Case report:

“Patient is cancer Pt that needed to have urgent hysterectomy under the Gynaecology Team at [DGH satellite] scheduled... She had F2F pre-assessment by a pre-assessment Nurse [two weeks beforehand]… together with her niece as Pt lacks capacity. Pt is with phenylketonuria which had not been communicated to anyone further and patient arrived for surgery without being referred to Consultant Anaesthetist review. When I spoke extensively to the family and explained to them the complexity of the situation, that there are very few patients that had undergone general anaesthesia for major surgery with this metabolic disorder and that there is very high likelihood for intra and post-operative complications for patient's health that cannot be exactly predicted and quantified this was shocking news to them. Patient's nephew and his wife preferred to defer the operation for today until they have some time to think about the situation and decide what should be their decision as they are patient's NOC as she lacks capacity.”                                    

Commentary:

As doctors, anaesthetists are taught about a wide range of rare conditions which might affect the conduct of anaesthesia and the patient’s perioperative course.  It is not possible for individual guidance to be provided for preoperative nurses about each of these conditions.  However, this patient’s lack of mental capacity associated with phenylketonuria should prompt a referral for a notes review by a Consultant Anaesthetist prior to admission. The Association is currently updating its guidance on consent [1] and publication is expected in the first half of next year. Shared decision-making has a much higher profile now and this is likely to increase [2]. This case is a good example of how it is vital to explore what is important to the patient and when necessary to involve the people close to them.

References:

[1] Consent for Anaesthesia. Association of Anaesthetists, 2017  

[2] Meek, T. Raising the bar: striving for excellence in consent. Anaesthesia 2023; 79: 7-10