I. INTRODUCTION

The postanesthesia care unit (PACU) is a complex and dynamic environment that provides both medical and ethical challenges to the anesthesiologist. Ethical challenges often arise in the setting of providing medical care and specific treatments in the postoperative period, while respecting patient autonomy. This chapter explores the complexities of the perioperative period, medical decision-making and obtaining informed consent in the PACU, special postanesthetic patient populations, and caring for the “do not resuscitate” (DNR)/“do not intubate” (DNI) patient in the perioperative period.

II. PERIOPERATIVE PERIOD

The perioperative period is defined in several ways:

A. The physical definition includes time and location of care in the hospital or ambulatory care facility, including preoperative evaluation of the patient in the preoperative clinic or holding area, administration of anesthesia in the operating or procedure room, and postoperative care until the patient is discharged from the PACU.

B. The physiologic definition includes the interval of altered physiology that begins with the onset of surgical illness and ends with the return to baseline that was present prior to surgical illness.

C. It is important to note that the patient’s perioperative physiology may resolve while the patient physically remains in the PACU.

1. Institutional guidelines vary regarding patient care in the physical location of the PACU after a patient meets PACU criteria for discharge but has not physically left the PACU.

a. Health care providers need to be aware of the specific guidelines in their institution.

1. Unfortunately, these do not always exist and this is often a “gray” area.

2. The providing clinician must always communicate with the patient and/or health care proxy if patient physiology changes.

2. The resolution of the patient’s perioperative physiology should be well defined and well documented, particularly if the patient is still physically in the PACU location.

III. DECISION-MAKING AND OBTAINING INFORMED CONSENT

A. Patient autonomy is a highly valued, guiding ethical principle in the practice of medicine in the United States. Adult patients with decision-making capacity may choose to accept or refuse medical therapies.

B. Decision-making capacity is determined by a medical doctor and is based on the elements of communication, understanding, reasoning, and values.

C. Autonomy can be very difficult to incorporate into medical decision-making in the PACU because of patients’ dynamic physiologic states.

1. During the postoperative period, the neurologic state of the patient may be altered secondary to lingering effects of anesthetic medications, and therefore patients may be unable to communicate, understand, or reason as effectively as they normally would. It should also be noted that many patients often do not recall making decisions while in the PACU.

2. Postoperative care units are often seen as an “area of coercion,” and therefore medical decisions made under such pretenses can be misinterpreted by the patient or the provider.

3. Postoperative patients are sometimes medically unstable as they enter the PACU and may require emergent medical or surgical treatments. In this circumstance, an advance directive should be employed, given one does exist.

D. An advance directive, or living will, is a legal document specifying the types of the treatment that the patient wishes to receive or reject should future need arise and often includes a designated surrogate.

1. The surrogate (health care proxy or power of attorney for health care) has the legal charge to execute the patient’s wishes should he/she become unable to do so.

a. The surrogate offers substituted judgment for the patient, providing decisions that the patient would make if capable.

b. If the patient has not designated a surrogate before becoming unable to make medical decisions, the next of kin may become the de facto surrogate in some states.

c. In some circumstances where no family is living or available, a trusted friend may act as the patient’s surrogate.

d. A court-appointed legal guardian may be necessary in rare instances in which no family member or friend is able to make decisions in the best interest of the patient.

2. In emergency situations, physicians may need to act in the best interest of the patient until the patient’s wishes, either directly from the patient or from an advance directive, can be elucidated.

E. Informed consent should be considered in the PACU for invasive procedures, testing of patients’ blood for blood-borne pathogens, and surgical reexploration. When a patient provides informed consent for anesthesia, the consent includes care extending through the perioperative period and including the PACU.

1. Consent for invasive procedures should be obtained in the absence of an emergency from the patient or from the patient’s surrogate. This includes new placement or replacement of invasive lines or epidural catheters.