Parental Desire for Perioperative Information and Informed
Consent: A Two-Phase Study
Zeev N. Kain, MD**, Shu Ming Wang, MD*,
and Linda C. Mayes, MDt$
Departments of *Anesthesiology, tYale Child Study Center, and @‘ediatrics,
New Haven, Connecticut -.
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The purpose of this investigation was to identify the
perioperative anesthetic information parents want
from the anesthesiologist,and to determine whether
the provision of detailed anestheticrisk information is
associated with increased parental anxiety. The investi-
gation consisted of a cross-sectional study followed by
a randomized controlled trial. In Phase 1, baseline and
situational anxiety, coping strategy, and temperament
were obtained from parents of children undergoing
surgery (n = 334). A questionnaireexamining the desire
for perioperative information was administered to all
parents. In Phase 247 parents were randomly assigned
to receive either routine anesthetic risk information
(control) or detailed anesthetic risk information (inter-
vention). The effect of the intervention on parental anx-
iety was assessed over four time points: prior to the in-
tervention, immediately after the intervention, day of
surgery in the holding area, and at separation to the
S
tudies in the United States and Europe have
shown that many patients are dissatisfied with
the amount of perioperative information re-
ceived from their physicians (l-3). A recent British
survey of over 5000 randomly chosen adult patients
revealed a considerable lack of knowledge relating to
the perioperative period (1). To rectify this situation, it
is essential to identify the aspects of perioperative
management about which patients desire the most
information (2). The desire for information among
parents of children undergoing surgery is of particular
interest, as parents frequently are more concerned
with their child’s health than with their own.
Anesthesiologists have an ethical and legal respon-
sibility to provide patients with detailed anesthetic
risk information when obtaining the informed consent
before surgery. How far disclosure must extend re-
mains controversial. A common reason given for not
Accepted for publication October 21, 1996.
Address correspondence and reprint requests to Zeev N. Kain,
MD, Department of Anesthesiology, Yale University School of Med-
icine, 333 Cedar St., New Haven, CT 06510-8051.
01997 by the International Anesthesia Research Society
0003~2999/97/$5.00
Lisa A. Caramico, MD*, Maura Hofstadter, PhD*,
Yale University School of Medicine,
operating room. For Phase 1, the majority of parents
(>95%) preferred to have comprehensive information
concerning their child’s perioperative period, includ-
ing information about all possiblecomplications. For
selected items, increased parental educational level was
associated with increased desire for information (P <
0.05). For Phase2, when the intervention group was
compared with the control group, there were no signif-
icant differences in parental anxiety over the four time
points [F(1,45) = 0.6, P = 0.41. Also, the interaction be-
tween time and group assignment was not significant
[F(3,135) = 1.66, P = 0.181. We conclude that parents of
children undergoing surgery desire comprehensive
perioperative information. Moreover, when provided
with highly detailed anesthetic risk information, the pa-
rental anxiety level did not increase.
(Anesth Analg 1997;84:299-306)
-
providing detailed anesthetic risk information is that it
may result in increased anxiety. Although an early
study suggested that detailed procedural information
may lead to increased patient anxiety (4), more recent
reports disagree (5-7). All previous investigations re-
garding detailed anesthetic information were con-
ducted either the day before surgery or on the day of
surgery. Inglis and Farnill(5) suggested in their recent
study that it is possible that increased anxiety in pa-
tients provided with detailed anesthetic risk informa-
tion may eventually develop given enough time for
contemplation of the risk information. Furthermore,
with the increasing practice of same-day admission
surgery, the traditional preoperative visit the evening
before surgery has been virtually eliminated and most
patients now receive their preoperative anesthesia
evaluation either on the morning of surgery or several
days before the day of surgery. Since the timing of the
anesthesiologist’s preoperative interview may have an
effect on the anxiety level of the patient (5,8), previous
investigations regarding detailed anesthetic risk infor-
mation may be irrelevant for the present practice.
