This concerns especially cardiac surgery, neurosurgery and treatments for patients with a significant burden of disease. The authors of this study propose that an information and consent form to undergo treatment in the intensive care unit should be included within the anaesthesia consent form.

Summary In law, consent allows the patient to determine what treatments they will accept or refuse. In this article, the common law of consent relating to anaesthesia is reviewed in order to highlight more recent changes to the standard of information provision and treatment of patients without capacity, and to form the basis of a critique of the current law. Practical and conceptual problems with the three core pillars of consent-voluntariness, capacity, and information-are analysed, along with the identification of logistical problems and contemporary theoretical challenges to the notion of patient autonomy as the basis of consent, concluding that 'assent' better describes the current legal position regarding treatment permission than 'consent'. In spite of this, the process of consent/assent is recognized as a major incentive towards data collection about patient-, operator-, and institution-specific risk, in order to better inform patients about the risks and benefits of treatment.

This case raises issues regarding the anesthesia and surgical components of preoperative informed consent and the differing views of anesthesiologists and surgeons with regards to informed consent, in the context of conversion to open surgery from a minimally invasive approach.

Background and Objectives: There is a great lack of theoretical subsidies to guide ethical principles, specifically in the case of Anesthesiology. The objective of the present study was to analyze the bibliographic production regarding Bioethics in studies published by the Brazilian Journal of Anesthesiology between 1999 and 2009., Methods: Three studies published between 1999 and 2009 by the Brazilian Journal of Anesthesiology were selected. Those studies covered bioethical issues in Anesthesiology or correlated anesthesia and Bioethics. A content analysis was used, according to the model of Bardin., Results: It was observed that Bioethical ideals were the most predominant issue, especially Principialism (f 23; 23.5%). On the other hand, the class that defines ethics as the cradle of Bioethics obtained the lowest amount of elementary context Units (CU) (f 15, 15.3%)., Conclusions: In the studies mentioned, Bioethics is considered an ideal to be achieved, facing difficulties to be applied in daily Anesthesia practice. The need of studies that focus on anesthesia and Bioethics more specifically, reflecting problems regarding both subjects, should be emphasized., (Copyright © 2011 Elsevier Editora Ltda. All rights reserved.)

Research on physicians', nurses' and enrolled nurses' experiences of ethical dilemmas have been conducted in many healthcare fields. The aim of this study was to elucidate ethical dilemmas before and during the induction of anaesthesia of children aged three to six years as described by nurse anaesthetists (NAs). Two group interviews with NAs were conducted where they were asked to describe ethically problematic situations. Three situations were chosen from a total of 15: administration of anaesthesia to an already sleeping child, lack of information given to a child, and a child is anaesthetized against his/her will. Conceivable and reasonable alternative options were identified and consequences of the different actions were presented. Finally the conflicts of value were discussed and commented on. The cases describe when a child's rights are given less weight and the child has little opportunity to participate in the decision making. However, parents and NAs acted in the best interest of the child. Analysing and reflecting on situations involving ethical dilemmas would enhance NAs critical thinking and guide NAs in their decision making when providing anaesthesia care.

The legal and ethical requirements related to an anaesthetist's communication with patients in preparing them for anaesthesia, assisting them in making appropriate decisions and obtaining consent in a formal sense are complex. Doing these things well takes time, skill and sensitivity. The primary focus should be to adequately prepare patients for surgery and to ensure that they are sufficiently well informed to make the choices that best meet their own needs. This is just an affirmation of the importance of patient-centred care.

In this exchange, a clinician (the first author) presents a case scenario for comment by an ethicist (the second author). The case concerns a 15-year-old boy with Duchenne's muscular dystrophy requested palliative surgical correction of a 60 degree thoraco-lumbar scoliosis. The surgical team were initially reluctant to offer surgery given their assessment of the perioperative and postoperative risks (anesthetic review suggested an 80% chance of surviving the surgery and 50% likelihood of returning home), but the operation proceeded. The case raises issues of the rights of patients to insist on nonfutile but high risk surgery, risk perception, resource allocation, autonomy, and the integrity of clinicians.

Situations where children refuse to undergo anesthesia and surgery can be challenging for anesthetists. Clear legal guidelines are lacking and decisions often need to be made with a degree of urgency. When a child refuses to cooperate with the induction of anesthesia, it is important to consider the autonomous capacity of the child, the presence of a legally valid consent from a suitable guardian, the urgency with which the surgery needs to proceed and the practical implications of proceeding without the child's cooperation. In this article, case scenarios are used to demonstrate how these considerations can be applied in practice.