he opinion presented here is focused on whether a stand-alone anesthesia consent form offers any advantage over the inclusion of the same information in the surgical procedure consent form. The perspective is that of an anesthesiologist who has spent 42 years in the same large academic department, the past 13 years as its chair.

Our current policy for obtaining anesthesia consent at the University of Washington Medical Center (UWMC) is a two-step process. The first step is for the patient or authorized representative to sign a surgical/anesthesia procedure consent form that is presented by the surgeon or proceduralist. This consent refers to the risk of anesthesia to include dental damage, nerve damage, damage to vital organs, brain damage and death. The next step is just prior to induction when a member of the anesthesia care team discusses the anesthesia risks as is required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). A statement on the preanesthesia assessment form that the risks were discussed is signed by the attending anesthesiologist. There is space to document specific risks as indicated. The anesthesia record also has a check-off list to show that the risks were discussed.

The subject of this editorial first appeared in the author’s clinical practice in 1995 when a “consultant” advising the UWMC about how to pass the next JCAHO inspection “suggested” to the hospital that the anesthesia consent should be separated from the surgical procedure consent. At this time, I had been chair of the department for two years and was completing an 11-year term as chair of the ASA Committee on Professional Liability. I thought this a worthwhile and reasonable project to undertake, so I began the task of developing an anesthesia-specific consent form to be signed by the patient. Due to a number of logistical concerns that arose, the issue was eventually abandoned. The final straw was when one of the other major hospitals in our system that utilized the combined surgical procedure/anesthesia consent form passed JCAHO inspection without a problem.

At this point, I have to confess that our department has just adopted a stand-alone anesthesia/sedation consent form. This is, however, for a defined group of patients who require our services for imaging procedures such as magnetic resonance imaging, computed tomography scan and ultrasound, where the procedural risks are minimal or absent and a procedural consent is not normally obtained. The radiologists objected to being forced to get a procedural consent signed by the patient for a procedure that had no risk, and where the only risk was for anesthesia, which they knew little about. We agreed and removed all reference to procedural risks so that only the anesthesia risks were presented. This particular consent is now titled “Anesthesia/Sedation.” Fortunately this represents relatively few cases in our practice.

The value of our two-step informed consent system was recently brought home to me after a patient, for whom I was the attending anesthesiologist, alleged that he woke up with a chipped tooth. When the medical record was retrieved, the preoperative evaluation in which I had documented my discussion of dental risk was missing. Fortunately we still had the procedural/anesthesia consent signed by the patient that explicitly noted the risk of dental damage.

Another logistic issue is whether the procedural consent should be witnessed. In Washington state, a witness to the procedural consent is not required. Thus our risk management department has not required a witness as it is not necessary for the legal process. New Centers for Medicare & Medicaid Services (CMS) regulations, however, call for a witnessed consent, so this has been added to our procedure/anesthesia consent form. Before implementing this procedure, the risk management department is awaiting CMS regulations as to how much of the risk discussion the witness has to be present for and what that witness’ qualifications should be. If the anesthetic risks were separated from the procedural consent, the anesthesiologist would be responsible for having a qualified witness sign the document. The logistics of this in large, busy operating rooms would seem to be daunting, especially for the first case of the day. Perhaps this could be done in the anesthesia care team mode of practice, but it is not immediately apparent to me where solo anesthesiologists in a busy operating room would readily find qualified individuals to witness a signed consent.

At the present time, there is a great deal of emphasis on the practice of evidence-based medicine. For those who advocate separation of the anesthesia and procedural consent form, I would ask to see the evidence that such a change would improve some aspect of our clinical practice. What problem will it solve? Will it improve patient care, operating room efficiency, cost of delivering care, patient satisfaction or provide legal protection? In terms of legal protection, it may be too much to ask to find a court decision supporting the value of a patient-signed anesthesia consent form over the same words in a combined procedural/anesthesia consent form. Some of the other factors, however, could be studied in a relatively controlled fashion. If the goal is to improve patient understanding of anesthesia risk, then a study could be designed to test the hypothesis that a stand-alone anesthesia risk consent is superior to the two-step process we currently use. If certain of our surgical colleagues declined to have a combined procedural/anesthesia consent form, then we would adapt as we have for our radiology colleagues. We would use the opportunity to test the aforementioned hypothesis. If it turned out that a separate anesthesia consent form adversely affected surgical turnover time, I suspect there might be some second thoughts.

Informed consent is an important and integral part of the practice of medicine. If we as a profession move to more standardized wording of the anesthesia consent, I would ask to have it included in our combined procedural/anesthesia consent form. If asked or required to have the anesthesia and procedural consents separated, I would ask for evidence to support the need for such a change in our current practice, which has the approval of both the University of Washington Risk Management Department and the claims review committee.

Frederick W. Cheney, M.D., is Professor and Chair, Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington.