Documentation of informed consent for anaesthesia: A single-site retrospective audit at a rural Australian hospital

Documentation of informed consent for anaesthesia: A single-site retrospective audit at a rural Australian hospital
Research Article
Yannick J De Silva, Luke Anderson
Anaesthesia and Intensive Care, 6 January 2025
Excerpt
   Respecting patient autonomy and providing relevant information are the foundations of informed consent, especially in anaesthesia due to the complexity of procedures, the impact on consciousness and autonomic function, and the specific risks and complications associated with delivering anaesthesia. It is important to note that a statement indicating the need for anaesthesia for an operation does not constitute informed consent for anaesthesia. The Australian and New Zealand College of Anaesthetists (ANZCA) recommends recording significant details of the discussion in the patient’s notes, including the material risks and the agreement of the patient to undergo the anaesthesia. This aligns with the recommendation from the Royal College of Anaesthetists (RCoA), based in the United Kingdom (UK), which suggests documenting the risks, benefits, alternatives and concerns raised by the patient.

We conducted a retrospective clinical audit on the anaesthetic records of patients undergoing emergency and elective procedures over a 3-week period at a rural hospital in Australia, starting from 1 January 2024. Data were collected with reference to the recommendations by ANZCA and RCoA for documenting informed consent for anaesthesia. Since informed consent for anaesthesia is not included in the procedure consent form at our hospital, our audit focused solely on anaesthetic records. Ethical approval was not deemed required as per our local health district’s checklist for ‘Ethical Considerations in Quality Improvement, Service Evaluation and Audit Activities’…