Preoperative Management
of Adolescents
Undergoing Elective
Surgery
Nina L. Shapiro, MD
Associate Professor
Department of Head and Neck Surgery
David Geffen School of Medicine at UCLA
TEENAGERS!!
Preoperative Management of
Adolescents
 Particular needs of this patient population
 Particular challenges of this patient
population
 Wide variation in physician practice
management
 Few standards to handle these challenges
Peri-operative Considerations for
Teenagers
 Informed Consent/Assent
 Pregnancy
 Drug Use
Ethical or Legal Dilemmas?
Informed Consent
A person’s agreement to allow or undergo
medical treatment or surgery that is based
on a FULL disclosure of the facts needed to
make that decision intelligently
Informed consent discussions with minors
should be conducted at a level that can be
understood by the minor
Patient
 A 13-year-old boy presents for sinus surgery.
On the day of surgery he answers all
questions appropriately, but when asked if
he has any questions he says ‘no’ because
he is NOT having surgery. He states that
‘this surgery is not necessary and I don’t
want it’.
 Parents insist that it must be done today.
Children who refuse surgery
 2007 Survey of SPA Members:




Response from 453/852
9% cancelled >1 case/year
25% cancelled >1 case/5 years
45% cancelled >1 case/career
 THOSE WITH MOSTLY PEDIATRIC PRACTICE WERE TWICE AS
LIKELY TO HAVE CANCELLED A CASE
 THOSE IN PRACTICE LONGER WERE MORE LIKELY TO
INCLUDE CHILD IN DECISION
 OVERALL 57% UNSURE WHAT TO DO
Patient Refusal: APSA vs. ASPO
 Survey of pre-operative adolescent care of APSA and
ASPO members
 108/698 APSA members (15.5%)
 51/380 ASPO members (13.4%)
 Would you cancel an elective surgery if adolescent
refuses?
 ASPO: 49% “Never”
 APSA: 79% “Never”
Children who refuse
 Restraint
 44% anesthesiologists use restraint in majority of
patients under age 1 year
 2% use restraint in patients over 11 years
 Median age SPA members consider a child’s
refusal:
 12 years
Right to Refuse
 Competent adults may refuse treatment at any stage
 Coercion may be considered assault
 AAP Policy Statement
 Informed consent, parental permission, and assent in
pediatric practice
 There are clinical situations in which a refusal to assent (or
dissent) may be ethically binding
Informed consent for (not by)
minors
 Informed consent is given based upon a clear
appreciation and understanding of the facts,
implications, and future consequences of an action
 When a parent signs an informed consent, full disclosure
from a minor to a parent must occur.
 DOES THIS HAPPEN??
TEEN PREGNANCY
Patient
 13-year-old for tonsillectomy
 LMP ‘unknown’
 Boyfriend with the family in preop area
 Do you ask about possibility of pregnancy?
 Or perform routine UCG?
 At what age?
 What do you do with the information?
Teen Pregnancy in the U.S.
Teen Pregnancy by the Numbers
 U.S. has the highest teen pregnancy rate of
industrialized nations
 75.4 pregnancies per 1000 girls (1
million/year)
 34% become pregnant at least once before
age 20
Pregnancy and Anesthesia
 No real evidence that pregnancy is harmful
to the developing fetus
 No real evidence that it is not
 Surgical/diagnostic study risks to pregnancy
 Cannot control for other insults– hypoxia,
hypercapnia, temperature control, meds,
etc
SAB and Low Birth weight
 Women requiring non-obstetric surgery during pregnancy
 Lowest rate of preterm birth if surgery in 2nd trimester
(11%)
 GA associated with lower birth weight (3053g vs. 3515g,
p=0.01)
 Longer, intra-abdominal, GA were independent risk
factors
Barriers to Adolescents
 Plan B needs prescription
 Fear of negative attitudes from physicians
 Belief that early care is unimportant
 Inexperience in medical care
 Lack of education
 Leads to inadequate care
The Law/’Un-informed’ Consent
 California law:
 A health care provider is NOT permitted to
share information of records regarding the
prevention or treatment (or diagnosis) of a
minor’s pregnancy with a parent or legal
guardian without the minor’s written
authorization.
