Abstract
The relationship between a physician and his or her patient is rooted in common moral principles of autonomy, beneficence, nonmaleficence, and justice. Respect for a patient’s autonomy underscores the patient’s right to be involved in decisions that affect her welfare. Throughout history, the role of this relationship during times of decision-making has ranged from paternalism, wherein the physician makes decisions for the patient, to full autonomy, wherein the physician provides the medical facts and the patient makes the decision with little or minimal input from her caregiver. Now, a healthy doctor-patient encounter falls somewhere in between: neither completely autonomous nor devoid of a touch of paternalism. Current focus on consumerism and a rise in patient advocacy have caused the foundation for patient-centered care to involve the creation of a partnership between the patient and her medical team. Meaningful dialogue is at the core of this relationship.
Keywords
Obstetric anesthesia, Shared decision-making, Informed consent, Legal situations, Clinical capacity
Chapter Outline
Informed Consent and Shared Decision-Making, 777
Decision Making in Obstetric Anesthesia, 780
Challenges in Obstetric Anesthesia, 780
Special Situations in Obstetric Anesthesia, 780
Vulnerable Populations, 782
Conflicts Arising out of the Maternal-Fetal Relationship, 786
Team-Based Communication, 788
Unanticipated Outcomes and Medical Errors, 789
The relationship between a physician and his or her patient is rooted in common moral principles of autonomy, beneficence, nonmaleficence, and justice. Respect for a patient’s autonomy underscores the patient’s right to be involved in decisions that affect her welfare. Throughout history, the role of this relationship during times of decision-making has ranged from paternalism, wherein the physician makes decisions for the patient, to full autonomy, wherein the physician provides the medical facts and the patient makes the decision with little or minimal input from her caregiver. Now, a healthy doctor-patient encounter falls somewhere in between: neither completely autonomous nor devoid of a touch of paternalism. Current focus on consumerism and a rise in patient advocacy have caused the foundation for patient-centered care to involve the creation of a partnership between the patient and her medical team. Meaningful dialogue is at the core of this relationship.
Informed Consent and Shared Decision-Making
Informed Consent
Though conspicuously absent from the Hippocratic Oath, the concept of informed consent is the backbone of the ethical practice of modern medicine in the United States. Its purpose is to facilitate care in a manner that honors the autonomy of the patient while acknowledging the expertise of the provider. As opposed to words signed on a form by the patient, true informed consent is a process whereby a patient and her health care provider engage in information exchange and discuss the patient’s condition and the nature of the proposed treatment, risks, benefits, and alternatives, including lack of treatment. The form is merely evidence of this discussion.
When engendered by a strong informed consent process, patient-physician communication has been associated with more realistic patient expectations, improved satisfaction, and a lower rate of medical malpractice claims. Evidence of this process and the physician’s involvement may be found among consultation notes (paper or electronic), informational aids shared with patients, and signed consent forms acknowledging that the process has occurred.
A solid and meaningful informed consent process includes the following hallmarks:
- 1.
A patient who has capacity and is able to understand the nature and consequences of the proposed therapy/procedure, and of alternatives, including no therapy
- 2.
A physician who tailors his or her disclosure to the patient’s particular competency, comprehension, and need and desire for detail
- 3.
Freedom from external influence (meaning it is given voluntarily)
- 4.
Understanding that consent can be withdrawn at any time before the therapy/procedure has occurred.
Legal precedent establishes what risks are essential to disclose during an informed consent discussion, specifically any risk that a “reasonable patient would consider reasonable and material to the decision of whether to consent to a procedure offered.” Dornette suggested that significant risk is one that poses a high (greater than or equal to 10%) incidence of a transient complication or a low (0.5% to 1%) incidence of permanent consequences. Broaddus and Chandrasekhar have recommended discussion of risks with high incidence, high morbidity, or adverse fetal effects.
Shared Decision-Making
Shared decision-making (SDM) is a process by which the physician expands upon the requirements of informed consent to establish a collaborative decision-making partnership. SDM shifts the focus in the delivery of care away from the disease process itself, and toward the patient and family navigating health care decisions. When ideally executed, SDM establishes a longitudinal partnership to address a series of decisions throughout the health care encounter. Recent advocacy efforts have defined patient- and family-centered care as a major component of health care quality and safety, and embraced SDM as a quality indicator.
At a minimum, SDM requires a patient and her clinician. The clinician frames the series of health care decisions that must be made, and for each, explains the integral elements of informed consent; elicits questions, values, and preferences from the patient; and guides the discussion toward a decision that is consistent with the patient’s values and preferences, and current evidence. Conversations may also involve family members, friends, and other members of the care team, according to the preferences of the patient. Clear communication is critical and requires careful attention to both verbal and nonverbal cues. Explanations must avoid language that is overly technical and clinical, but also remain specific enough to meaningfully guide the patient to an understanding of the complex clinical decisions she faces.
Decision aids may be used to facilitate SDM, and are available online, on paper, or on video. Just as cognitive aids can help guide operating room teams through the critical steps of a crisis, decision aids help patients absorb clinical evidence and communicate their preferences. The use of decision aids also helps clinicians set aside their traditional paternalistic role in order to be partners and coaches in the patient-centered process. Explicitly asking “what matters to you?” can help the team align its interventions. When SDM occurs, a properly informed patient can choose between various options (e.g., between different methods of pain management or between regional and general anesthesia) on the basis of her own values and preferences, even when the decision differs from her clinician’s preferred decision.
The process of SDM appears to increase patients’ subsequent participation, compliance, and self-monitoring. A Cochrane review of 105 trials published through 2015 demonstrated that the use of decision aids resulted in increased patient knowledge, more accurate perceptions of treatment risks, better alignment of treatments with patient values, a decreased sense of conflict for patients, and greater patient participation.
According to observations, focus groups, and questionnaires conducted as part of the Making Good Decisions in Collaboration (MAGIC) program in the United Kingdom, even when SDM conversations are imperfect or when there is a lack of complete agreement on best choices, the process of bringing perspectives together improves the likelihood that decisions are more informed and better accepted by patients, families, and staff. Using a “plan-do-study-act” rapid-cycle approach, MAGIC researchers determined that incorporating effective SDM requires a holistic bundle of interventions to drive culture change and to establish a supportive health care delivery system. Younger patients, women, and those with more education are most likely to prefer SDM, according to a study of anesthesia decision-making in Germany that measured preferences using the autonomy preference index (API) and the preference for involvement in care scale (PICS). Based on a Swiss study of 197 clinician-patient dyads, anesthesia clinicians frequently overestimate how much SDM occurs. In this study, Flierler et al. showed that 94% of surgical patients wanted to be involved in preoperative anesthetic management decisions. Patients had a stronger desire for a “balanced” decision-making process, wherein each party would have an equal contribution to decision making (desired by 65% of patients versus 32% of clinicians). Satisfaction decreased when patients perceived insufficient opportunity for involvement, and when anesthesia providers underestimated patient preference for SDM.
Beyond patient compliance and satisfaction, the impact of SDM on clinical outcomes is less clear. A 2015 systematic review of SDM identified a positive relationship between SDM and patient outcomes for 42 of 97 unique outcomes assessed, among 39 studies that met inclusion criteria. The authors noted differences in the way SDM was measured (patient-reported, observer-reported, and clinician-reported). Regardless of measurement methods, 54% of affective-cognitive outcomes were positively associated with the patient’s perception that SDM had occurred; such outcomes included improved patient satisfaction, resolved concerns and anxieties about illness, resolved decisional conflict, improved knowledge, and enhanced confidence in the decision. Thirty-seven percent of the behavioral outcomes studied were improved with the presence of SDM, including greater medication adherence. Twenty-five percent of the clinical outcomes studied were improved when there was SDM, with specific improvements in patient ratings of overall health, quality of life, depressive symptoms, and physiologic measures such as blood pressure. Evidence for improved clinical outcomes appears most robust for patients with chronic conditions that require self-management, such as hypertension. Certainly unsatisfactory communication with patients has been associated with treatment noncompliance in diabetes, asthma, and chronic disease.
Clinical Capacity versus Legal Capacity
For the informed consent process to be both meaningful and legal, the adult patient, or guardian for a minor patient, must have capacity to (1) understand the relevant information, (2) appreciate the situation and its consequences, (3) reason about treatment options, and (4) communicate a choice. Competence is an alternative term for capacity that is used in some legal jurisdictions. Characteristics such as an individual’s level of education, intellectual ability, preferred conversational language, and cultural background may influence how the individual processes information, but should not impair legal capacity to make an informed decision. It is the provider’s responsibility to make the information accessible and understandable. Translation services are a legal requirement for health care in the United States.
Even when information is presented at an appropriately straightforward level, there are patients who may not have capacity to truly understand the information being disclosed by the physician. The patient’s capacity may be compromised temporarily or permanently by her condition, medications, or a combination of the two. By definition, incapacitated patients cannot give informed consent. In emergency situations in which there is no indication to the contrary, physicians can provide necessary care under the presumption that a reasonable person would have consented to the anticipated treatment, which is discussed further later. In most clinical situations, incapacitated patients require a surrogate decision-maker who can engage with the informed consent process as if he or she were the patient. Legally, it is necessary both to establish the need for a surrogate decision maker, and to identify the most appropriate person to serve in this role.
In cases of permanent impairment, a court may have already made a determination of legal incapacity of a particular patient, and invested a surrogate with authority to make medical decisions on behalf of the patient. Such legal determinations are usually made in the course of a petition for guardianship filed on behalf of the allegedly incapacitated individual, supported by evidence of clinical incapacity. Petitions for guardianship are sometimes made in the course of other legal proceedings, such as a motion to confirm a health care proxy (in which the health care proxy agent must prove the existence of the health care proxy document, executed at the time the patient had clinical and legal capacity to do so, as well as the fact that the patient currently lacks clinical capacity as determined by an appropriately licensed clinician).
A surrogate decision maker may have been established through legal guardianship, durable power of attorney for health care, a binding living will, or other advance directive. Regardless of how decision-making authority was legally established, the named surrogate generally serves as the final decision maker for all health care decisions for that patient.
Decision-making authority for patients who lack legal capacity can be revoked only if the patient or some other third party goes back to court and challenges the determination, either because circumstances have changed and the patient has regained clinical capacity, or because the patient or third party appeals the initial determination of the court and has it overturned.
If a court has not yet made a legal determination that a patient lacks legal capacity (or, is legally incompetent, as termed in some states), then the determination of a patient’s clinical capacity to give informed consent is a professional judgment made by the treating clinician. At a minimum, a judgment of clinical incapacity must be documented in the medical record by a licensed physician (or nurse practitioner in some states) before utilizing a surrogate decision maker. Some states may have additional requirements detailing how such a determination is recorded and published (e.g., Minnesota requires all conditions and circumstances to be documented within the medical record). It is often helpful to have a mental health clinician or, in the case of a patient with neurologic issues, a neurologist, weigh in on the determination, as it will be more authoritative if reviewed in court or challenged in any way by a third party.
If a surrogate decision maker has not been previously identified, then state statutes may delineate the process to identify the most appropriate surrogate. Some states designate a default list of family members and other persons (in order of priority) who may give consent. Other states limit surrogate decision makers to health care proxy agents previously designated by the patient (when she had capacity to do so) on a specific health care proxy form (e.g., Massachusetts), durable powers of attorney for health care (e.g., Ohio), or a guardian appointed by a court after a petition has been filed and evidence regarding the incapacity presented (e.g., Arizona). Even in states in which there is no line of kin prescribed by statute, there are generally provisions for how to manage consent in emergency situations (such as using available family, or presuming consent, or both).
All surrogate decision makers are required to make “substituted judgment” decisions on behalf of the patient (i.e., they are obligated to decide as they believe the patient would, not according to the surrogate’s own preferences). This may differ from the decision the surrogate decision maker might make for himself or herself. Thus it is imperative to encourage and, where possible, require that the surrogate make decisions from the point of view of the patient: “the surrogate decision maker (judge or guardian) should attempt to determine what the incapacitated person would decide regarding the proposed treatment or procedure were he or she competent.” When it is impossible to determine what decision the patient would have made (e.g., the patient never had capacity as a result of an intellectual disability that has existed from birth, or the surrogate decision maker did not know the patient well enough to discern what decision she might have made when she was most capacitated) and there is little or no collateral information to help guide the surrogate, it may be necessary to switch to a “best interest” standard rather than a “substituted judgment” one. Regardless, it is not appropriate for the surrogate to impose his or her own values on the decision-making process. If the surrogate seems to be unable to follow this obligation, it may be necessary to challenge that surrogate’s right to make decisions for the patient, either through institutional processes governed by the policies and procedures of the institution or through the courts.
