Acta Anaesthesiol Scand 2014; 58: 1249–1257 Printed in Singapore. All rights reserved
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12413
Patient fear of anesthesia complications according to surgical type: potential impact on informed consent for anesthesia C. M. Burkle, C. E. Mann, J. R. Steege, J. S. Stokke, A. K. Jacob and J. J. Pasternak Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
Background: Past research has explored patients’ expectations about the informed consent process. However, it is currently unknown if the complexity of the surgical procedure influences the type of anesthesia-related risks that patients wish disclosed. This study explored fears of anesthesia-related complications and whether these changed based on severity of surgery classification. Methods: Patients presenting to our pre-operative evaluation clinic from February 2013 to May 2013 were asked to participate in a survey-based study meant to evaluate their perception of five possible anesthetic risks (peripheral nerve injury, death, nausea and vomiting, heart attack and stroke) when confronted with differing levels of surgical severity. Results: One thousand surveys were administered, and 894 were returned for an overall response rate of 89%. Fear of death was the greatest concern as compared to the other risk factors independent of the severity of surgery. The level of fear for all
T
he informed consent process remains a critical aspect to providing medical care. Current patient care is focused on the patient–physician relationship with patients becoming increasingly involved in their own health-care decisions.1 The process of informing and consenting to medical care therefore remains an important component of ‘the legal embodiment. . . . that each individual has the right to make decisions that affect his or her health’.1 Anesthesia providers are ethically, morally, and legally responsible to understand and properly enact the informed consent process.1–4 They are required to disclose significant risks in order to obtain consent for anesthesia; however, it is not an expectation that all conceivable complications be discussed with patients.1,5–7 Unfortunately, the professional standard does not provide explicit guidelines regarding the disclosure of risks; thus, the crucial decisions regarding disclosure have
risk factors, with the exception of stroke and heart attack, were dependent on the severity of surgery. Fear of death decreased as the severity of surgery decreased (major 46%, moderate 38%, minor 25%). For major surgery, the fear of perioperative death differed significantly with age (P < 0.001); specifically, with increasing age came a lessened fear of death. Conclusion: Awareness by anesthesia providers of those fears that patients report may allow for a more personalized approach to providing information that may better allay anxiety. Further, these results may better tailor the informed consent process to one that meets particular patient concerns. Accepted for publication 17 August 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
largely been left to anesthesia providers to decide what is best for their particular patients.1 It is therefore important to determine patients’ attitudes, concerns, and expectations regarding being informed of the specific risks associated with the administration of anesthesia. The process of attempting to comprehend and be sensitive to our patients’ needs regarding potential risks involved with receiving anesthesia is complex, as each patient’s preference and autonomy should be taken into consideration. Past research has explored patients’ expectations about the informed consent process, specifically risk information stratification, the preferred method and timing of delivery, and the roles that patients’ anxiety and understanding might have on the process as a whole.3,8–11 However, it is currently unknown if the complexity of the surgical procedure influences the type of anesthesia-related risks
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that patients prefer disclosed to them during the informed consent process. Therefore, the primary objective of this prospective questionnaire-based survey study was to assess both the types of anesthesia-related complications that patients fear most and whether those fears change with the type of surgical procedure they are to undergo. It is hoped that understanding the fears that patients feel prior to undergoing a particular type of surgical procedure will better allow the anesthesia provider to tailor the informed consent process accordingly.
Methods Following Mayo Clinic Institutional Review Board approval (Mayo Clinic Institutional Review Board, 201 Building 4-60, 200 First Street SW, Rochester, MN 55905, USA, protocol number 12-009921, approved 12/28/2012), consecutive patients presenting to our pre-operative evaluation (POE) clinic from February 2013 to May 2013 were asked to participate in a survey intended to evaluate their perception of five possible anesthetic risks. Participation in this study was voluntary and restricted to adult patients (18 years of age and older) who had already been consented for their surgical procedure by the surgical team prior to enrollment in the study. Participants were first asked to provide demographic data (e.g., age, sex, highest level of education) (Fig. 1). Respondents were provided with a list of multiple surgical procedures and asked to choose which procedure category best described the procedure they were planning to undergo. Finally, patients were then asked the time interval before their surgical procedure, including tomorrow, within the next week, within the next month, and greater than a month away. Respondents were given the opportunity to abstain from answering any or all of the questions. Respondents were then asked to stratify their fear of five possible anesthetic complications ranking them from least feared to most feared for minor, moderate, or major surgery (Fig. 1). The potential anesthetic complications listed were death, heart attack, stroke, nerve injury, and nausea and vomiting. Participants were asked to stratify their fears of these complications when considering having minor (e.g. carpal tunnel or cataract), moderate (e.g. hysterectomy or prostatectomy), and major (e.g. cardiac or neuro) surgery. A table with common life experiences having the same incidence of occurrence as the anesthetic com-
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plications listed was provided to each participant (Fig. 1). This table was included to help the participants better comprehend the risk of an anesthetic complication occurring, thus helping them to respond to the questions in a more realistic and reliable manner. Finally, participants were asked to again consider each possible anesthetic complication individually and compare each complication to the others when considering having major vs. minor surgery. Respondents were to answer as to if they felt each complication was of more, less, or the same importance when considering a major vs. minor surgical procedure. Data from this study were presented as a percent of total respondents. Exploratory analyses were performed to assess whether survey responses differ according to various demographic or procedural characteristics (e.g. age, sex, timing, and type of surgery). These analyses were performed using the Chi-squared test for independence. In all cases, P values ≤ 0.05 were considered statistically significant.
