Treatment options and informed consent
Stem
Mr. Okafor, a 63-year-old man, 92 kg, is scheduled tomorrow for an elective right total knee replacement. He has well-controlled hypertension and no other medical problems. You and the surgeon agree that a spinal anesthetic with sedation or a general anesthetic are both reasonable. The history and physical are complete; do not repeat them. Your task: discuss his anesthetic options and obtain verbal consent.
Question
The surgeon mentioned something about a needle in my back. Honestly, that makes me nervous. What are my options for tomorrow?
Ideal answer
Headline"You have two good options. I suggest a spinal, and the decision is yours."
- Concern first. "I'm Dr. Reyes, your anesthesiologist for tomorrow. Your full name and date of birth? What do you understand about the surgery? The needle worry is very common, and I'm glad you told me. Anything else worrying you?"
- Options in lay terms. "With a spinal, I numb a small spot on your back and a very thin needle gives medicine that numbs you from the waist down for a few hours; medicine in your IV keeps you relaxed and drowsy. People usually need less strong pain medicine afterward. Or a general anesthetic: fully asleep with a breathing tube."
- Risks: common, rare, mitigation. "Spinal: low blood pressure, itching and nausea are common and mild, and quickly treated. A headache is uncommon with my fine needle. Serious nerve damage, including bleeding around the spine, is very rare, 1 in 20,000 to 30,000;1 I check your blood thinners and watch you throughout. General: sore throat and nausea are common; a damaged tooth or awareness during surgery is rare."
- Questions, teach-back, his choice. "What questions do you have? Tell me in your own words what we'd do. I'm comfortable either way."
Breaking down the answer
- What is scored — seven observable behaviors from the published content outline, not my knowledge of complications; the written exam did that.2
- The sample station — the ABA's own example is typical: a 68-year-old with COPD for rotator cuff repair, worried about pain, general and regional both on offer, verbal consent sufficient, history and physical not to be repeated.3
- Why the order — a frightened patient does not hear risk information, so concern precedes content. Conduct is told from his side (IV, sedation, position, the pressure of the needle, numbness), because patients consent to experiences, not procedures.
- Proportion — the outline asks for both risk tiers,2 and proportion matters as much as completeness. The 1–2 in 100 headache figure, even with a fine pencil-point needle, comes from obstetric patients,4 so for a 63-year-old man I say "uncommon."
- Fit the risk to the procedure — changes if it is a peripheral block: the rare-serious item is then nerve injury: neuropathy under 3 in 100, interscalene about 2.8%, permanent injury rare.5
- Mitigation shows I own the risk — ultrasound guidance, a small pencil-point needle, blood thinners held on a set schedule, monitoring throughout.
- Close on an uncoerced decision — "What questions do you have?" signals questions are expected; teach-back checks understanding; the checklist explicitly scores a final decision and affirmative consent without coercion.2
Follow-up question
He shakes his head: "My cousin was paralyzed by an epidural. I'm not letting anyone near my spine." He crosses his arms and waits. What do you say?
Follow-up answer
HeadlineFear-driven refusal: I acknowledge, ask, give one number, and hand the decision back. No arguing, no louder statistics.
"That sounds frightening, and it makes sense you'd be worried." I ask what happened to his cousin, because the story often holds a misunderstanding I can address. I give the real number once, calmly, and how his situation differs, if it does. Then: "If you'd rather not have a spinal, we'll do a general anesthetic, which is also safe. Here's what that involves." I confirm he understands and feels no pressure; respecting the refusal is the scored behavior. If he asks "What would you do?", I answer honestly with my reasoning, then hand the decision back.
Pitfalls that cost points
- Leading with the consent form instead of the conversation.
- Jargon: "hypotension," "post-dural puncture headache," "neuraxial."
- Offering no alternative, which turns consent into permission.
- Persuading past one honest recommendation; that is coercion.
Rapid-fire
Q: How do I phrase a 1-in-10,000 risk? A: "If ten thousand people had this, about one would have that problem; it is very rare, and here is what I do to prevent it."
Q: Do I give my recommendation? A: Yes, once, with the reason; then the alternative is acceptable and the choice is theirs.
Q: What if the patient wants no information? A: I respect it, confirm they understand the nature of the procedure, and document.
Q: What if the patient speaks limited English? A: A certified medical interpreter, not a family member, and I speak to the patient, not the interpreter.
Numbers to know
| Item | Value |
|---|---|
| Station time | 8 min, 4-min read, warning at 6 min6 |
| Consent checklist behaviors | 72 |
| Headache after 27-gauge pencil-point spinal (obstetric) | ~1.7%4 |
| Accidental dural puncture with epidural; headache after it | ~1.5%; about half (52%)4 |
| Severe neurologic complication after spinal (Sweden) | 1 in 20,000–30,0001 |
| Neuropathy after peripheral block; permanent | <3 in 100, interscalene ~2.8%; permanent rare5 |
Links
- OSCE day: stations, timing, who is in the room, Ethical issues: DNR, capacity, surrogates, refusal, Disclosing a peri-procedural complication or error, Spinal anesthesia: dosing, spread, hypotension, Interscalene block and its complications
- ASA Guidelines for the Ethical Practice of Anesthesiology; ASA Statement on Informed Consent for Anesthesiology Care
Sources
- 1.Severe neurological complications after central neuraxial blockades in Sweden 1990-1999 · Anesthesiology, 2004 · ebi.ac.ukAbstract via Europe PMC (PMID 15448529); 33 spinal hematomas in ~1.71 million blocks.
- 2.APPLIED Examination OSCE Content Outline · ABA · theaba.org
- 3.OSCE Example Scenarios · ABA, 2023 · theaba.org
- 4.PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies · Canadian Journal of Anesthesia, 2003 · ebi.ac.ukAbstract via Europe PMC (PMID 12734154); obstetric population.
- 5.Neurological complications after regional anesthesia: contemporary estimates of risk · Anesthesia & Analgesia, 2007 · ebi.ac.ukAbstract via Europe PMC (PMID 17377115).
- 6.What to Expect for Your APPLIED Exam (APPLIED Exam Manual) · ABA, 2026 · theaba.orgRevised July 2026.
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.