It is also important to note that some decisions the surrogate decision maker might want to make, or some clinical interventions, might require additional court involvement. These kinds of decisions are often referred to as “extraordinary” decisions, and can include major surgery, general anesthesia, use of antipsychotic medications, amputation, sterilization, hysterectomy, chemotherapy, institution of comfort measures only, the removal of life-sustaining treatment, or other change of code status. The necessity to return to court to request specific authority for these “extraordinary” decisions is driven by state law, and so it is important to determine the breadth of a surrogate decision maker’s authority to consent to various treatments and care plans within the laws of the state in which the treatment is being provided. The authority of a health care proxy agent or a durable power of attorney for health care may also have been limited by the patient in the language within the health care proxy or power of attorney document itself, underscoring the importance of consulting these documents as well.
Finally, in states that allow for binding living wills or other advance directives, a surrogate decision maker may be bound to follow the directives within such documents that may impact the decisions being made. Therefore, it is critical to know whether any such documents exist, and if they do, whether they are binding or merely evidentiary as collateral information; some states explicitly do not recognize the binding nature of these advance directives but do hold them to be persuasive in helping determine what the patient would have wanted done in a particular clinical circumstance.
Decision Making in Obstetric Anesthesia
Challenges in Obstetric Anesthesia
There are unique challenges to obtaining consent and engaging in SDM in the labor and delivery setting. These can include the balancing of competing interests of mother and fetus, the interaction with distressed patients, who can be part of a complex family system, and interdisciplinary collaboration during rapidly evolving clinical situations. The anesthesia provider must work quickly to establish trust, elicit preferences for information and decision making, and tailor SDM to the patient and her chosen support team, while coordinating decisions with other members of the interdisciplinary care team. This is no easy task. Misunderstandings, unmet expectations, patient dissatisfaction, and liability are potential outcomes.
Historically, consent for anesthesia was incorporated into consent for surgery, and direct participation of the anesthesia provider in the consent conversation was not mandated. Now most states require separate consent conversations (and forms) for surgery and anesthesia procedures. This separate, focused discussion on the benefits and risks of anesthesia provides a unique opportunity to address misconceptions and discuss the facts. In a survey study of 509 English-speaking parturients (63% white, 23% Hispanic, 14% African-American) admitted to a single institution, Toledo et al. showed that 39% of participants expressed concerns regarding neuraxial anesthesia. These ranged from general misunderstandings about the anesthetic (e.g., epidurals slow down labor or cause cerebral palsy), fears about long-term complications of the procedure, and lack of trust in providers, to concerns regarding fetal effects of medications administered in the epidural space. Ideally, informed consent discussions about anesthesia services begin with an antepartum consultation or with the admission history and physical examination, and address possible delivery scenarios and corresponding anesthetic options in general terms. This conversation opens an ongoing dialogue to support SDM, which continues throughout the hospitalization for delivery.
The informed consent document may be amended as needed, with the additional conversations documented in the medical record. Alternatively, specific informed consent for each anesthetic procedure may be obtained shortly before the intervention. At many institutions, a separate written consent signed by the patient is not obtained before administration of anesthesia. A 1995 survey of obstetric anesthesia providers in the United States and the United Kingdom indicated that 52% of U.S. anesthesia providers (but only 15% of UK anesthesia providers) obtained a separate written consent for epidural analgesia during labor. In a survey performed in the United Kingdom in 2007, only 7% of obstetric units routinely obtained written informed consent for epidural analgesia during labor. In a 2004 survey from Australia and New Zealand, less than 20% of anesthesia providers obtained written consent before initiating neuraxial labor analgesia. Some health care facilities and organizations have begun using a single consent form for obstetric and anesthetic procedures that may be desired or necessary during labor and delivery. The process of reviewing and signing the consent form provides a specific opportunity for the patient to ask questions. It also provides additional documentation that consent was obtained. The combined form has the additional advantage of not requiring the patient to sign multiple medicolegal documents. Although a signed consent form is not necessary, at a minimum, it should be standard practice for anesthesia providers to document that a discussion of risks and benefits of labor analgesia took place and that verbal informed consent was obtained before administration of anesthesia.
Many patients have strong opinions about their analgesic options, based on information gathered from their obstetric provider, websites, books, magazines, classes, and friends and family. The nature of the consent process will differ depending on the level of prior knowledge, health literacy, decision-making preferences, and clinical circumstances, but a paternalistic approach, grounded on the premise that patients cannot have the same clinical knowledge of the clinicians, can no longer be justified.
