Anesthesiology. 2021 Jul 1;135(1):111-121. doi: 10.1097/ALN.0000000000003795.
Calls to better involve patients in decisions about anesthesia-e.g., through shared decision-making-are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia.
This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia.
The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences.
Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists' attention away from important humanistic aspects of communication such as decreasing patients' anxiety.
越来越多的人呼吁让患者更多地参与麻醉决策，例如通过共同决策。然而，麻醉咨询有几个特点，使得患者应该如何参与决策并不明确。要评估在麻醉中实施共同决策的可行性和可取性，就需要更好地了解术前的对话。本定性研究的目的是描述初次膝关节置换术的术前咨询如何就主要麻醉做出决策。
本聚焦民族志在美国一所学术医疗中心进行。作者对 8 名麻醉师对 36 名初次膝关节置换术患者的咨询进行了录音。患者和麻醉师还参加了半结构化访谈。咨询和访谈记录在一个迭代过程中进行编码，以解释麻醉师和患者如何对主要麻醉做出决策。
作者发现，麻醉师和患者对咨询是否是协作式决策场景的描述存在差异，或者仅仅是为了告知患者。咨询中展示了许多决策模式，从麻醉师不透露选择到麻醉师严格坚持平衡立场；然而，大多数咨询都介于这两个极端之间，麻醉师提出选择，建议一种，并说服犹豫不决的患者接受。麻醉师通过与更熟悉的经历进行广泛比较，让患者对他们提出的方法感到更舒适。
麻醉咨询是多方面的相遇，具有多种功能。在某些情况下，让患者参与确定麻醉方法的程度可能不是这些功能中最重要的。应广泛考虑共同决策在麻醉咨询中的适用性和可行性。旨在增强患者参与决策能力的干预措施的潜在好处应与它们可能使麻醉师注意力从沟通的重要人性化方面（如减轻患者焦虑）转移开来的潜在风险相权衡。