Results One thousand surveys were administered, and 894 were returned for an overall response rate of 89%. Sixty-two percent of respondents were planning to undergo surgery the following day, 84% were above the age of 50, and 52% were female (Table 1). Respondents’ greatest fear stratified with respect to surgery can be found in Fig. 2. Overall, the fear of death was the greatest concern as compared to the other risk factors independent of the severity of surgery. The level of fear for all risk factors, with the exception of stroke and heart attack was dependent on the severity of surgery. The fear of death decreased as the severity of surgery decreased (major 46%, moderate 38%, minor 25%). Opposing this, the fear for peripheral nerve injury increased as the severity of surgery decreased (major 5%, moderate 9%, minor 22%). For major surgery, the most feared risk factor differed significantly with age (P < 0.001) and highest level of education (P = 0.005). Overall, death was the most feared risk factor (Fig. 2); fear of death was greatest among younger patients and those with some college or college graduates (Table 2). There was no significant association between most feared risk factors and sex (P = 0.967) or timing of surgery (P = 0.680). There was a statistically significant difference between age groups and the reported fear
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Fig. 1. Patient survey questionnaire.
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Fig. 1. Continued
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for peripheral nerve injury (P = 0.001), stroke (P < 0.001), nausea and vomiting (P = 0.004), and heart attack (P = 0.048). Likewise, there was a significant difference between patients with differing Table 1 Demographics of respondents. Demographic
Age (y) 18–30 31–50 51–65 > 65 Sex Male Female Timing of surgery Next day Within 1 week Within 1 month Greater than 1 month from now Highest level of education Some or no high school High school graduate Some college 4-year college degree More than a 4-year college degree Type of surgery Breast surgery Colorectal surgery Vascular surgery Eye surgery General surgery Gynecologic surgery Neurosurgery or neurosurgery spine surgery Oral surgery Orthopedic surgery or orthopedic spine surgery Plastic surgery Urologic surgery
Number (%) of respondents* (n = 894) 5 (1) 140 (15) 418 (47) 330 (37) 425 (48) 469 (52) 557 (62) 223 (25) 91(10) 14 (2) 18 (2) 172 (19) 268 (30) 181 (20) 248 (28) 21 (2) 12 (1) 6 (1) 31 (3) 77 (9) 43 (5) 92 (10) 21 (2) 378 (42) 16 (2) 168 (19)
*No response in age (n = 1), timing of surgery (n = 9), highest level of education (n = 7), type of surgery (n = 29).
levels of education and the reported fear for peripheral nerve injury (P = 0.009), stroke (P = 0.005), death (P = 0.014), nausea and vomiting (P = 0.029), and heart attack (P = 0.017). The reported fear for any of the five risk factors did not differ significantly between men and women, nor was it affected by the timing of the anticipated surgery. For minor surgery, again the most feared risk factor differed significantly with age (P < 0.001) and highest level of education (P < 0.001). Similar to major surgery, death was reported overall as the most feared risk factor (Fig. 2); again, greatest among younger patients and those with some college or college graduates (Table 3). Similar to major surgery, there was no significant association between most feared risk factors and gender (P = 0.391) or timing of surgery (P = 0.260). There was a statistically significant difference between age groups and the reported fear for peripheral nerve injury (P < 0.001), stroke (P = 0.009), nausea and vomiting (P = 0.001), and heart attack (P = 0.032). Likewise, there was a significant difference between patients with differing levels of education and the reported fear for peripheral nerve injury (P < 0.001), death (P < 0.001), nausea and vomiting (P = 0.011), and heart attack (P = 0.040), but not stroke (P = 0.058). Similar to major surgery, the reported fear for any of the five risk factors did not differ significantly between men and women, nor was it affected by the timing of the anticipated surgery.