Special Situations in Obstetric Anesthesia
Patient Who Is in Pain
A study of women’s preferences for labor analgesia counseling revealed that most women prefer to learn about the options for labor analgesia from their obstetric care providers. This is not surprising given the trust that exists within the bounds of an established relationship. However, a discussion of anesthetic options for the first time frequently takes place upon arrival to the labor and delivery unit. A survey of Canadian women revealed their strong preference to be informed of all possible complications of epidural anesthesia, especially serious ones, even when the risk was quite low. This study and others have emphasized the parturients’ desire to have these discussions as early in labor as possible.
Unfortunately, the anesthesia provider often first encounters the patient when she is in severe pain. Many have questioned the ethics and truly “informed” nature of consent when it is obtained from a patient who is experiencing severe pain (e.g., during labor). Although the provider may tailor the consent process to the circumstances, the presence of maternal pain and distress does not obviate the need for a frank discussion of the risks associated with anesthesia as well as the alternatives. A 2005 study evaluated whether labor pain and neuraxial fentanyl administration affect the intellectual function of laboring women. The Mini-Mental Status Examination (MMSE) was used to evaluate orientation, registration, attention, calculation, recall, and language both before and after initiation of analgesia in 41 laboring women. There was no difference in MMSE scores before and after administration of neuraxial analgesia.
Other investigations have shown that women in labor demonstrate not only adequate understanding of options but also good recall of the discussions afterward. Gerancher et al. performed a study to evaluate the ability of laboring women to recall the details of a pre-anesthesia discussion and to determine whether verbal consent alone or a combination of verbal and written consent provided better recall. The investigators randomly assigned 113 laboring women to one of two groups, those from whom verbal consent alone was obtained and those from whom verbal consent plus written consent was obtained. The verbal-plus-written consent group had significantly higher median (range) recall scores (90 [80 to 100]) than the verbal-only group (80 [70 to 90]). Only two women (both in the verbal group) believed that they were unable (because of either inadequate information or situational stress) to give valid consent. The investigators concluded that “the high recall scores achieved by the women in both groups suggest that the majority of laboring women are at least as mentally and physically competent to give consent as preoperative cardiac patients.”
Clark et al. randomly assigned hospital inpatients to receive either a verbal anesthesia discussion alone or both a verbal anesthesia discussion and a preprinted anesthesia consent form. In contrast with the results of Gerancher et al., these investigators found that “patients remembered less of the information concerning anesthetic risks discussed during the preoperative interview if they received a preprinted, risk-specific anesthesia consent form at the beginning of the interview.” They speculated that “patients who see an anesthesia consent form for the first time during the preoperative interview may try to read and listen simultaneously, and with their attention divided, may remember less of the preoperative discussion.”
Thus, it seems reasonable for the patient to provide her signature as evidence of her consent, if her condition permits. This consent can be distinguished on a separate anesthesia consent form or as part of a consent form for all obstetric care, including anesthesia. In the event that a consent form is not available, it should be standard practice for the anesthesia provider to explain the intended procedure, risks, and alternatives, and to document this discussion in the medical record.
Patient Who Has Received Sedatives
Though it may be tempting to assume that a patient who has received a sedative or opioid medication is incapable of providing informed consent, this may not be the case. Judicious use of sedatives to alleviate significant anxiety or opioids to treat severe pain can enhance the patient’s ability to interact and participate in SDM. Nevertheless, it is inappropriate to use sedatives to manipulate the patient’s decision or to eliminate her decision-making capacity. Use of drugs with amnestic potential merit thoughtful consideration as the patient may not recall the informed consent process afterward. However, even when a patient cannot recall the details of the informed consent discussion, that does not necessarily mean that she did not, at the time consent was obtained, understand the risks, benefits, and alternatives presented.
Patient satisfaction has been used as a surrogate measure of the adequacy or effectiveness of the consent conversation. Pattee et al. sought to quantify the influence of factors including pain, anxiety, opioid premedication, and patient education on patient satisfaction with the consent process. In this survey study of 60 patients, queried up to 2 months after delivery, the level of patient satisfaction was high (8.1/10) and not affected by any of these complicating factors ( r = 0.013 for pain and r = 0.048 for anxiety). Subsequently, a study conducted by Gerancher et al. demonstrated no difference in patient satisfaction with the consent process, whether or not the patient had received opioid premedication before obtaining consent.
