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

TEENAGERS!!

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

Peri-operative Considerations for Teenagers

Informed Consent/Assent

Pregnancy

Drug Use

Ethical or Legal Dilemmas?

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

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.

Children who refuse surgery

2007 Survey of SPA Members:Response from 453/8529% cancelled >1 case/year25% cancelled >1 case/5 years45% 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

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”

Children who refuse

Restraint44% 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

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

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??

TEEN PREGNANCY

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?

Teen Pregnancy in the U.S.

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

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

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

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

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.

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.

Practice vs. Ethics (ASA)

Practice: Need for testing pts even if deny possible

pregnancyTest all females vs. Informed refusal of test

Ethics:Personal information that belongs to patientRight to proceed with anesthesia and surgery if

she desiresTesting offered but not required?

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

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.

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?

Drugs and Alcohol

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’

Drug Use

Do you ask about drug use?

Would you test this patient?

Can you tell the family the results of the testing?

Drug use in teenagers: What are they doing?

CDC Survey: Ages 12-18

Alcohol81% have had at least one drink32% had first drink before age 1331% 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

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)

Ethics vs. Law

AAP Policy StatementInvoluntary 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?

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.

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’

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

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 casesConsider an ethics consult

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

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.