Discussion In our survey exploring patient fears when preparing to undergo anesthesia demonstrated that death was most concerning regardless of the severity of surgery. Certain fear of risks did change based upon the type of surgery proposed. As one example, peripheral nerve injury was a greater fear among
Fig. 2. Feared risk factors. Percentage fear for five separate complications according to severity of surgery type groupings.
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Consent for anesthesia Table 2 Most feared anesthesia-related risk when considering major surgery. Age(y) < 50 51–65 > 65 Sex Male Female Education High school graduate Some college College graduate Post-baccalaureate Timing of surgery Next day Within 1 week More than 1 week
Death (%)
Nerve injury (%)
Stroke (%)
Nausea and vomiting (%)
Heart attack (%)
90 (76) 199 (59) 124 (54)
9 (8) 19 (6) 12 (5)
14 (12) 72 (21) 57 (25)
4 (3) 36 (11) 24 (11)
2 (2) 10 (3) 10 (4)
197 (61) 216 (60)
20 (6) 21 (6)
63 (20) 80 (22)
31 (10) 33 (9)
11 (3) 11 (3)
69 (55) 128 (64) 95 (65) 117 (56)
5 (4) 10 (5) 8 (5) 18 (9)
33 (27) 35 (18) 27 (19) 47 (23)
12 (10) 21 (10) 14 (10) 17 (8)
5 (4) 6 (3) 3 (2) 8 (4)
255 (61) 99 (58) 56 (63)
25 (6) 9 (5) 6 (7)
86 (20) 39 (23) 16 (17)
44 (11) 13 (8) 6 (7)
8 (2) 9 (5) 5 (6)
Table 3 Most feared anesthesia-related risk when considering minor surgery. Death (%) Age(y) < 50 51–65 > 65 Sex Male Female Education High school graduate Some college College graduate Post-baccalaureate Timing of surgery Next day Within 1 week More than 1 week
Nerve injury (%)
Stroke (%)
Nausea and vomiting (%)
Heart attack (%)
57 (53) 114 (35) 52 (25)
30 (28) 84 (26) 78 (38)
10 (9) 62 (19) 43 (21)
11 (10) 53 (16) 30 (14)
1 (1) 10 (3) 5 (2)
105 (35) 118 (35)
92 (30) 101 (30)
61 (20) 54 (16)
36 (12) 58 (17)
9 (3) 7 (2)
30 (33) 80 (43) 48 (36) 52 (26)
34 (29) 51 (28) 33 (25) 75 (37)
20 (17) 29 (16) 26 (20) 39 (20)
17 (14) 22 (12) 23 (17) 32 (16)
7 (6) 2 (1) 4 (3) 3 (1)
131 (33) 61 (39) 30 (37)
115 (29) 48 (31) 29 (36)
73 (19) 24 (15) 15 (19)
68 (17) 19 (12) 6 (7)
10 (3) 4 (3) 2 (3)
those considering minor surgery vs. major surgery (Tables 2 and 3). While patients feared death less as they aged, fear of stroke increased with increasing age. These findings are consistent with the results of a survey published in 2011 that noted stroke to be among the five most feared diseases among Americans.12 The potentially disabling impact resulting from a stroke, such as loss of independence and quality of life, is thought to account for this fear.13 One of the more common concerns among the elderly is the loss of their independence.14 Perhaps as a consequence of the anxiety associated with loss of independence, older respondents in our survey may have felt a greater concern for the consequences associated with suffering a stroke.
