CHAPTER 7 Preoperative care
Introduction
Approximately three million operations are performed each year in the UK National Health Service (NHS). Good preoperative care is the key to a successful outcome of these operations. This includes four main aspects: choosing the most appropriate operation, counselling and obtaining consent, preoperative assessment and preoperative preparation. The aim of this care is to optimize the patient’s preoperative condition to achieve the best outcome from surgery and to minimize morbidity. Another important objective of preoperative care is to alleviate the patient’s fear and anxiety whilst waiting for her surgery. Good preoperative care will also help to avoid delays and cancellations of surgery, thereby maximizing the patient’s satisfaction during her journey through the hospital system. Although preoperative care is a patient-centred procedure, it should also involve preparation of the patient’s family as well as members of the multidisciplinary teams involved with the care of the patient. Details of the intended operative procedure as well as any social or health concerns should be communicated with the relevant hospital teams.
Choosing the Operation
Choosing the optimum surgical procedure is a crucial first step in the preoperative care of patients. All management options should be carefully considered after full and thorough assessment of the patient’s gynaecological as well as other coexisting medical conditions. All treatment options should be explored including no treatment, non-surgical alternatives or more conservative surgery. For example, a patient requesting sterilization should be informed about reversible long-term contraception, and she and her partner should be informed about vasectomy. Likewise, a patient requesting hysterectomy for menorrhagia should be informed of the reversible progestogen-releasing intrauterine system or less invasive endometrial ablation. It is the clinician’s duty to make the patient fully aware of all her options. All the pros and cons and implications of various treatments as well as no treatment should be fully explained to patients. The final decision on the optimum treatment should be mutually agreed between the surgeon and the patient, taking into consideration her wishes and social circumstances (General Medical Council 2008). Quite often, patients do not remember all the information given to them verbally during their consultation. It is therefore important to hand them printed leaflets containing more detailed information on their intended procedure, as well as other relevant treatments. These should also be available in languages other than English depending on the local demographics. With the availability of information on the Internet, patients are very likely to read up on their intended procedures from various unknown Internet sources. Clinicians should therefore direct their patients towards trusted websites offering unbiased information, such as that of the Royal College of Obstetricians and Gynaecologists which provides specific information leaflets for patients.
Consent
Valid consent
It is a legal requirement and an ethical principle to obtain valid consent before starting any treatment or investigation. Although verbal consent is acceptable for most investigations and medical treatments, it is necessary to obtain written and signed consent before any surgical intervention under anaesthesia, with the exception of some emergency situations. For consent to be valid, it must be given voluntarily by an appropriately informed person (either the patient or someone with parental responsibility if the patient is under 16 years of age) who has the capacity to consent to the intervention. The woman must be informed regarding the nature of her condition. Written information should be given, especially as patients are often admitted on the day of surgery and have less time to ask questions. As discussed above, the patient must also be aware of the alternatives to surgery and the option of no treatment. The Royal College of Obstetricians and Gynaecologists, the General Medical Council and the Department of Health all place importance and have provided guidance on valid consent (Department of Health 2001, General Medical Council 2008, Royal College of Obstetricians and Gynaecologists 2008a).
Consent and operative risks
Patients should be informed of frequent and established serious adverse outcomes related to the procedure. The likelihood of complications associated with the intended surgical procedure should be presented in a fashion comprehensible to the patient. The discussion should include all possible intraoperative risks as well as short- and long-term postoperative complications. Table 7.1 summarizes the risks associated with common gynaecological operations as detailed by the Royal College of Obstetricians and Gynaecologists (2004a–c, 2008a–d).
