ANZCA Bulletin June 2011 - Australian and New Zealand College of ...

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Knowledge resources update The College recently commissioned a review of the archives, library and museum, collectively known as “Knowledge resources”. Consultants interviewed the honorary curators and archivist, and other Fellows and staff over several months, and as well as museum professionals at other organisations. The report from this review will help the College preserve and share these historically important resources, which are treasured by the Council and Fellows. An issue that consistently arose during the review was the need for a clearly articulated vision for history and heritage at the College and how history and heritage will be captured, retained and shared among the fellowship. In concert with this, history and heritage need to be communicated in the context of our overall public awareness strategy. These strategies will be developed under the aegis of Council over the coming months. To oversee the historical collections of the College, a Knowledge Resources Committee has been established that reports to the Council Executive. The committee is working with the report towards cataloguing the collection, relocating the display to Ulimaroa (the historic building at ANZCA headquarters in Melbourne) and preparing for the 20th anniversary of the College next year. The full report, including strategic plans for the three units, is published on our website at www.anzca.edu.au Professional documents – update The professional documents of ANZCA and the Faculty of Pain Medicine are an important resource for promoting the quality and safety of patient care for those undergoing anaesthesia for surgical and other procedures, and for patients with pain. They are used to defi ne the requirements for training and for hospitals providing such training, to provide guidance to the Fellows on standards of anaesthetic and pain medicine practice, to defi ne policies, and for other purposes that the College deems appropriate. Professional documents are also referred to by government and other bodies, particularly with regard to accreditation of healthcare facilities. Professional documents are subject to regular review and are amended in accordance with changes in knowledge, practice and technology. In April 2011, professional document TE17 Policy on Advisors of Candidates for Anaesthesia Training was withdrawn by Council as, since the accreditation of departments rather than posts, the role of advisor of candidates for anaesthesia training is obsolete. Queries or feedback regarding this or other professional documents can be directed to profdocs@anzca.edu.au. The complete range of ANZCA professional documents is available via the ANZCA website: www.anzca.edu.au/resources/ professional-documents. Faculty of Pain Medicine professional documents can be accessed via the FPM website: www.anzca.edu.au/fpm/resources/ professional-documents. 6 ANZCA Bulletin June 2011
“How do I prepare for surgery” This was a question that appeared in the Ask the Naturopath column of Sunday News Ltd newspapers throughout Australia on February 6 and it raises a number of interesting issues. Obviously if patients don’t receive information from their relevant healthcare practitioners they will seek it from other people, most of whom not only have opinions, but also are very willing to express them without due consideration of the consequences. In the movie Ghostbusters there was a team responsible for the eradication of ghosts and the theme lyrics were “… who ya gonna call Ghostbusters!” This highlights the importance of having the right people for the job, and the right people for informing patients about anaesthesia matters are anaesthetists. Although ANZCA can provide guidance in general terms, an anaesthetist is best equipped to deal with the specific queries that patients may have. The skill of communication, which is included in the new curriculum, is paramount in achieving this goal. Failure to adequately inform patients and the community tends to drive them to seek information from other sources, in which case it should be no surprise if they acquire distorted perceptions. Fear of the unknown is a common and real fear. Most patients facing surgery are preparing to experience anaesthesia for the first time, or are presenting for a different surgical procedure and consequently facing the unknown in each case. This fear, which is often not divulged, can be mitigated by the patient gaining some insight or understanding. If this is not forthcoming from the anaesthetist then patients will seek it from whatever source is willing to provide it. In the above mentioned newspaper article, the author presents reasonable general advice spanning a number of issues. However, one comment typifies the lack of understanding of anaesthesia when advising on the perioperative use of supplements. The concern is in the statement “It should not interfere with the anaesthetic, but check with your nurse or doctor”. Underlying this advice is the erroneous assumption that anaesthesia is simple enough that any nurse or doctor has sufficient knowledge to advise on anaesthesia issues and is sufficiently expert in drug interactions. The reference to “the doctor” will invariably be interpreted as either their general practitioner or their surgeon, neither of whom may be the appropriate person to provide anaesthesia advice. Another aspect of the preoperative preparation is the previously common practice, by our physician colleagues and sometimes the patient’s general practitioner, of providing gratuitous instructions. These instructions were typically to avoid hypoxia and hypotension, particularly in the cohort of patients who were already hypoxic and hypotensive or who had a significant predisposition to hypoxia and hypotension. Then there were the occasions where patients had been instructed that they must never have a general anaesthetic while others had been instructed that they must never have a “spinal”. But the classic of them all was the assessment of fitness for anaesthesia, resulting in the conclusion that the patient was either fit or unfit for anaesthesia, without differentiating between local anaesthesia, regional anaesthesia, general anaesthesia or sedation. The medico-legal implications are noteworthy. The risk is that when there is more than one view, but only one can be adopted, there will be debate, and generally any view that is associated with a poor outcome will be discarded. Consider an assessment where the patient is assessed by the physician as unfit for anaesthesia; however, the anaesthetist, recognising the anaesthesia risk factors, decides that it is in the patient’s