Our study found that among patients contemplating minor surgery, the fear of peripheral nerve injury and death differed based on level of education (P < 0.001). The fear of peripheral nerve injury trended upward as the level of education increased from respondents attending some college to obtaining more than a 4-year degree. Results from the same set of respondents found that the fear of death initially decreased as the level of education rose to increase again in those holding post-baccalaureate degrees. In an earlier study by Caumo et al., preoperative anxiety levels were not associated with increasing years of formal education.15 One explanation offered by the authors was that individuals with greater degrees of education may be better informed
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as to the risks of surgery and anesthesia. Overall, studies attempting to correlate degrees of anxiety to levels of education have been found to be inconsistent, with some showing an increase in anxiety among better educated individuals while others reporting opposite findings.15 Future and more rigorous research will need to be done to better establish a trend line as well as any causal relation between perioperative anxiety levels and educational background. Our study found no relationship between the levels of fear of the five stated anesthetic risk factors based on sex. This result is inconsistent with several prior reports. Caumo et al. observed a twofold increase in pre-operative anxiety levels among females.15 Several other studies have shown a similar relation between increasing anxiety and female sex.15 Suggested causes for this genderbased difference in pre-operative anxiety levels among women have included fluctuations in estrogen and progesterone levels.15 A possible cause for the incongruent findings noted in our study is that the public’s knowledge of medicine (including anesthesia and surgery) has increased greatly over recent years due in part to greater Internet access and other technological informational platforms. Greater access to this information may result in lessened fear of the type of complications explored in our study. The implications of our findings are important in helping to tailor the information provided to patients prior to undergoing an anesthetic. As an example, some jurisdictions require medical practitioners to follow a ‘reasonable physician’ standard, while others demand a ‘reasonable patient’ standard when informing patients of risks of medical procedures.16 The reasonable physician or professional standard requires medical practitioners to offer patients information that another practitioner having the same skills and practicing in a similar community setting would offer. The reasonable patient or materiality standard uses the patient as the basis of information type query by requiring the medical practitioner to offer the patient information that they believe a reasonable patient would wish to be informed of prior to undergoing the procedure.16 Still others have proposed an even more patientcentric approach known as the ‘specific patient approach’, whereby information important to that particular patient is sought, explored, and provided.17 The last two approaches, the ‘reasonable patient ‘and ‘specific patient’, require a better appreciation of what patients want to know before decid-
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ing how to proceed with a medical intervention. Relating back to our study findings, peripheral nerve injury risk may be of significant interest to those patients preparing for minor surgery despite less of a concern given the risks inherent with more severe types of surgical processes. The ability to appreciate the differences in fears among patients undergoing varied surgical procedures may better meet the ethical, moral, and legal foundations that informed consent plays in the patient–physician relationship. The present investigation is not without limitations. First, the investigation was undertaken in a single-center setting. While our institution has a large referral base which is geographically and socioeconomically diverse, it suffers from a relative lack of ethnic diversity. Second, our respondent sample contains few patients between the ages of 18 and 30. This is largely due to the fact that typically healthy patients are often not referred to the POE clinic for workup of conditions that may impact their anesthetic care. In addition, we did not inquire as to whether patients responding to our survey had undergone surgery in the past. Having experienced the surgical and anesthetic process at some point in the past may lessen fears in undergoing future procedures overall and perhaps lessening the anxiety for some risks while increasing others. We also did not analyze whether the type of surgical procedure that the patient was actually scheduled in the days to come had an impact on the answers they provided for hypothetical categories (major and minor) of surgery. Lastly, this questionnaire was administered pre-operatively without post-operative follow-up. Further, like that concern voiced with the lack of assessing prior surgical and anesthetic experiences, failure to perform post-operative follow-up may fail to elicit how fears may have changed following surgery. In summary, awareness by providers of those fears that patients report may allow for a more personalized approach to providing information that may better allay anxiety for patients. Given that preoperative anxiety may impact pre-operative care and patient satisfaction, the results of our study may improve discussions with patients in the pre-clinical setting. Further, these results may better tailor the informed consent process to one that meets particular patient concerns and provides more patientspecific care. Conflicts of interest: None. Funding: Provided by departmental and institutional resources.
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Acknowledgement The authors would like to thank Ms Janet Henderson for her technical assistance on this manuscript.
References 1. Paterick TJ, Carson GV, Allen MC, Paterick TE. Medical informed consent: general considerations for physicians. Mayo Clin Proc 2008; 83: 313–9. 2. Bottrell MM, Alpert H, Fischbach RL, Emanuel LL. Hospital informed consent for procedure forms: facilitating quality patient-physician interaction. Arch Surg 2000; 135: 26–33. 3. Burkle CM, Pasternak JJ, Armstrong MH, Keegan MT. Patient perspectives on informed consent for anaesthesia and surgery: American attitudes. Acta Anaesthesiol Scand 2013; 57: 342–9. 4. Papadimos T, Marco A, Filatoff G. Anesthesiology, autonomy, and justice: getting it right. The Internet Journal of Anesthesiology 2004; 9. Available at: http://ispub.com/ IJA/9/1/12209 (accessed 5 December 2013). 5. Epstein MJ, Blumenreich GA. Informed consent and anesthesia. Aana J 1987; 55: 506–8. 6. O’Leary CE. Informed consent for anesthesia: has the time come for a separate written consent document? ASA Newsl 2006; 70: 11–2. 7. Waisel DB. Let the patient drive the informed consent process: ignore legal requirements. Anesth Analg 2011; 113: 13–5. 8. El-Wakeel H, Taylor GJ, Tate JJ. What do patients really want to know in an informed consent procedure? A questionnaire-based survey of patients in the Bath area, UK. J Med Ethics 2006; 32: 612–6. 9. Ivarsson B, Larsson S, Luhrs C, Sjoberg T. Extended written pre-operative information about possible complications at cardiac surgery – do the patients want to know? Eur J Cardiothorac Surg 2005; 28: 407–14.