Consent for additional procedures
It is always good practice to discuss, and include in the consent, any possible additional procedures that may be required during the intended operation. Generally, any additional surgical treatment which has not previously been discussed with the woman should not be performed, even if this means a second operation (Royal College of Obstetricians and Gynaecologists 2008a). One must not exceed the scope of authority given by the woman, except in a life-threatening emergency. There are three different situations where an additional procedure may be necessary during the course of an elective surgery. Firstly, when a minor pathology related to the patient’s symptoms is detected such as endometriosis or adhesions in women undergoing laparoscopy for pelvic pain or infertility. In this situation, treatment can be performed if the patient has been made aware of this possibility and has consented for additional minor treatment. The second situation arises when a more complex disease is detected such as a pelvic mass, suspicious looking ovary, severe endometriosis or severe adhesions. Surgery in these situations should be deferred to a second operation after adequate counselling of the patient. In particular, oophorectomy for unexpected disease detected at surgery should not normally be performed without previous consent. The third situation involves intraoperative complications such as injury to the bowel or urinary tract that could lead to serious consequences if left untreated. Corrective surgery must proceed in these cases, and full explanation should be given as soon as practical following surgery.
Who should obtain the consent?
It is the responsibility of the clinician undertaking the surgical procedure to obtain consent. However, if this is not possible, it may be delegated to another doctor who is adequately trained and has sufficient knowledge of the procedure to be performed (General Medical Council 2008). The consent, however, remains the responsibility of the surgeon performing the operation. The clinician obtaining the consent should see the patient on her own first, for at least part of the consultation. She should then be allowed the company of a trusted friend or relative for support if she wishes. If consent is taken on the day of surgery, enough time should be allowed for discussion (Royal College of Obstetricians and Gynaecologists 2008a).
Additional consents
Duration of consent
The consent will remain valid indefinitely unless withdrawn. However, if new information is available between the consent and the procedure (e.g. new evidence of risk or new treatment options), the doctor should inform the patient and reconfirm the consent. It is also wise to refresh the consent form if there is a significant amount of time between consent and the intervention (Department of Health 2001).
Consent of special groups of patients
Jehovah’s Witnesses
Jehovah’s Witnesses are an Adventist sect of Christianity founded in the USA in the late 19th Century. They believe that accepting a blood transfusion, even autologous blood transfusions in which one’s own blood is stored for later transfusion, is a sin. This includes red blood cells, white blood cells, platelets and plasma. Jehovah’s Witnesses are aware of the possible risk to life in refusing blood transfusion and they take full responsibility for this. It is important to respect their wishes and to consider alternative measures to blood transfusion. There are special consent forms for Jehovah’s Witnesses’ refusal of blood products, stating clearly that this may result in the death of the patient. They also specify what blood fractions they might accept (e.g. interferons, interleukins, albumin, clotting factors or erythropoietin) as well as any blood salvage procedures, such as cell saver that recycles and cleans blood from a patient and redirects it to the patient’s body. More information can be found on the official website of Jehovah’s Witnesses (www.watchtower.org).
Adults without capacity
The Mental Capacity Act 2005
Clinicians should work on the assumption that every adult has the capacity to make decisions about her care. The patient should only be regarded as lacking capacity if she is considered unable to comprehend and retain information in order to make a decision after all practical steps to help her do so have been taken without success. A woman is entitled to make a decision based on her own religious beliefs or values as long as she understands what is entailed in her decision, even if it is the clinician’s belief that this is not in her best interests. Likewise, a woman should not be thought to lack capacity because she has previously made an unwise decision. The capacity of people with a learning disability, mental illness or apparent inability to communicate should not be underestimated. Capacity may also be temporarily affected by factors such as confusion, pain, fatigue, medication or shock.
Within the English legal system, no one is able to give consent to treatment of adults unable to give consent for themselves. The key principle in care of an incapable adult is that the treatment should be in their best interests. It is lawful to carry out a procedure that is in the best interests of the patient. One cannot sign the consent form on their behalf; rather, one should document in the medical notes why the patient cannot consent for the procedure and why it is in their best interests. This is not confined to the best medical interests; it is to preserve life, health or well-being of the patient. This also covers procedures such as washing and dressing.
It is good practice to involve those close to the patient in order to find out about the patient’s values and preferences prior to the loss of capacity. In addition, patients should be encouraged and supported, as far as they are able, to be involved in decisions about their care.
