Preoperative Management of Adolescents Undergoing Elective Surgery

1. Preoperative Management of Adolescents Undergoing Elective Surgery Nina L. Shapiro, MD Associate Professor Department of Head and Neck Surgery David Geffen School of Medicine at UCLA

2. TEENAGERS!!

3. Preoperative Management of Adolescents • Particular needs of this patient population • Particular challenges of this patient population • Wide variation in physician practice management • Few standards to handle these challenges

4. Peri-operative Considerations for Teenagers • Informed Consent/Assent • Pregnancy • Drug Use Ethical or Legal Dilemmas?

5. Informed Consent A person’s agreement to allow or undergo medical treatment or surgery that is based on a FULL disclosure of the facts needed to make that decision intelligently Informed consent discussions with minors should be conducted at a level that can be understood by the minor

6. Patient • A 13-year-old boy presents for sinus surgery. On the day of surgery he answers all questions appropriately, but when asked if he has any questions he says ‘no’ because he is NOT having surgery. He states that ‘this surgery is not necessary and I don’t want it’. • Parents insist that it must be done today.

7. Children who refuse surgery • 2007 Survey of SPA Members: • Response from 453/852 • 9% cancelled >1 case/year • 25% cancelled >1 case/5 years • 45% cancelled >1 case/career • THOSE WITH MOSTLY PEDIATRIC PRACTICE WERE TWICE AS LIKELY TO HAVE CANCELLED A CASE • THOSE IN PRACTICE LONGER WERE MORE LIKELY TO INCLUDE CHILD IN DECISION • OVERALL 57% UNSURE WHAT TO DO

8. Patient Refusal: APSA vs. ASPO • Survey of pre-operative adolescent care of APSA and ASPO members • 108/698 APSA members (15.5%) • 51/380 ASPO members (13.4%) • Would you cancel an elective surgery if adolescent refuses? • ASPO: 49% “Never” • APSA: 79% “Never”

9. Children who refuse • Restraint • 44% anesthesiologists use restraint in majority of patients under age 1 year • 2% use restraint in patients over 11 years • Median age SPA members consider a child’s refusal: • 12 years

10. Right to Refuse • Competent adults may refuse treatment at any stage • Coercion may be considered assault • AAP Policy Statement • Informed consent, parental permission, and assent in pediatric practice • There are clinical situations in which a refusal to assent (or dissent) may be ethically binding

11. Informed consent for (not by) minors • Informed consent is given based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action • When a parent signs an informed consent, full disclosure from a minor to a parent must occur. • DOES THIS HAPPEN??

12. TEEN PREGNANCY

13. Patient • 13-year-old for tonsillectomy • LMP ‘unknown’ • Boyfriend with the family in preop area • Do you ask about possibility of pregnancy? • Or perform routine UCG? • At what age? • What do you do with the information?

14. Teen Pregnancy in the U.S.

15. Teen Pregnancy by the Numbers • U.S. has the highest teen pregnancy rate of industrialized nations • 75.4 pregnancies per 1000 girls (1 million/year) • 34% become pregnant at least once before age 20

16. Pregnancy and Anesthesia • No real evidence that pregnancy is harmful to the developing fetus • No real evidence that it is not • Surgical/diagnostic study risks to pregnancy • Cannot control for other insults– hypoxia, hypercapnia, temperature control, meds, etc

17. SAB and Low Birth weight • Women requiring non-obstetric surgery during pregnancy • Lowest rate of preterm birth if surgery in 2nd trimester (11%) • GA associated with lower birth weight (3053g vs. 3515g, p=0.01) • Longer, intra-abdominal, GA were independent risk factors

18. Barriers to Adolescents • Plan B needs prescription • Fear of negative attitudes from physicians • Belief that early care is unimportant • Inexperience in medical care • Lack of education • Leads to inadequate care

19. The Law/’Un-informed’ Consent • California law: • A health care provider is NOT permitted to share information of records regarding the prevention or treatment (or diagnosis) of a minor’s pregnancy with a parent or legal guardian without the minor’s written authorization.

