Communicating Anesthetic Risk to Clients

This post is written by Dr. Erik Hofmeister, a board-certified veterinary anesthesiologist currently providing, promoting, and teaching excellent anesthesia care at Auburn University College of Veterinary Medicine.

Dr. Erik Hofmeister DVM DACVAA DECVAA MA MS discusses his approach to communicating the risks - big and small - surrounding anesthetic events for veterinary patients.

Even though I’m an academic anesthesiologist and therefore don’t get to talk directly to clients often, I think a lot about what clients think about anesthesia. One of my earliest studies was looking into how people found and used information about anesthesia on the internet. I think it’s because I HAVE had experiences with client perceptions about anesthesia: they don’t want their dog to get a certain drug, or they believe their breed is “sensitive” to anesthesia, or they don’t want an epidural for their pet. Also, it’s critically important that we teach students how to communicate effectively with clients about anesthesia. Here is my take on effectively communicating the risks of anesthesia to clients.

First, I have to acknowledge that spending time doing this is time not spent writing records, seeing other clients, or having some down time. Also, not every client needs or wants to talk about anesthetic risk. However, I think it’s valuable because, in the event of something untoward happening, a prepared client will be more accepting and understanding than an unprepared client.

I think a real key to a positive outcome in life is setting expectations. Have you ever gone to a movie you were SUPER excited about? What happened when it didn’t perform to your expectations? Even if it was a good movie, you probably felt a little bit let down. What if a client expects that their pet will be returned to them in the exact same state you gave them before anesthesia, and they have an area shaved that was unexpected? They may be unhappy with that, even though the procedure was highly successful. So we need to set expectations. If we don’t, clients will attempt to “educate” themselves without us, which may or may not turn out well.

“Anytime we sedate or anesthetize a patient, there is some risk.” I think this is a useful opener to setting expectations. It makes sure the client knows that this isn’t a walk in the park. We’re basically giving a toxin (granted in a carefully controlled manner)! So, let them know there is some risk. Now what risks do we tell them about? Extremely rare events, like an esophageal stricture? More common events, like hypothermia? Clients differ, and you may have your own spiel, but I tend to focus on what I think clients care about: death, significant disability, and physical appearance.

Good monitoring and supportive care can go a long way towards mitigating some of the risks of anesthesia. The capnograph waveform here is typical for an expiratory one-way valve that is stuck. This can lead to hypercapnia, hypoxemia, and awareness.

“We will continuously monitor Fluffy under anesthesia and make sure their pain is controlled and their heart and lungs are working well. Even so, there is a risk of death any time anesthesia is given. It is low, less than 1 in 1,000 in dogs. OPTIONAL: Your pet has a slightly higher risk due to disease/being brachycephalic/etc.” I think this helps to assure the client that WE are doing what we can to minimize risk, but that there’s ALWAYS a risk of death. What do you do if this makes a client MORE anxious? Well, my opinion is I would rather they know than not know and then be surprised if their pet dies. If a client does become more anxious, you can continue to communicate with them to allay their concerns. If they decide not to do the procedure, well, I would rather have that outcome than have an unexpected death and have an extremely distraught client.

“There are several other risks which are very rare, but impossible to predict or prevent against. We’ll give you an information sheet so you are aware of what some of those are.” I’m thinking here about esophageal stricture specifically, but others might include tracheal tear, airway obstruction, or corneal ulcer. You decide which you think are important for the client to learn about. I choose these because they are the most devastating in terms of ongoing problems after anesthesia which the client might need to handle. I would suggest using an information sheet to minimize the amount of time, because these events are truly rare. But some clients want to know about ANY potential risk, even if it’s 1 in 1,000,000.

The euphoric feline behaviors sometimes precipitated by opioid analgesics can be unsettling unless owners are told about them beforehand.

“We’ll shave Fluffy in a few places to allow us to place catheters and do nerve blocks to manage their pain. They may look a little odd when they get home, and the hair may grow back slowly or a different color.” I’ve seen clients get really upset about shave jobs. One complained because we shaved the tail for an arterial catheter. The shave job is what the client SEES; they don’t know everything else that went into the procedure. So I think setting that expectation is important.

You could also make up an information sheet which covers all of this. That will be more time-efficient, but won’t give you the opportunity to take questions and allay any concerns they raise. You could also outsource this to the nursing staff, as long as you have trained them on what to say and how to address additional concerns and questions which clients raise.

What about patients who are at a higher risk? I think you need to make that very clear to the clients. They might have no idea how sick their pet is if you don’t tell them, and they don’t know what the risk is if you don’t tell them. I would suggest making it crystal clear that their pet is a higher risk and why. Some clients want to do everything for their pet and may not want to hear how sick they are. If you think it’s a bad idea to anesthetize that patient, make it very clear to the client. Ask them to repeat back to you what you said to make sure they understand.

This is also true for aggressive animals. Now that we have alfaxalone, it’s much easier to sedate sick aggressive animals. But I would add a caveat, “Because Fluffy is very aggressive, and I need to make sure that my staff is safe, we will have to heavily sedate them. We will use drugs that are relatively safe, but it is a higher risk because we can’t touch Fluffy and do a thorough exam before sedating them.” Some people don’t understand that their pet is aggressive and how that affects their care. So, explain it to them!

I think it IS important to talk to clients about the risk of anesthesia. I think the worst thing is to call up a client, tell them Something Bad happened, and they had absolutely no idea that was possible. They’re upset, they’re shocked, and, worst-case-scenario, they are angry. You can’t prevent all of those feelings, but I DO think that setting expectations makes that phone call a little bit easier.

What conversations do you have with owners? How do you decide with the owner what is an acceptable risk?