10. Kindler CH, Szirt L, Sommer D, Hausler R, Langewitz W. A quantitative analysis of anaesthetist-patient communication during the pre-operative visit. Anaesthesia 2005; 60: 53–9. 11. Moores A, Pace NA. The information requested by patients prior to giving consent to anaesthesia. Anaesthesia 2003; 58: 703–6. 12. Higgins A 2013 Survey reveals ‘most feared’ diseases in U.S.. Health Insurance. Available at: http://www.insureme.com/ health-insurance/most-feared-diseases (accessed 5 December 2013). 13. Dahlöf B. Prevention of stroke: new evidence. Eur Heart J 2009; 11: F33–8. 14. Quine S, Morrell S. Fear of loss of independence and nursing home admission in older Australians. Health Soc Care Community 2007; 15: 212–20. 15. Caumo W, Schmidt AP, Schneider CN, Bergmann J, Iwamoto CW, Bandeira D, Ferreira MB. Risk factors for preoperative anxiety in adults. Acta Anaesthesiol Scand 2001; 45: 298–307. 16. Sanbar SS. Alternative dispute resolution. In: American College of Legal Medicine Textbook Committee ed. Legal medicine, 7th edn. Philadelphia: Mosby Elsevier, 2007: 305– 13. 17. Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. J Am Coll Surg 2009; 208: 627–34.
Address: C. M. Burkle Department of Anesthesiology Mayo Clinic Rochester MN 55905 USA e-mail: [email protected]
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© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12413
Patient fear of anesthesia complications according to surgical type: potential impact on informed consent for anesthesia C. M. Burkle, C. E. Mann, J. R. Steege, J. S. Stokke, A. K. Jacob and J. J. Pasternak Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
Background: Past research has explored patients’ expectations about the informed consent process. However, it is currently unknown if the complexity of the surgical procedure influences the type of anesthesia-related risks that patients wish disclosed. This study explored fears of anesthesia-related complications and whether these changed based on severity of surgery classification. Methods: Patients presenting to our pre-operative evaluation clinic from February 2013 to May 2013 were asked to participate in a survey-based study meant to evaluate their perception of five possible anesthetic risks (peripheral nerve injury, death, nausea and vomiting, heart attack and stroke) when confronted with differing levels of surgical severity. Results: One thousand surveys were administered, and 894 were returned for an overall response rate of 89%. Fear of death was the greatest concern as compared to the other risk factors independent of the severity of surgery. The level of fear for all
T
he informed consent process remains a critical aspect to providing medical care. Current patient care is focused on the patient–physician relationship with patients becoming increasingly involved in their own health-care decisions.1 The process of informing and consenting to medical care therefore remains an important component of ‘the legal embodiment. . . . that each individual has the right to make decisions that affect his or her health’.1 Anesthesia providers are ethically, morally, and legally responsible to understand and properly enact the informed consent process.1–4 They are required to disclose significant risks in order to obtain consent for anesthesia; however, it is not an expectation that all conceivable complications be discussed with patients.1,5–7 Unfortunately, the professional standard does not provide explicit guidelines regarding the disclosure of risks; thus, the crucial decisions regarding disclosure have
risk factors, with the exception of stroke and heart attack, were dependent on the severity of surgery. Fear of death decreased as the severity of surgery decreased (major 46%, moderate 38%, minor 25%). For major surgery, the fear of perioperative death differed significantly with age (P < 0.001); specifically, with increasing age came a lessened fear of death. Conclusion: Awareness by anesthesia providers of those fears that patients report may allow for a more personalized approach to providing information that may better allay anxiety. Further, these results may better tailor the informed consent process to one that meets particular patient concerns. Accepted for publication 17 August 2014 © 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
largely been left to anesthesia providers to decide what is best for their particular patients.1 It is therefore important to determine patients’ attitudes, concerns, and expectations regarding being informed of the specific risks associated with the administration of anesthesia. The process of attempting to comprehend and be sensitive to our patients’ needs regarding potential risks involved with receiving anesthesia is complex, as each patient’s preference and autonomy should be taken into consideration. Past research has explored patients’ expectations about the informed consent process, specifically risk information stratification, the preferred method and timing of delivery, and the roles that patients’ anxiety and understanding might have on the process as a whole.3,8–11 However, it is currently unknown if the complexity of the surgical procedure influences the type of anesthesia-related risks
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that patients prefer disclosed to them during the informed consent process. Therefore, the primary objective of this prospective questionnaire-based survey study was to assess both the types of anesthesia-related complications that patients fear most and whether those fears change with the type of surgical procedure they are to undergo. It is hoped that understanding the fears that patients feel prior to undergoing a particular type of surgical procedure will better allow the anesthesia provider to tailor the informed consent process accordingly.