Patient with a Birth Plan
The birth plan is a document wherein mothers-to-be state their wishes and preferences for the management of certain aspects of their labor and delivery course. The practice of using a formal, written birth plan dates back to the 1970s. Its intended purpose was to enhance communication between the expectant mother and health care provider. The premise was that patient participation in childbirth decision making would result in a positive labor and delivery experience for the mother. To investigate the association between presence of a birth plan, mode of delivery, obstetric intervention, and patient satisfaction, Afshar et al. prospectively studied a cohort of 300 women in a tertiary care center. Compared with the group that did not have a birth plan ( n = 157), the 143 women with a birth plan experienced fewer intrapartum obstetric interventions such as oxytocin augmentation (61% versus 78%, P < .01) and artificial rupture of membranes (15% versus 29%, P < .01). There was no difference in the cesarean delivery rate between the groups. Interestingly, parturients with a birth plan reported less satisfaction with their birth experience compared with parturients without one. A possible explanation for this finding may be that a departure from the expected plan may be met with disappointment, irrespective of the outcome.
Although birth plan documents vary on the level of detail, a typical birth plan may include the woman’s preference for pain management during labor. In the previously mentioned study by Afshar et al., there was no difference between groups regarding use of intravenous analgesia; however, women with a birth plan were less likely to utilize epidural analgesia.
The birth plan is a written expression of the patient’s wishes, not a binding contract that prevents her from receiving epidural analgesia at a later time. As such, it provides a good starting point for a thoughtful discussion that dispels myths, addresses anxieties, and educates the patient on the evidence-based risks and benefits of analgesia and anesthesia for labor and delivery. As a birth plan is typically drafted before admission to the labor and delivery unit, it is possible that a patient may change her mind regarding her wishes. It reflects her best assessment of the balance between risks and benefits before the onset of labor. As the pain of labor escalates, the benefit of epidural analgesia becomes increasingly salient, and she may shift her rational calculus accordingly. Although she may have specifically stipulated, “I don’t want any kind of anesthesia offered to me during labor,” she may change her mind in the course of labor, and request and receive any anesthetic or analgesic service. This highlights an important aspect of informed consent: it must be contemporaneous with the actual situation. It is incumbent on health care providers to read this document and use it as a tool to facilitate communication during SDM. As with all decisions regarding informed consent, a surrogate decision maker can use substituted judgment, as described earlier in this chapter, to modify the birth plan for an incapacitated patient, recognizing that pain alone is not grounds to question a patient’s capacity to make her own decisions. In such a case, it would be important for the clinicians involved in the patient’s care to question a surrogate carefully regarding significant alterations, because the document may be the best evidence of the patient’s wishes.
Emergency Procedures
Generally, health care professionals should provide emergency treatment under a “presumed consent” model, meaning that, absent any collateral information to the contrary, a patient should receive care in her “best interest” in emergent situations even if such a patient cannot provide informed consent. However, in many jurisdictions, family or the decision-making surrogate can refuse such care on behalf of the incapacitated patient if they can genuinely state that they know the patient would refuse such care were the patient able to consent herself. When in doubt as to the accuracy of the family’s refusal, it may be necessary to preserve the best interest of the patient in the face of uncertainty as to the patient’s wishes. If the health care providers’ treatment was authorized under a medical emergency, the providers should carefully document their determination. The documentation in the patient’s medical record should contain a description of the patient’s presenting condition, its immediacy, its magnitude, and the nature of the immediate threat or harm to the patient. It is advisable for at least two health care providers to document this information, because the documentation would support their actions if a lack-of-informed-consent lawsuit were filed. The provider should provide only the care that is reasonable for the patient’s condition.
Vulnerable Populations
Consenting Minors
Traditionally, minors have not been allowed to provide informed consent, based on concerns that they may lack the experience or capacity to inform judgments related to health care decisions. Consequently, in most states, a minor child needs a parent or guardian to make legal decisions, including informed consent for treatment. Exceptions to this rule are based on both statutory laws (i.e., by the state legislature) and case law (i.e., decided by judges in court decisions, which then become binding precedent in the jurisdiction represented by the court). In some states, pregnant women younger than 18 years of age are considered “emancipated minors” and may consent for procedures related to their prenatal, intrapartum, and postpartum care, as well as interventions that benefit the fetus. Regulations pertaining to consent from pregnant emancipated minors vary among the individual states. Minor and parental rights in Massachusetts are presented in Tables 32.1 and 32.2 .
Related posts:
Patient Safety and Team Training
Systemic Analgesia: Parenteral and Inhalational Agents
Anesthesia for Cesarean Delivery
Liver Disease
Psychiatric Disorders
Practice Guidelines for Obstetric Anesthesia: an Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology
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