This morning, I was supposed to have a colonoscopy sone, but when I reported for the exam, they would not do it because I wrote on the consent: :no sedation (discussed with the doc in advance because of side-effects), no blood or blood products.........Several years back, I had IPT and got a platelet transfusion (always from multiple dorors)..........all went o.k. until I got a letter month's later from the Red Cross telling that I had received a batch of blood products that was not screened for HIV or Hep C before being released....so I had received a blood product from multiple donors and none of it was even routinely screened due to "errors by the Red Cross")......so, needless to say, I will NEVER consent to receiving blood products again...My question is: If I note on the consent when I have surgery or a procedure that I do not want blood or blood products, do they have to honor my wishes? The gastro doc is furious that the nurses sent me away (after a nasty prep), and she wants me to reschedule due ot bad symptoms and terrible family history. I will not agree to any blood or blood products; do I need to have her sign the note on the consent form also??? thanks

Dear aap2:

Most hospitals have a waiver of consent form for contemplated procedures, including the administration of blood or blood products. Ask your provider to have such a form available for you to sign IN ADVANCE of the procedure, preferably prior to your arrival at the hospital. If they don't have such a form, check to see if, in the state in which you live, your handwritten and initialled instructions on a consent form constitute legal directive. To be certain your wishes are recognized and respected, it might be a good idea to obtain an Advance Medical Directive form (your hospital should have these, many times offered by Registration on admission). Fill it out, have it witnessed or notarized according to the law in your state, and CARRY IT WITH YOU in your wallet at all times. I believe, in most states, that writing your wishes on the consent form would be adequate, but you should contact your physician and find out what is adequate from his/her standpoint. I hope this has been of some help.

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Jan Grossberg, RN, BSN
Editorial Team

thanks, that is a big help........I ran into a similar problem with a surgical consent; I told them that I would only consent to TIVA with propofol and fentanyl dew to previous bad reactions.....everyone agreed and said that they would honor my request...but, when I wrote a note to this effect on the consent, the anesthesia nurse freaked out. What can be wrong with documenting what we agreed to?

Dear aap2,

You're right that whatever you and your doctor have agreed on prior to the procedure should be put into writing. You should be informed of the possible side effects of anesthetics & analgesics such as propofol & fentanyl. Precisely, we call it informed consent.

Did I get you right, that you prefer propofol and fentanyl (TIVA), but you don't want sedation?

Actually, I have given an anesthetic/analgesic for colonoscopy a few times. A colleague MD of mine in the hospital where I work underwent the procedure. He requested that no sedation be given so I gave fentanyl and parecoxib for the pain. But he went on to say that if ever he will not tolerate the pain, I could give additional anesthetic. He was awake and could see the the procedure through the TV monitor. However, as the scope was going higher into the intestine, he could not tolerate the pain and so I added propofol. The rest of the procedure went smoothly. In a few minutes after the colonoscopy, he was awake and without hangover.

Regards,

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Angelina A. Gapay, MD

Thanks Dr for the reply; I have had terrible problems with "conscious sedation", so I wanted to avoid it....everyone agreed and all was fine until I documented it on the consent......so I never did get the colonoscopy despite symptoms and first degree relatives who died at a young age from colon cancer....oh well. The request for TIVA with propofol/fentanyl was for a surgical procedure (gen anes with airway support)......I get severe PONV from inhalation agents, sevo and nitrous made me so sick that I ended up being admitted. The best part is that the anesthesia nurse agreed, but freaked out when I wanted to document it. It has been a long time since I worked in healthcare; if a patient ever mentioned a documented problem with any drug, I would be sure to avoid it.......especially with the anesthesia drugs available today, so many good choices...well, I guess that things have changed.......

Yes, nitrous oxide and opioids like fentanyl and to a lesser degree inhalation anesthetics produce PONV, however, propofol has an anti-emetic effect and is a better choice. So, if the procedure is only a colonoscopy, propofol alone may be enough to get you through. A few of my colleagues have undergone colonoscopy with propofol alone and worked in their clinics few hours later without hangover.

As SOP, any previous experience with anesthetics or any drug should always be documented in patient's chart. I always try to avoid anesthetics which have previously produced adverse reactions in my patients.

If your gastroenterologist and anesthesiologist agree to your request that propofol be your anesthetic then go ahead with your colonoscopy. If its inevitable that fentanyl be used, you may ask for a preop anti-emetic agent .

Hope this will help you and your MDs. Thanks.

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Angelina A. Gapay, MD

Thanks doctor for the reply. Earlier in the year, I had ulnar nerve transposition.CTS with just propofol/fentanyl (more or less conscious sedation) with no problem at all.it's just when the inhalation agents are added that I get really bad PONV. Just my luck: I need ot have 2 more procedures which require general anesthesia: greenlight laser surgery for BPH and abdominoplasty; both are outpatient procedures and I was wondering if TIVA with propofol and fentanyl would be a reasonable thing to ask for? I'm asking you because even if I schedule the surgery, the anesthesia dept will not talk to the patient until right before surgery...I really appreciate your answers and help. thanks

I appreciate your suggestion about the colonoscopy; I had it done on monday.....and it was done without any drugs because I was tired of arguing with the people at the surgi-center about my bad experience with versed etc.....it was uncomfortable, but not intolerable. The GI doc told me that I will need to have them frequently for a while and suggested perhaps fentanyl only for the few painful spots or propofol as you had suggested. I asked why all the resistance to getting the exam with nothing and she was quite honest: marketing.....they don't want patients having a painful exam and telling others how bad it is.....then few people will get the exam and lots will die from cancer. works for me.....I thought that i was special since I did the exam without drugs, until the GI doc told me that she just had one without drugs and that the exam is harder in women. ......

Hi aap2!

congratulations on your colonoscopy without much ado! Good you tolerated it well. It's a fact, different individuals have different levels of tolerance to pain or discomfort. Some may need more analgesics/anesthetics especially if the level of anxiety is high.

On your other surgical procedures on outpatient basis, it is ok if you request for TIVA with propofol and fentanyl. Many procedures done on outpatient basis are done with these 2 drugs as both are short acting. If you had a pleasant experience with TIVA in an earlier surgical procedure, then go ahead and have the same anesthetics. I'm not familiar with abdominoplasty and the other procedure but your anesthesiologist would know best.

Thanks and regards,

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Angelina A. Gapay, MD

Dear aap2,

As we age we will need more and more medical care of some sort. Since the possibility of this happening while you will not be able to speak for yourself could happen, you need an advance directive and a durable power of attorney for health care. The durable feature means if you cannot speak for yourself someone else can.

This will prevent you from being exposed to a number of problems like living probate.

It would also be good to carry a medical alert bracelet. You will not be able to put what you want on it. You can put no _________ and what ever you want to avoid. This will make them look for alternatives.

Next the nurses.

The nurses can become like the Soup Nazi. The only difference, "No health care for you!" I am a nurse and have been treated this way.

My wife, pregnant and bleeding, was refused by three hospitals. It was the nurses who were refusing to allow her to be seen by the doctors. They cited policy and procedure.

By going directly to the doctor, it was possible to get seen and get past the nurses. So if this is ever a problem, say you want to speak to the doctor, surgeon or anesthesiologist. Usually the anesthesiologist administers blood in surgery.

Also you need to know that the consents usually indicate that another doc could step in.

This means you could get a doc that says he would be willing to do it with out blood or products and he is injured in an accident and another steps in. The difference is that the new doc is not experienced or skilled in advance transfusion practice.

So the Nurse Nazi is really doing you a favor, especially if there is a change you might not be aware of.

Good health to you.