best interests to proceed and administers anaesthesia. Where the outcome is good no questions are raised about the assessment of fitness for anaesthesia. However, where the outcome is poor there is no doubt that this assessment would weigh significantly in the court’s decision. Similarly, for patients in whom the instruction preoperatively was to “avoid hypoxia and hypotension” but who suffered any degree of either it could be difficult to place these into perspective. I often used to wonder about the interpretation of the “fitness for anaesthesia” assessment. Were patients deemed unfit for anaesthesia because I was administering anaesthesia and they had to be much fitter to tolerate my technique or were they unfit for all anaesthetics by all anaesthetists Joking aside, the ramifications of such assessments are widespread, including the impact on the patient’s state of mind and anxiety, as well as the medico-legal implications. Are these concerns sufficient to warrant action If so, what action Firstly, the ongoing education of our colleagues is essential to ensure that their advice, which is greatly appreciated, is specific, and limited to the opinion sought on basic anaesthesiarelated matters. Our colleagues should be encouraged to advise patients to direct more complicated anaesthesiarelated questions to their anaesthetist. Secondly, genuine communication with our patients is imperative. I firmly believe that communication with our patients and the community contributes to educating them and to providing them with the insight and understanding they need. This not only allays anxiety but also allows for realistic expectations, and reduces the likelihood of them gaining distorted views. Furthermore, it will reduce the incidence of patients seeking information from inappropriate sources. Finally, it could be anticipated that these measures may lead to anaesthesia being appreciated as the truly professional medical specialty that it is, and for anaesthetists being appreciated and respected as caring health professional exhibiting empathy and professionalism. Dr Peter Roessler, FANZCA Director of Professional Affairs (Professional Documents) Melbourne Letter to the editor Perioperative patient preparation – the importance of communication “Our colleagues should be encouraged to advise patients to direct more complicated anaesthesia-related questions to their anaesthetist.” The article in the ANZCA Bulletin (March 2011) “Perioperative patient preparation – the importance of communication” addressed some highly relevant concerns for anaesthetists. The author comments that he “used to wonder about the interpretation of ‘fitness for anaesthesia’ assessment”. He considers the situation where a physician has assessed a patient as unfit for anaesthesia, yet the anaesthetist “decides that it is in the patient’s best interests to proceed” with anaesthesia. Anaesthetists not uncommonly advise patients who are high risk for anaesthesia-related complications, and who present for surgery. While we are generally not able to comment in detail on the risks and benefits of surgery, we (and not generally physicians, unless they have a particular interest in perioperative morbidity and mortality) are best placed to advise on anaesthesiarelated risks. The concept of shared decisionmaking is not new. The advice that a patient “needs” surgery is being replaced with an approach where surgery is one option. Other options must always include doing nothing, even if that appears to be an irrational choice. In order for patients to realistically define what they “need”, patients deserve good advice, including advice on the risks and benefits of proposed interventions, such as anaesthesia. Only then will patients be able to weigh up the different options, including no surgery, and make decisions in line with their values. Doctors (surgeons, anaesthetists, physicians and family doctors) may not fully comprehend each patient’s value system and their tolerance to risk. While we may have a view as to what is in a patient’s best interests, it is our duty to advise patients of our recommendations, and allow them to make their own decisions. Only a patient can ultimately decide what is in his or her best interests. I think the concept of anaesthetist as “gatekeeper”, defining a patient as fit or unfit for anaesthesia belongs to a bygone era. I endorse Dr Roessler’s view that the job of the anaesthetist is to communicate with patients and the community, and to educate them “and provide them with the insight and understanding they need”. Joanna Sutherland, FANZCA Department of Anaesthesia Coffs Harbour Health Campus, New South Wales Queen’s birthday honour Dr Anthony Kirkwood from Orange, New South Wales, was a recipient of the Order of Australia Medal (OAM) for his services to medicine as an anaesthetist. It was announced as part of the Queen’s birthday honours list on June 13, 2011. The Dr Ray Hader Trainee Award for Compassion Nominations are sought from ANZCA trainees and Fellows within three years of fellowship by examination for the Dr Ray Hader Trainee Award for Compassion. The deadline for nominations is September 30, 2011. Dr Ray Hader was an ANZCA trainee who grew up and lived in Victoria. He died in 1997 of an accidental drug overdose after a long struggle with drug addiction. To mark the 10-year anniversary of his death, a friend, Dr Brandon Carp, established an award that promotes a compassionate approach to the welfare of anaesthetists, their colleagues, patients and the community. Eligibility At the deadline for submissions, the nominee will be an accredited ANZCA trainee resident in any ANZCA training region or an ANZCA Fellow within three years of admission to fellowship by examination. The nominee will have made a significant contribution to the welfare of an individual, a group or a system that promotes welfare and compassion. The individual, group or system will be preferentially related to anaesthesia, but may alternatively be related to other colleagues, patients or the community (locally or internationally). Nomination Nominees will be nominated and seconded by accredited ANZCA trainees resident in any ANZCA training region or ANZCA Fellows within three years of admission to fellowship by examination. The nominator will describe in 1000 words or less how the candidate has made a significant contribution. The description will be accompanied by a covering letter signed by the nominator and seconder. Deadline Nominations must be received by ANZCA chief executive officer by 5pm on September 30, 2011. Prize The winner will receive $A2000 to be used for training or educational purposes, and a certificate. ANZCA Bulletin June 2011 7
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