Methods Following Mayo Clinic Institutional Review Board approval (Mayo Clinic Institutional Review Board, 201 Building 4-60, 200 First Street SW, Rochester, MN 55905, USA, protocol number 12-009921, approved 12/28/2012), consecutive patients presenting to our pre-operative evaluation (POE) clinic from February 2013 to May 2013 were asked to participate in a survey intended to evaluate their perception of five possible anesthetic risks. Participation in this study was voluntary and restricted to adult patients (18 years of age and older) who had already been consented for their surgical procedure by the surgical team prior to enrollment in the study. Participants were first asked to provide demographic data (e.g., age, sex, highest level of education) (Fig. 1). Respondents were provided with a list of multiple surgical procedures and asked to choose which procedure category best described the procedure they were planning to undergo. Finally, patients were then asked the time interval before their surgical procedure, including tomorrow, within the next week, within the next month, and greater than a month away. Respondents were given the opportunity to abstain from answering any or all of the questions. Respondents were then asked to stratify their fear of five possible anesthetic complications ranking them from least feared to most feared for minor, moderate, or major surgery (Fig. 1). The potential anesthetic complications listed were death, heart attack, stroke, nerve injury, and nausea and vomiting. Participants were asked to stratify their fears of these complications when considering having minor (e.g. carpal tunnel or cataract), moderate (e.g. hysterectomy or prostatectomy), and major (e.g. cardiac or neuro) surgery. A table with common life experiences having the same incidence of occurrence as the anesthetic com-
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plications listed was provided to each participant (Fig. 1). This table was included to help the participants better comprehend the risk of an anesthetic complication occurring, thus helping them to respond to the questions in a more realistic and reliable manner. Finally, participants were asked to again consider each possible anesthetic complication individually and compare each complication to the others when considering having major vs. minor surgery. Respondents were to answer as to if they felt each complication was of more, less, or the same importance when considering a major vs. minor surgical procedure. Data from this study were presented as a percent of total respondents. Exploratory analyses were performed to assess whether survey responses differ according to various demographic or procedural characteristics (e.g. age, sex, timing, and type of surgery). These analyses were performed using the Chi-squared test for independence. In all cases, P values ≤ 0.05 were considered statistically significant.
Results One thousand surveys were administered, and 894 were returned for an overall response rate of 89%. Sixty-two percent of respondents were planning to undergo surgery the following day, 84% were above the age of 50, and 52% were female (Table 1). Respondents’ greatest fear stratified with respect to surgery can be found in Fig. 2. Overall, the fear of death was the greatest concern as compared to the other risk factors independent of the severity of surgery. The level of fear for all risk factors, with the exception of stroke and heart attack was dependent on the severity of surgery. The fear of death decreased as the severity of surgery decreased (major 46%, moderate 38%, minor 25%). Opposing this, the fear for peripheral nerve injury increased as the severity of surgery decreased (major 5%, moderate 9%, minor 22%). For major surgery, the most feared risk factor differed significantly with age (P < 0.001) and highest level of education (P = 0.005). Overall, death was the most feared risk factor (Fig. 2); fear of death was greatest among younger patients and those with some college or college graduates (Table 2). There was no significant association between most feared risk factors and sex (P = 0.967) or timing of surgery (P = 0.680). There was a statistically significant difference between age groups and the reported fear
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Fig. 1. Patient survey questionnaire.
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Fig. 1. Continued
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Fig. 1. Continued
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for peripheral nerve injury (P = 0.001), stroke (P < 0.001), nausea and vomiting (P = 0.004), and heart attack (P = 0.048). Likewise, there was a significant difference between patients with differing Table 1 Demographics of respondents. Demographic
Age (y) 18–30 31–50 51–65 > 65 Sex Male Female Timing of surgery Next day Within 1 week Within 1 month Greater than 1 month from now Highest level of education Some or no high school High school graduate Some college 4-year college degree More than a 4-year college degree Type of surgery Breast surgery Colorectal surgery Vascular surgery Eye surgery General surgery Gynecologic surgery Neurosurgery or neurosurgery spine surgery Oral surgery Orthopedic surgery or orthopedic spine surgery Plastic surgery Urologic surgery
Number (%) of respondents* (n = 894) 5 (1) 140 (15) 418 (47) 330 (37) 425 (48) 469 (52) 557 (62) 223 (25) 91(10) 14 (2) 18 (2) 172 (19) 268 (30) 181 (20) 248 (28) 21 (2) 12 (1) 6 (1) 31 (3) 77 (9) 43 (5) 92 (10) 21 (2) 378 (42) 16 (2) 168 (19)
*No response in age (n = 1), timing of surgery (n = 9), highest level of education (n = 7), type of surgery (n = 29).
