Perchance to Dream

Fair warning, I will be mixing my Shakespeare analogies. The title is a quote from Hamlet’s soliloquy. The following is from Romeo and Juliet and Romeo and Mercutio having a conversation.

Romeo: I dreamt a dream tonight.

Mercutio: As did I.

Romeo: What did you dream?

Mercutio: That dreamers often lie.

Romeo: In bed asleep while they do dream things true.

This is a play on words and a true statement all at the same time.

To lie in bed is to be prone. And dreams are sometimes true and sometimes false.

Okay, lit session over.

I did dream last night, lying in bed. I’ve had really vivid dreams about work before but I am rarely in the operating room, mostly I search for my med surg patients to give them their 0900 meds and it is 1430. But last night I dreamt of consents.

I was in an operating room, room 2 I think, and the patient was being induced for anesthesia. (that means put under the anesthesia). The anesthesia team and I were discussing the case as they put in the LMA and I was holding the chart in my hands, open to the consent.

When I spy what looks like a consent across the room, on the charting desk.

It was! A completely different consent, with different fingers than the surgeon marked and the room had planned for. With different instrument needs and a different implant system. The patient and the surgeon had both signed it.

Why was it not in the chart?

Why wasn’t it the most current consent? Or was it? Which had the latest signatures? Because there is a date and a time on each consent for each signer for a reason.

What was going on?

What is the appropriate response?

Anesthesia suggested that we ignore the older consent, the one that was what was on the schedule, the digits the surgeon had marked, and belied the conversation that I had had with the patient about their expectations of what was going to happen and the surgery plans all because the new consent that appeared out of nowhere was the newer consent.

No. Not even close.

The appropriate answer is to wake the patient up.

Yeah, I know that it is radical but they know best.

It is true that sometimes patients will just sign any paper put in front of them, even after reviewing the plan with the surgeon and the pre-op nurse.

It is also true that sometimes, immediately before a surgery, the surgeon will rewrite a consent and have discussion with the patient about the new consent. And sometimes they don’t have the conversation with the patient.

No. It is better for the patient not to do the incorrect surgery. It is better for the liability of all involved if everyone is on the same page (pun non intended) regarding the plan and the consent.

Have I had a surgeon off-handedly tell me that they had had a last-minute conversation with the patient and the plan changed?

Yes.

Is it the correct and appropriate thing to do to ignore what is not listed on the consent, thinking that the standard boiler-plate consent will cover you?

Not if you cherish your nursing license.