2019 FSA Posters

P044: PATIENT CENTERED CARE, HOW TO PREPARE THE PATIENT FOR DIFFICULT INTUBATION: A CASE REPORT
Taylor Brown, MD, Nelson Nicolas Algarra, MS, MD; University of Florida

Introduction: Patient centered care is recognized as a desirable attribute of health care as it honors patients’ preferences, needs, values, and goals.¹ This practice can be incorporated with informed consent as in this case of a difficult intubation from a tonsillar and thyroid mass in which the patient was scheduled for an awake tracheostomy, preferred an asleep intubation, and eventually expressed understanding and consented for an awake nasal fiberoptic intubation.

Case Presentation: A 54-year-old female presented to the University of Florida ENT clinic with progressive dysphagia, dyspnea, and limited oral intake. She has a known history of right tonsillar mass discovered on previous intubation at an outside hospital and thyroid mass. Intraoral examination revealed right exophytic, papillamotous tonsillar mass appearing to occupy the majority of the oral airway. Neck examination revealed a large anterior cervical scar and significant thyromegaly. On further evaluation with computed tomography (CT) of the head and neck, a 30x23x31 mm right tonsillar mass was identified obstructing greater than 80% of the airway. In addition, CTA of the chest revealed a very large left-sided thyroid mass extending into the mediastinum and pushing the airway to the right.

ENT initially scheduled her for an awake tracheostomy, but her distorted anatomy prompted the discussion for other airway management options with the anesthesia team. As well, the patient preferred an asleep intubation. After hearing the concerns of the patient, the surgical and anesthesia teams discussed the safest options with the patient. The patient was informed about the process of the awake and asleep procedures, including potential benefits and risks. The patient made her decision by signing an informed consent and verbally expressing the intubation choice.

Discussion: Informed consent is an ongoing process of communication that begins in the preoperative period for anesthesiologists. With patient centered care in mind, informed consent must be considered a shared decision between the patient and the physician especially in a case that can lead to potentially life changing and fatal outcomes. Not only has patient-centered care resulted in improved care processes² but has also increased health outcomes, including survival.³ Therefore it is important to incorporate the eight principles of patient-centered care when deliberating between initial preferences to reach an informed decision. This case is an example of appropriately contributing to patient decision-making instead using coercion by integrating emotional support, physical comfort, information/education, coordination with multiple teams, and respecting patients’ preferences.

References:

1. Greene SM, Tuzzio L, Cherkin D. A Framework for Making Patient-Centered Care Front and Center. The Permanente Journal. 2012;16(3):49-53.

2. Greenfield S, Kaplan SH, Ware JE, Jr, Yano EM, Frank HJ. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988 Sep–Oct;3(5):448–57.

3. Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Health Serv Res. 2010 Oct;45(5 Pt 1):1188–204.