HIPAA/ California Law
Providers who reveal confidential
information in violation of California’s
Confidentiality of Medical Information Act
and HIPAA can be found guilty of
“unprofessional conduct” and can held
criminally and civilly liable, and may loose
their medical license.
Practice vs. Ethics (ASA)
 Practice:
 Need for testing pts even if deny possible
pregnancy
 Test all females vs. Informed refusal of test
 Ethics:
 Personal information that belongs to patient
 Right to proceed with anesthesia and surgery if she
desires
 Testing offered but not required?
Options
 Educational information during office visit
 Questionnaire without parental presence
 Thorough history
 Importance of full disclosure
 Confidentiality and judgment-free discussion
 “Universal testing”
 UCLA: all females ages 10-53 yo
ASPO and APSA: Pregnancy
 65% of ASPO and APSA members ask about possibility of
pregnancy ‘always’
 70% of ASPO and APSA members ‘always’ get pregnancy
test
 ASPO members more likely than APSA to change their
plan for surgery after learning that a patient was
pregnant (p=0.007).
 Physicians in private practice (ASPO and APSA) more
likely to cancel elective surgery in pregnant patient
than those in University or Childrens’ Hospitals.
Pre-Operative Pregnancy Dilemma
 If we test all adolescents, what do we do
with the results?
 If we do not tell the family, are they giving
‘informed’ consent?
Drugs and Alcohol
Patient
 15 yo for ESS for chronic sinusitis calls
surgeon with concerns regarding risks of
drug use and anesthesia and asks how long
he must be ‘clean’ before having surgery.
Patient was told an arbitrary 1 month and
case was rescheduled.
 On day of surgery, patient seems ‘nervous’
Drug Use
 Do you ask about drug use?
 Would you test this patient?
 Can you tell the family the results of the
testing?
Drug use in teenagers:
What are they doing?
CDC Survey: Ages 12-18
 Alcohol
 81% have had at least one drink
 32% had first drink before age 13
 31% had >5 drinks on >1 occasion in the 30 days prior to the
survey
 Marijuana
 47% have used
 11% used before age 13
 27% at least once in 30 days prior to survey
ASPO vs APSA Drug Screening
 5-10% ‘always’ speak with patient alone
 25-40% ‘always’ ask about alcohol/tobacco
 20% ‘always’ ask about drug use
 10-20% ‘always’ change surgical plan based on drug
history
 Those with >15 years experience and higher percentage
of adolescents in practice more likely to ‘always’ ask
about alcohol/tobacco (p<0.01)
Ethics vs. Law
 AAP Policy Statement
 Involuntary testing is not appropriate in
adolescents with decisional capacity, even
with parental consent, and should be
performed only if there are strong
medical or legal reasons to do so.
 Is preoperative state a ‘strong’ medical
reason?
California Law
 A minor who is >12 years old may consent to medical
care and counseling relating to the diagnosis and
treatment of a drug or alcohol-related problem.
 Any program receiving federal funding or registered
with Medicare MAY NOT reveal any information to
parents without minor’s written consent.
What Do We Do?
 Educational information to patient/family during office
visit
 Questionnaire without parental presence
 “Parentectomy”
 Thorough history on phone or in person prior to surgery,
with importance of ‘full disclosure’
 Include confidentiality assurance and judgment-free
discussion
 Drug testing ‘prn’
Conclusions
 Adolescent patients are a unique population who
are developmentally capable of participating in
their care and should be included in the
preoperative discussion
 Physicians vary, based on specialty, practice
setting, and experience, in how they involve
adolescents in the decision-making process for
surgery, and how they approach assent, pregnancy,
and drug use
Conclusions
 The concept of assent is ethically and legally
difficult to define
 Dissent or absolute refusal to give assent must be
considered carefully before proceeding.
 Consider postponing elective cases
 Consider an ethics consult
Conclusions
 Risk of anesthesia and surgery on a fetus or
pregnant individual, or risk of anesthesia
with acute or chronic drug use is difficult
(or impossible) to convey in informed
consent when parent is signing consent
without violating confidentiality
Conclusions
 Asking the right questions in the right setting will
arm us with the knowledge needed to provide safe
care for teens, and help parents make ‘informed’
decisions.
 Involving adolescents in their preoperative care
will enable them to better understand
ramifications of surgery and anesthesia.