Certain procedures such as sterilization, management of menorrhagia and abortion do occasionally arise in women with severe learning disabilities who lack capacity to consent. They give special concern about the best interests and human rights of the person who lacks capacity. They can be referred to court if there is any doubt that the procedure is the most appropriate therapeutic recourse. The least invasive and reversible option should always be favoured (Department of Health 2001).
Children and young people
People aged 16 years and over are entitled to consent to their own medical treatment using the same criteria for competency as for adults. It is not legally necessary to obtain consent from the person with parental responsibility in addition.
Girls aged less than 16 years must be assessed as ‘Gillick competent’ to consent for their procedure. This is named after the case of Gillick vs West Norfolk and Wisbeth AHA 1986. Mrs Gillick challenged the lawfulness of Department of Health guidance that doctors could provide contraceptive advice and treatment to girls under the age of 16 years without parental consent or knowledge. The House of Lords held that a doctor could give contraceptive advice and treatment to a young person under the age of 16 years if:
This case was specifically about contraceptive advice and treatment, but the case of Axon vs Secretary of State for Health (2006) makes it clear that the principles also apply to decisions about treatment and care for sexually transmitted infections and abortion. Thus, if a child is ‘Gillick competent’ and is able to give voluntary consent after receiving appropriate information, the consent is valid. It is not legally necessary to obtain agreement of an additional person with parental responsibility. It is, however, good practice to encourage them to inform their parents, unless it is clearly not in the child’s best interest to do so. It is important to ensure that the consent is voluntary and to be aware of undue influences by parents, carers or sexual partner.
Conversely, if a child assessed as ‘Gillick competent’ refuses treatment, the person with parental responsibility can over-rule this decision if it is in the best interests of the child. Consideration should be given to applying for a court ruling for this intervention. For parents to be in a position to over-rule a competent child’s refusal, they must be provided with sufficient information about the child’s condition. This may be in breach of confidence on the part of the doctor treating the child, but may be justifiable in view of the child’s best interests. The child should still be as involved as possible in making decisions about their care.
Finally, refusal of treatment by a competent child and persons with parental responsibility for a child can be over-ruled by a court if this is in the best interests of the child (Department of Health 2001).
Preoperative Assessment
The purpose of preoperative assessment is to achieve an accurate diagnosis and to assess the patient’s fitness for surgery (risk assessment).
Accurate diagnosis
A thorough clinical examination aided by specific investigations (as necessary) is essential in patients undergoing gynaecological surgery to confirm the diagnosis and to ensure correctness of the planned operation. Special attention should be paid to the extent and complexity of the disease, and the involvement of other organs. For example, patients with complex endometriosis should be assessed for possible involvement of the bowel, bladder or ureter with this disease. Patients undergoing pelvic surgery for stress incontinence should be considered for urodynamic studies if detrusor instability is suspected, if they have had previous surgery for stress incontinence or if they have substantial voiding dysfunction.
Although the diagnosis is usually established during the initial consultations in the outpatient clinic, it is important to reassess the patient closer to or on the day of surgery to detect any changes in her gynaecological condition that may require alteration or even cancellation of the planned surgery. A common example of this is the disappearance of an ovarian cyst prior to ovarian cystectomy. Another example is the enlargement of a leiomyoma to an extent that may necessitate a change in the planned route of surgery. In these cases, a repeat preoperative pelvic ultrasound scan close to the day of surgery should be considered.
Risk assessment
One should start with a thorough assessment of the patient’s risk by way of a full medical and surgical history followed by general examination. This will determine which patients require further investigations. Routine preoperative testing of healthy individuals is of little benefit. Guidelines from the National Institute for Health and Clinical Excellence (2003) conclude that no routine laboratory testing or screening is necessary for preoperative evaluation unless there is a relevant clinical indication. Preoperative testing is a substantial drain on NHS resources, and substantial savings can be achieved by eliminating unnecessary investigations (Munro et al 1997). False-positive results may also cause unnecessary anxiety and result in additional investigations causing a delay in surgery. The indications and aims of common preoperative tests are shown in Table 7.2.
Full access? Get Clinical Tree