An&h Analg 1997;84:299-306 299
300 PEDIATRIC ANESTHESIA KAIN ET AL. ANESTH ANALG
PERIOPERATIVE INFORMATION: EFFECT ON PARENTS 1997;84:299-306

The purpose of Phase 1 of this investigation was to Canada, was administered to all parents (13,14). Each
identify the information that parents want from the questionnaire contained a list of 14 statements relating
anesthesiologist about the perioperative period. In specific details of anesthesia and surgery. The parents
Phase 2, we hypothesized that the provision of de- indicated how they felt about receiving the informa-
tailed information about anesthesia-related risk, in- tion contained in each of the statements. The available
cluding incidence of adverse outcomes, is associated choices were “Prefer not to know,” “Would like to
with increased parental anxiety. know,” and “Have the right to know,” and subjects
were asked to indicate only one choice. An index of
the overall desire for information (overall desire in-
Methods dex) was calculated for each parent by applying the
This investigation consisted of a cross-sectional study weights 1, 2, and 3 to the response categories “Prefer
followed by a randomized controlled trial. The study not to know, ” “Would like to know,” and “Have the
population was drawn from consecutive parents of right to know,” respectively.
children who underwent surgery and general anesthe-
sia at the Children’s Hospital of Yale-New Haven. Study Protocol-Phase 2
Non-English-speaking parents were excluded from
the study. Only one parent per child was allowed to Of the 334 parents who participated in Phase 1 of the
participate in the study. All subjects were recruited study, 47 were enrolled in Phase 2. No parent declined
O-10 days prior to surgery while the children were participation in this phase of the study. These were
undergoing preoperative evaluation. After recruit- parents of children aged 4-12 yr, ASA physical status
ment, sociodemographic data, including age, race, I or II, who underwent elective outpatient surgery and
gender, marital status, educational level and income, general anesthesia. To avoid potential confounding
birth order, number of siblings, family size, day care, variables, any history of previous surgery, hospitaliza-
and previous hospital and surgical experience were tion, chronic illness, or developmental delay disqual-
obtained. The study was approved by our institutional ified parents and their children from participation in
review board and informed consent was obtained this phase of the study.
from all parents. Immediately prior to the anesthetic interview, the
anxiety of the parent (STAI) and child (VAS) was
Assessment Tools assessed (Tl). Next, parents were randomly assigned
to receive either routine anesthetic information (con-
Data regarding the following behavioral assessment
trol) or detailed anesthetic information (intervention).
tools and questionnaires are reported in detail in Ap-
The randomization was done using a random num-
pendix I: Stressful Situation Coping Instrument (SSCI)
bers table. The routine and detailed anesthetic infor-
(9); Emotionality, Activity, Sociability, Impulsivity
mation are included in Appendix II. Briefly, the highly
(EASI) Instrument of child temperament (10); State-
detailed information included statistics about adverse
Trait Anxiety Inventory (STAI)‘; and Anxiety Visual
outcomes associated with anesthesia (e.g., “Brain
Analog Scale (VAS) (11,12).
damage occurs in 1 in 80,000 patients; death occurs in
Study Protocol-Phase 1 1 in 200,000 patients”), while the routine information
included general statements (e.g., “other complica-
The study population for Phase 1 consisted of 361 tions are more serious but occur much less frequent-
parents of children between the ages of 4 and 12 yr, ly”). To standardize the manner in which the anes-
ASA physical status I or II, who underwent outpatient thetic information was presented, one of three
surgery and general anesthesia. Ten subjects declined attending anesthesiologists read the information as
participation in Phase 1 of the study and 17 patients shown in Appendix II. All parents were given the
did not complete the questionnaire (n = 334). This opportunity to ask the investigator to clarify anything
phase was conducted either during a preadmission that they did not understand, after which their state
visit (l-10 days prior to surgery) or on the day of anxiety was reassessed by a second STAI (T2). Timing
surgery. Demographic data, baseline and situational of the intervention ranged from 1 to 10 days prior to
anxiety (STAI), and coping strategy (SSCI) of the par- surgery. On the day of surgery, parental anxiety was
ent were obtained using validated behavioral instru- again assessed in the preoperative holding area (STAI,
ments. Temperament (EASI) and situational anxiety VAS) (T3) and after the child was taken into the op-
(VAS) of the child were noted as well. Next, the Desire erating room (STAI) (T4).
