New Law Clarifies ‘Informed Consent’ Related to Anesthesia Care
Act address unintended consequences of 2017 Supreme Court ruling
HARRISBURG (July 1, 2021) --- Gov. Tom Wolf has enacted a new law that remedies the years-long fallout from a complex ruling by the state’s top court that had the unintended consequence of restricting the administration of anesthesia.
Issues related to “informed consent” were brought about by the state Supreme Court’s interpretation of the Medical Care Availability and Reduction of Error (MCare) Act, under the Shinal v. Toms case, regarding a physician’s ability to delegate the duty to obtain the informed consent of a patient prior to specified procedures.
The court’s interpretation, part of a June 20, 2017, ruling, impacted patient care by ruling that only a physician can obtain informed consent.
The ruling had a profound effect on advanced practice providers like certified registered nurse anesthetists, especially those who work without physician anesthesiologists, because it made the surgeon, who is not an anesthesia expert, responsible for talking to a patient about anesthesia care and obtaining their consent.
Anesthesia teams comprising CRNAs and anesthesiologists also were affected. In many cases, CRNAs would obtain their own consents prior to the ruling. But after the court handed down its decision, anesthesiologists had to pulled off other tasks to perform this duty, affecting workplace flow for patient care.
This new law essentially clarifies that while physicians remain responsible for the overall care of their patients, the task of obtaining a patient’s informed consent may be delegated by a physician to a qualified practitioner, including CRNAs.
“We heard from CRNAs across Pennsylvania over the years how this ruling really affected day-to-day procedures, making their work more challenging and causing confusion among patients during what is already a stressful time,” said Matt McCoy, DNP, CRNA, President of the Pennsylvania Association of Nurse Anesthetists (PANA), which represents more than 3,700 CRNAs and students in the commonwealth.
The measure (S.B. 425), sponsored by state Sen. John Gordner (R-Columbia), received unanimous approval in both the Senate and House. With the governor’s signature, the legislation now becomes Act 61 of 2021.
By Patti FlesherAANA Public Relations and CommunicationsAlthough most COVID-19 patients recover without any additional health issues, some, called “long haulers,” have lingering effects such as loss of smell and taste, fatigue, and confusion. Knowing the risks, Michael Hartman, DNP, CRNA, clinical education coordinator and staff Certified Registered Nurse Anesthetist (CRNA) at Lehigh Valley Health Network in Pennsylvania, stepped up to work on the front lines at the beginning of the pandemic.
Pictured: Michael Hartman, DNP, CRNA
This dedication of patient care was not anxiety free. Like many healthcare workers, he was concerned about COVID exposure and its potential side effects, especially changes to his cognitive functions. To ensure that his experiences were not lost if that occurred, Hartman recorded his experiences of working on a COVID airway team.“During the first wave, there were a lot of unknowns,” Hartman said. “I began to keep a diary as the COVID pandemic emerged in the United States so that if something happened to me, the story would still be told.”Several years prior to the pandemic, Hartman attended a seminar addressing bioterrorism and preparedness of the anesthesia provider as a frontline provider. What he learned then helped to prepare him for COVID. “Our role as CRNAs changed with COVID. Many if not all surgeries were postponed and CRNAs were assigned to COVID airway teams. At Lehigh, there were two CRNAs on a COVID airway team that would be available 24 hours. Anyone that needed airway assistance with COVID, we were called to intubate them. In addition, our assigned schedules with regular hours, now varied because of COVID.”Hartman started to research the virus before it surged in the United States and several early key points were proven true throughout the pandemic. For example, he saw that gastrointestinal distress among COVID patients increased their morbidity. “All the patients I intubated had GI distress and they all did poorly. I recall one patient, a person in their 40s, pleading for their life. Asking for God and me to save them. I successfully intubated the person, but the fear it brought was new and challenging,” he said. “A COVID airway itself is difficult. With a healthy airway, the tissue is pink and reflects the laryngoscope light, allowing for illumination for placement of the endotracheal tube. On the other hand, a COVID airway presented with a dark discoloration which absorbed the laryngoscope light and added a challenge for intubation.” Hartman quickly saw that COVID was not the flu. It impacted all sorts of people, not just those at high-risk such as the elderly. And the physical aspects of the disease for patients was often outweighed by the psychological issues.
“A few months into the pandemic, patients started to become aware that an intubation often meant little chance of recovery. One patient was in the hospital on high-flow oxygen and did not want to be intubated. The patient knew what would happen next,” Hartman said. “The patient struggled for three days, but was in distress and the best possible outcome could only be achieved with intubation. After consent obtained the patient was intubated. The patient entered into eternal rest within a few days of advanced care.”For Hartman, being a CRNA means being an advocate for the patient, often when they are incapable of speaking for themselves. “We stand up for the patient and protect the patient during surgery. As the last person a patient sees before they proceed for surgery, we make the decision to proceed with surgery. This is what makes us leaders in patient care. In addition to patient management skills, CRNAs have time management and airway skills. We perform most of our work in the high-stress arena of the operating suite. We uphold a pivotal role in the operative patient care model.”With COVID, these last moments with patients take on a new meaning.
“COVID patients' last breaths may occur with me, before an intubation. We have had moments of prayer, exchanges of last words with family members,” Hartman said. “A patient I will never forget was an 80-year-old a veteran of the United States military who had a toe amputation done. While in the nursing home for rehab, the patient contracted COVID and came back to the hospital. When I arrived to intubate, donned in my personal protective equipment, the patient was apologizing to the staff for coming back to the hospital. The patient stated that, ‘It got me.’ The intensive care nurses, burned out, were crying. As I pushed the patient’s induction medications prior to intubation, the patient saluted me. The patient entered into eternal rest within hours of receiving advanced care.” Out of the despair of the disease, however, innovation sprang. Hartman found several ways to help keep him and those in the room safe when intubating a COVID patient. The aerosolized nature of COVID led to protective measures that did not exist when prepping a patient for surgery. “Before COVID when we prepared a patient for intubation, they would have a mask with pre-oxygen, we would provide medication to relax them and place a breathing tube,” Hartman said. “With COVID, intubation now meant protecting the healthcare staff from aerosolization of the contagion as soon as we opened the air
way. Patients were now covered with plastic drapes or towels to minimize the aerosolization on intubation and extubation. Operating room protocols were implemented to handle COVID patients requiring emergency surgery. Operating rooms uphold positive pressure air exchange to assist in maintaining a sterile environment. The protocol for protecting the operating staff within the suite entailed utilization of a HEPA filter.” Hartman is assisting in the development of a protective device for additional protection from aerosolized contagions for prehospital and hospital services. As a CRNA, Hartman had been empowered from the heartfelt interactions of those cared for stricken from COVID. Thus, he had written a memoir to aid present and future generations through telling the last breath patient experiences as a frontline COVID airway team member. “Together we can help one another heal our souls and set those patient souls who entered into eternal rest free. Together we can champion present and future contagions!”
👏 👏 👏 Thanks to all the Geisinger Health System / Bloomsburg University of Pa. Nurse Anesthesia CRNAs and SRNAs who turned out in Sunbury on April 20 and Shamokin on April 22 as part of a community service project with the United Way to help vaccinate rural Pa. residents. One of our SRNAs was able to vaccinate her sister, who was 2016 graduate of the nurse anesthesia program. Check out the photos and be sure to watch the clip from Eyewitness News WBRE WYOU.
