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CHAPTER 1
The Context of Perioperative Care
What is Perioperative Practice?
The word ‘perioperative’ is a fairly recently devised term. The Association for Perioperative Practice (AfPP 2005) describes the perioperative environment as the area utilised immediately before, during and after the performance of a clinical intervention or clinically invasive procedure.
Previously, the care of the patient undergoing a surgical procedure was separated into distinct and separate areas of care. In the case of elective surgery the majority of patient journeys began with a visit to the GP, followed by a wait, hopefully appropriate to the urgency of their disease needs, for a referral to a specialist surgeon to come to fruition and then again, subject to urgency, another wait for an admission date to a hospital for surgery possibly after a series of investigations. Once admitted, the patient started on another journey in less familiar surroundings which, dependent on age, ethnicity and language, competence and understanding may have caused anxiety and fear which the healthcare professionals responsible for the care of the patient must make every effort to resolve as part of their service to the people who need their help and support.
It was then at this point that the perioperative care in anaesthesia, surgery and postanaesthetic recovery took place as suggested by the AfPP.
More recently, the patient has been considered holistically and the term ‘perioperative’ now much better describes the care of the patient from initial referral and diagnosis to full recovery, or as full as that recovery might be for their physical condition. That final outcome may inevitably be death and it is not necessary to deem that conclusion as a failure.
The word ‘peri’ derives from the Latin ‘around’, so perioperative means around the operation or intervention. Therefore perioperative care should start with good-quality information-giving and sharing with the patient from the first time they interact with a healthcare professional in the doctor’s surgery or possibly in the emergency department of a hospital. Today’s elective patients are likely to have investigated their own symptoms, often using unregulated internet sites and may arrive for their first healthcare consultation believing that they have already discovered their own diagnosis. The patient’s first interaction and continuing care may be as part of the caseload of a surgical nurse consultant or advanced surgical care practitioner, who may care for the patient throughout their surgical journey and should be considered as perioperative.
All patients should be treated as individuals and not as a diagnosis or surgical operation. Sometimes, in this busy pressurised world, there may a tendency to forget that the patient does not experience the surgical environment every day as do the specialised healthcare professionals. Even the least complex procedure in the perioperative environment may be a major event for the patient.
Where Does it Take Place?
Historically, perioperative care was undertaken in an operating theatre or suite of theatres in an acute hospital, but more recently the settings for surgery have expanded after recognition that as long as the allocated area meets standards required for asepsis and infection management, conventional environments are not necessarily the only available option. These various settings can include doctors’ surgeries and treatment centres for routine and more minor cases, keeping the acute or tertiary setting for the most complex and urgent surgeries. Patients can therefore access their surgical care closer to home and with less personal inconvenience and, it is hoped, with reduced waiting times. Healthcare is unfortunately enmeshed with the political system, but one of the better outcomes for patients over the last decade is that they usually have to wait less time than previously to see a specialist and receive appropriate treatment for non-urgent surgery.
In addition, in the current climate of global unrest, life-saving surgery is undertaken in conflict zones across the world and standards expected in more settled places may not be able to be fully met, the first priority being the saving of life. For example, surgery takes place in mobile operating rooms, in vehicles and ships, tents and other settings which will be completely alien to the practitioner who works in a standard hospital operating room. Working in the armed forces, for non-governmental organisations, charities and the like can broaden the practitioner’s experience at the same time as engendering appreciation of their own high-quality operating suites within a recognised standard situation. Many advances in care and treatment have been innovated and initiated in times of conflict because of the needs of the patient with multiple trauma injuries.
Perioperative practice caregiving is delivered by a range of professionals who work collaboratively towards the best-quality outcome for the patient. There is a confusing range of these roles; names may differ across organisations and countries, but despite the differing titles their functions are similar. Boundaries have been crossed in recent times, with role expansion and development for many perioperative practitioners.
Many practitioner roles now have their own patient caseload and perform tasks within the surgical field that were previously only performed by medical staff. Through training and supervision, continuing assessment and quality outcome measurements, it has been shown that practitioners other than medical staff can perform many surgical procedures competently. The medical staff are then freed to perform more complex procedures. These less difficult cases are being performed competently and the stability or care delivery has been shown to have better outcomes for patients and the practitioners undertaking these advanced roles often become the instructors for junior medical staff, given their expertise and the stability of their role.
The Patient’s Perspective – Consent and Competence
At all times it must be remembered that the patient must be at the centre of individualised care and unless their capacity to make decisions is compromised, their autonomy to make decisions for themselves must be respected. From an ethical perspective, each competent adult is an autonomous person and their own decisions about ‘self’ must be respected and followed.
Coercion to undergo treatment is unacceptable but difficult to avoid in a healthcare setting. With admission on the day of surgery becoming common practice, if consent has not been taken preadmission, then the patient has had insufficient time to ask further questions should they wish to gain the necessary information on which to base a decision. Decision-making on the morning of surgery or when the patient has already changed into a theatre gown is not appropriate or good practice.
As Martin Hind, senior lecturer in critical care, states ‘it may be difficult to prevent some degree of coercion in securing consent from a patient, but misrepresentation of the facts or overt manipulation of the patient should be avoided’ (Woodhead and Wicker 2005). What healthcare professionals must also always accept is that refusal to consent is as valid as agreement to consent to treatment, even if that decision is contrary to what they would advise.
Consent should be taken recognising the following conditions; these are not exclusive but examples of what may block fully informed consent being made by the patient:
- Language: Does the patient understand the person taking consent? Is the patient, deaf, blind, lacking understanding of the language being used or might they require support from a translator or signer? Does the consent taker, speak the patient’s language sufficiently well? In a multi-ethnic system real comprehension of information given and received can be difficult.
- Understanding: Has the healthcare professional used medical terminology that can be understood by the patient? Without understanding of what the treatment entails, including any likely complications, the patient is not sufficiently able to make a fully informed decision. With good planning, the patient can be given language- and age-specific information about their disease, treatment, outcomes and complications along with frequently asked questions. Written information along with a verbal interaction between the patient and a competent information-giver, while sounding like utopia, is best practice and should be a clinical aspiration.
- Capacity: Is the patient a child or do they suffer from learning difficulties or another impairment such as unconsciousness or brain injury? Consent for minors under the age of 16 in the UK is taken from parents, legal guardians and legal caregivers. In cases where there are difficulties best interest principles must be used or the intervention of the legal system to ensure that the patient is at all times at the centre of the process and outcomes.
- Best interest principles: These have to be taken into account in a range of situations where the patient does not have the capacity to make a decision for themselves. The UK Mental Capacity Act 2005 identifies a single test for assessing whether a person lacks capacity to take a particular decision at a particular time.
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