For Information Questionnaire, adapted from previ-
ous studies conducted in Australia, Scotland, and Statistic and Analytic Approaches
For Phase 1 of the study, demographic variables were
1 Spielberger CD. Manual for the State-Trait Anxiety Inventory
(STAI: Form Y). Palo Alto, CA, Consulting Psychologists Press, examined using inferential statistics, including un-
1983. paired Student’s t-test and 2 analysis. Items of the
ANESTH ANALG PEDIATRIC ANESTHESIA KAIN ET AL. 301
1997;84:299-306 PERIOI’ERATIVE INFORMATION: EFFECT ON PARENTS

Desire For Information Questionnaire were analyzed Table 1. Characteristics of Children and Their Parents
by frequency distribution and 2 statistics. To examine Studied in Phase 1
the effect of timing (in relation to surgery) of the Study subjects
preoperative interview on parental desire for informa- (n = 334)
tion, we analyzed the results based on four time cat- Child’s age (mo), median (range) 60 (48-144)
egories: the day of surgery, l-3 days prior to surgery, Parent’s age (yr), mean k sn 36 +- 6
4-7 days prior to surgery, and more than 7 days prior Timing of study (days)“, median (range) 4 (O-10)
to surgery. Analysis of variance was used to compare Previous hospital and surgical
the “overall desire index” of the four time groups. experience (%)
Yes 42
Next, we examined the effect of timing on the desire No 58
for information for each of the 14 questionnaire items; Parent
this was done using a series of 3 X 4 tables. The STAI trait, mean + SD 37 + 9
association between the desire for information and STAI state, mean 2 SD 41 ? 11
various demographic variables was examined using Education (%)
>High school 89
Spearman correlation analysis, cross-tables, t-test, and <High school 11
analysis of variance. Also, stepwise multiple regres-
sion was used to determine which of the variables
STAI = State-Trait-Anxiety Inventory.
deemed relevant by the literature and our data could a Number of days between start of study and surgery.
predict the desire for information. Comparisons were
considered significant if P < 0.05.
“all possible complications” (96%) and not only “com-
For the second phase of the study, demographic
mon complications” (97%) or “dangerous complica-
variables were examined using inferential statistics,
tions” (95%). Scores on the overall desire index ranged
including t-tests and 2 statistics. Sample size was
from 15 to 42 with a median of 34.
calculated in advance and was based on STAI anxiety Timing of the preoperative interview had no effect
scores of patients after routine anesthetic interviews either on the overall desire index (P = 0.58) or on the
(5). A 30% difference in the anxiety level (i.e., 35 ? 12 responses to 12 of 14 questionnaire items (P > 0.05).
vs 46 + 15) between the intervention and control Parents who were studied on the day of surgery,
groups was considered clinically significant. Thus, a however, indicated that they have a right to know
sample size of 23 subjects in each group was sufficient about all possible complications less frequently than
to detect a 30% difference in anxiety level with a parents who completed the questionnaire 1-3 days
power of 0.8 and an (Yof 0.05. Statistical analysis over prior to surgery (49% vs 67%, P = 0.02). Similarly,
the four time points (i.e., Tl-T4) was performed using parents who were studied on the day of surgery indi-
repeated measures analysis of covariance with trait cated that they have a right to know about common
anxiety and coping strategy as covariates. Post hoc complications less frequently than parents who com-
analysis was done using paired t-test with Bonferroni pleted the questionnaire l-3 days prior to surgery
correction for multiple comparisons indicating signif- (44% vs 58%, P = 0.05).
icance at P < 0.013. The relation between a subject’s We have also examined whether any of the demo-
preinterview anxiety (Tl) and the change in anxiety graphic or baseline variables are a predictor for in-
observed at separation to the operating room (T4-Tl) creased desire for information. Temperament of the
was examined by using scatter plots and by calculat- child; race, gender, marital status, educational level,
ing the Pearson correlation coefficient (7). Data are and income of parent; birth order, number of siblings,
expressed as mean + SE. day care, previous hospital or surgical experience of
the child and parent, ASA status, and the surgical
procedure were not associated with an increased de-
sire for information. Similarly, a multivariate linear
regression model, in which the overall desire index
Results was the outcome, identified no demographic predica-
Phase 1 tors. For questionnaire items 2, 3, and 8-14, however,
a large proportion of parents with a higher level of
Baseline and demographic variables are presented in
education chose the “have a right to know” option
Table 1. An overwhelming majority of parents indi-
(P < 0.05).
cated that they either “would like to know” or “have
a right to know” for all the 14 items of the Desire for
Phase 2
Information Questionnaire (Table 2). Of particular in-
terest was the finding that most parents indicated that There were no significant differences between the con-
they would like to know or have a right to know about trol and intervention groups regarding demographics
302 PEDIATRIC ANESTHESIA KAIN ET AL.
PERIOPERATIVE INFORMATION: EFFECT ON
Table 2. Parental Desire for Perioperative
All possible complications
Dangerous complications
Common complications
Details of needles used
Length of anesthesia
Details of pain/pain relief
Alternative methods of anesthesia
When allowed to get up
When allowed to eat and drink
Location of operating rooms
Meeting the anesthesiologist
Details regarding an intravenous,
Foley catheter
Place of anesthesia recovery
Details of premedicant drugs
such as age, gender, educational level, or baseline
anxiety and temperament of the child or parent (Table
3). The mean STAI preintervention anxiety scores of
the routine and detailed information groups were
46 + 11 and 42 + 10, respectively (P = not significant).