levels of education and the reported fear for peripheral nerve injury (P = 0.009), stroke (P = 0.005), death (P = 0.014), nausea and vomiting (P = 0.029), and heart attack (P = 0.017). The reported fear for any of the five risk factors did not differ significantly between men and women, nor was it affected by the timing of the anticipated surgery. For minor surgery, again the most feared risk factor differed significantly with age (P < 0.001) and highest level of education (P < 0.001). Similar to major surgery, death was reported overall as the most feared risk factor (Fig. 2); again, greatest among younger patients and those with some college or college graduates (Table 3). Similar to major surgery, there was no significant association between most feared risk factors and gender (P = 0.391) or timing of surgery (P = 0.260). There was a statistically significant difference between age groups and the reported fear for peripheral nerve injury (P < 0.001), stroke (P = 0.009), nausea and vomiting (P = 0.001), and heart attack (P = 0.032). Likewise, there was a significant difference between patients with differing levels of education and the reported fear for peripheral nerve injury (P < 0.001), death (P < 0.001), nausea and vomiting (P = 0.011), and heart attack (P = 0.040), but not stroke (P = 0.058). Similar to major surgery, the reported fear for any of the five risk factors did not differ significantly between men and women, nor was it affected by the timing of the anticipated surgery.
Discussion In our survey exploring patient fears when preparing to undergo anesthesia demonstrated that death was most concerning regardless of the severity of surgery. Certain fear of risks did change based upon the type of surgery proposed. As one example, peripheral nerve injury was a greater fear among
Fig. 2. Feared risk factors. Percentage fear for five separate complications according to severity of surgery type groupings.
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Consent for anesthesia Table 2 Most feared anesthesia-related risk when considering major surgery. Age(y) < 50 51–65 > 65 Sex Male Female Education High school graduate Some college College graduate Post-baccalaureate Timing of surgery Next day Within 1 week More than 1 week
Death (%)
Nerve injury (%)
Stroke (%)
Nausea and vomiting (%)
Heart attack (%)
90 (76) 199 (59) 124 (54)
9 (8) 19 (6) 12 (5)
14 (12) 72 (21) 57 (25)
4 (3) 36 (11) 24 (11)
2 (2) 10 (3) 10 (4)
197 (61) 216 (60)
20 (6) 21 (6)
63 (20) 80 (22)
31 (10) 33 (9)
11 (3) 11 (3)
69 (55) 128 (64) 95 (65) 117 (56)
5 (4) 10 (5) 8 (5) 18 (9)
33 (27) 35 (18) 27 (19) 47 (23)
12 (10) 21 (10) 14 (10) 17 (8)
5 (4) 6 (3) 3 (2) 8 (4)
255 (61) 99 (58) 56 (63)
25 (6) 9 (5) 6 (7)
86 (20) 39 (23) 16 (17)
44 (11) 13 (8) 6 (7)
8 (2) 9 (5) 5 (6)
Table 3 Most feared anesthesia-related risk when considering minor surgery. Death (%) Age(y) < 50 51–65 > 65 Sex Male Female Education High school graduate Some college College graduate Post-baccalaureate Timing of surgery Next day Within 1 week More than 1 week
Nerve injury (%)
Stroke (%)
Nausea and vomiting (%)
Heart attack (%)
57 (53) 114 (35) 52 (25)
30 (28) 84 (26) 78 (38)
10 (9) 62 (19) 43 (21)
11 (10) 53 (16) 30 (14)
1 (1) 10 (3) 5 (2)
105 (35) 118 (35)
92 (30) 101 (30)
61 (20) 54 (16)
36 (12) 58 (17)
9 (3) 7 (2)
30 (33) 80 (43) 48 (36) 52 (26)
34 (29) 51 (28) 33 (25) 75 (37)
20 (17) 29 (16) 26 (20) 39 (20)
17 (14) 22 (12) 23 (17) 32 (16)
7 (6) 2 (1) 4 (3) 3 (1)
131 (33) 61 (39) 30 (37)
115 (29) 48 (31) 29 (36)
73 (19) 24 (15) 15 (19)
68 (17) 19 (12) 6 (7)
10 (3) 4 (3) 2 (3)
those considering minor surgery vs. major surgery (Tables 2 and 3). While patients feared death less as they aged, fear of stroke increased with increasing age. These findings are consistent with the results of a survey published in 2011 that noted stroke to be among the five most feared diseases among Americans.12 The potentially disabling impact resulting from a stroke, such as loss of independence and quality of life, is thought to account for this fear.13 One of the more common concerns among the elderly is the loss of their independence.14 Perhaps as a consequence of the anxiety associated with loss of independence, older respondents in our survey may have felt a greater concern for the consequences associated with suffering a stroke.