20. HIPAA/ California Law Providers who reveal confidential information in violation of California’s Confidentiality of Medical Information Act and HIPAA can be found guilty of “unprofessional conduct” and can held criminally and civilly liable, and may loose their medical license.

21. Practice vs. Ethics (ASA) • Practice: • Need for testing pts even if deny possible pregnancy • Test all females vs. Informed refusal of test • Ethics: • Personal information that belongs to patient • Right to proceed with anesthesia and surgery if she desires • Testing offered but not required?

22. Options • Educational information during office visit • Questionnaire without parental presence • Thorough history • Importance of full disclosure • Confidentiality and judgment-free discussion • “Universal testing” • UCLA: all females ages 10-53 yo

23. ASPO and APSA: Pregnancy • 65% of ASPO and APSA members ask about possibility of pregnancy ‘always’ • 70% of ASPO and APSA members ‘always’ get pregnancy test • ASPO members more likely than APSA to change their plan for surgery after learning that a patient was pregnant (p=0.007). • Physicians in private practice (ASPO and APSA) more likely to cancel elective surgery in pregnant patient than those in University or Childrens’ Hospitals.

24. Pre-Operative Pregnancy Dilemma • If we test all adolescents, what do we do with the results? • If we do not tell the family, are they giving ‘informed’ consent?

25. Drugs and Alcohol

26. Patient • 15 yo for ESS for chronic sinusitis calls surgeon with concerns regarding risks of drug use and anesthesia and asks how long he must be ‘clean’ before having surgery. Patient was told an arbitrary 1 month and case was rescheduled. • On day of surgery, patient seems ‘nervous’

27. Drug Use • Do you ask about drug use? • Would you test this patient? • Can you tell the family the results of the testing?

28. Drug use in teenagers: What are they doing?

29. CDC Survey: Ages 12-18 • Alcohol • 81% have had at least one drink • 32% had first drink before age 13 • 31% had >5 drinks on >1 occasion in the 30 days prior to the survey • Marijuana • 47% have used • 11% used before age 13 • 27% at least once in 30 days prior to survey

30. ASPO vs APSA Drug Screening • 5-10% ‘always’ speak with patient alone • 25-40% ‘always’ ask about alcohol/tobacco • 20% ‘always’ ask about drug use • 10-20% ‘always’ change surgical plan based on drug history • Those with >15 years experience and higher percentage of adolescents in practice more likely to ‘always’ ask about alcohol/tobacco (p<0.01)

31. Ethics vs. Law • AAP Policy Statement • Involuntary testing is not appropriate in adolescents with decisional capacity, even with parental consent, and should be performed only if there are strong medical or legal reasons to do so. • Is preoperative state a ‘strong’ medical reason?

32. California Law • A minor who is >12 years old may consent to medical care and counseling relating to the diagnosis and treatment of a drug or alcohol-related problem. • Any program receiving federal funding or registered with Medicare MAY NOT reveal any information to parents without minor’s written consent.

33. What Do We Do? • Educational information to patient/family during office visit • Questionnaire without parental presence • “Parentectomy” • Thorough history on phone or in person prior to surgery, with importance of ‘full disclosure’ • Include confidentiality assurance and judgment-free discussion • Drug testing ‘prn’

34. Conclusions • Adolescent patients are a unique population who are developmentally capable of participating in their care and should be included in the preoperative discussion • Physicians vary, based on specialty, practice setting, and experience, in how they involve adolescents in the decision-making process for surgery, and how they approach assent, pregnancy, and drug use

35. Conclusions • The concept of assent is ethically and legally difficult to define • Dissent or absolute refusal to give assent must be considered carefully before proceeding. • Consider postponing elective cases • Consider an ethics consult

36. Conclusions • Risk of anesthesia and surgery on a fetus or pregnant individual, or risk of anesthesia with acute or chronic drug use is difficult (or impossible) to convey in informed consent when parent is signing consent without violating confidentiality

37. Conclusions • Asking the right questions in the right setting will arm us with the knowledge needed to provide safe care for teens, and help parents make ‘informed’ decisions. • Involving adolescents in their preoperative care will enable them to better understand ramifications of surgery and anesthesia.