Our study found that among patients contemplating minor surgery, the fear of peripheral nerve injury and death differed based on level of education (P < 0.001). The fear of peripheral nerve injury trended upward as the level of education increased from respondents attending some college to obtaining more than a 4-year degree. Results from the same set of respondents found that the fear of death initially decreased as the level of education rose to increase again in those holding post-baccalaureate degrees. In an earlier study by Caumo et al., preoperative anxiety levels were not associated with increasing years of formal education.15 One explanation offered by the authors was that individuals with greater degrees of education may be better informed
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as to the risks of surgery and anesthesia. Overall, studies attempting to correlate degrees of anxiety to levels of education have been found to be inconsistent, with some showing an increase in anxiety among better educated individuals while others reporting opposite findings.15 Future and more rigorous research will need to be done to better establish a trend line as well as any causal relation between perioperative anxiety levels and educational background. Our study found no relationship between the levels of fear of the five stated anesthetic risk factors based on sex. This result is inconsistent with several prior reports. Caumo et al. observed a twofold increase in pre-operative anxiety levels among females.15 Several other studies have shown a similar relation between increasing anxiety and female sex.15 Suggested causes for this genderbased difference in pre-operative anxiety levels among women have included fluctuations in estrogen and progesterone levels.15 A possible cause for the incongruent findings noted in our study is that the public’s knowledge of medicine (including anesthesia and surgery) has increased greatly over recent years due in part to greater Internet access and other technological informational platforms. Greater access to this information may result in lessened fear of the type of complications explored in our study. The implications of our findings are important in helping to tailor the information provided to patients prior to undergoing an anesthetic. As an example, some jurisdictions require medical practitioners to follow a ‘reasonable physician’ standard, while others demand a ‘reasonable patient’ standard when informing patients of risks of medical procedures.16 The reasonable physician or professional standard requires medical practitioners to offer patients information that another practitioner having the same skills and practicing in a similar community setting would offer. The reasonable patient or materiality standard uses the patient as the basis of information type query by requiring the medical practitioner to offer the patient information that they believe a reasonable patient would wish to be informed of prior to undergoing the procedure.16 Still others have proposed an even more patientcentric approach known as the ‘specific patient approach’, whereby information important to that particular patient is sought, explored, and provided.17 The last two approaches, the ‘reasonable patient ‘and ‘specific patient’, require a better appreciation of what patients want to know before decid-
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ing how to proceed with a medical intervention. Relating back to our study findings, peripheral nerve injury risk may be of significant interest to those patients preparing for minor surgery despite less of a concern given the risks inherent with more severe types of surgical processes. The ability to appreciate the differences in fears among patients undergoing varied surgical procedures may better meet the ethical, moral, and legal foundations that informed consent plays in the patient–physician relationship. The present investigation is not without limitations. First, the investigation was undertaken in a single-center setting. While our institution has a large referral base which is geographically and socioeconomically diverse, it suffers from a relative lack of ethnic diversity. Second, our respondent sample contains few patients between the ages of 18 and 30. This is largely due to the fact that typically healthy patients are often not referred to the POE clinic for workup of conditions that may impact their anesthetic care. In addition, we did not inquire as to whether patients responding to our survey had undergone surgery in the past. Having experienced the surgical and anesthetic process at some point in the past may lessen fears in undergoing future procedures overall and perhaps lessening the anxiety for some risks while increasing others. We also did not analyze whether the type of surgical procedure that the patient was actually scheduled in the days to come had an impact on the answers they provided for hypothetical categories (major and minor) of surgery. Lastly, this questionnaire was administered pre-operatively without post-operative follow-up. Further, like that concern voiced with the lack of assessing prior surgical and anesthetic experiences, failure to perform post-operative follow-up may fail to elicit how fears may have changed following surgery. In summary, awareness by providers of those fears that patients report may allow for a more personalized approach to providing information that may better allay anxiety for patients. Given that preoperative anxiety may impact pre-operative care and patient satisfaction, the results of our study may improve discussions with patients in the pre-clinical setting. Further, these results may better tailor the informed consent process to one that meets particular patient concerns and provides more patientspecific care. Conflicts of interest: None. Funding: Provided by departmental and institutional resources.
Consent for anesthesia
Acknowledgement The authors would like to thank Ms Janet Henderson for her technical assistance on this manuscript.
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Address: C. M. Burkle Department of Anesthesiology Mayo Clinic Rochester MN 55905 USA e-mail: [email protected]
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