These means are similar to those reported by Spiel-
berger’ for medical and surgical patients (42 + 14).
There were no significant differences in parental anx-
iety for the two groups over the four time points
[F(1,45) = 0.6, P = 0.41 (Figure 1). Also, the interaction
between time and group assignment was not signifi-
cant [F(3,135) = 1.66, P = 0.181 (Figure 1). Further,
there was also no evidence to suggest that parents
with an anxious personality (upper 25% of STAI trait
subscale) who had been given highly detailed infor-
mation became more distressed at any of the three
postinterview assessments(P < 0.05) compared with
calm parents (lower 25% of STAI trait subscale).
Finally, the correlation (Y) between a subject’s pre-
interview anxiety (Tl) and the change in anxiety ob-
served at separation to the operating room (T4-Tl)
was -0.5 (P < 0.001) for the control group and -0.46
(P < 0.001) for the intervention group. That is, the
more anxious the parents were before the preopera-
tive interview, the less they experienced an increasein
their anxiety upon separation from their children to
the operating room.
Discussion
This study demonstrates that the vast majority of par-
ents prefer to have comprehensive information con-
cerning their child’s general anesthetic, including in-
formation about all possible complications. Moreover,
in parents of children undergoing general anesthesia
and outpatient surgery, very detailed anesthetic infor-
mation of what might go wrong does not increase
ANESTH ANALG
PARENTS 1997;84:299-306
Information
Parental desire preferences (%)
“Prefer not to know” “Like to know” “Have a right to know”
4 35 61
5 36 59
2 44 54
4 49 47
1 51 48
1 46 53
4 51 45
1 55 44
1 54 45
2 55 43
1 57 42
1 49 50
1 56 43
1 44 55
parental anxiety, and has the advantage of allowing
parents a fully informed choice.
Comparative studies investigating anxiety levels in
patients given a limited amount of information versus
more detailed information concerning procedural and
anesthetic risks report conflicting results. Alfidi (15)
found that, although the majority of patients were
satisfied when they received more detailed informa-
tion about the risks of angiography, up to 35% of
patients were made uncomfortable by the informa-
tion. Similarly, in a study by Miller and Mangan (4),
adult patients who were given extensive information
preoperatively were found to be more tense, de-
pressed, and uncomfortable. Conversely, no increase
in preoperative anxiety was demonstrated in a study
of British and Scottish men undergoing elective her-
niorrhaphy when presented with detailed risk infor-
mation (7) or in Danish patients undergoing general
anesthesia (6). Likewise, in a recent study performed
in Australia, Inglis and Farnill(5) showed that patients
who received detailed information, including numer-
ical estimates of anesthesia-related complications,
were no more anxious than those given minimal in-
formation regarding risks.
Some of these contradictory results may be ex-
plained by the methodological complexity of this is-
sue. None of the previous studies have examined the
effect of variables, such as coping, on the response of
the individual patient, and most studies used global
measures of anxiety with no documentation of ade-
quate instrument reliability and validity. In addition,
previous studies (excluding one) were performed with
subjects from Great Britain, Denmark, and Australia,
leaving open the question of American subjects’ reac-
tions to extended anesthetic information on preoper-
ative anxiety. The only published American study to
date is by Lankton et al. (16) who used a linear visual
ANESTH ANALG PEDIATRIC ANESTHESIA KAIN ET AL. 303
1997;84:299-306 PERIOPERATIVE INFORMATION: EFFECT ON PARENTS

Table 3. Characteristicsof Children and Their Parents Studied in Phase2

Control (n = 24) Intervention (n = 23) P value
Child’s age (mo), 67 (48-140) 75 (51-136) NS
median (range)
Parent’s age (yr), mean 34 +- 5 36 t 6 NS
+- SD
Timing of study (days)“, 4 (O-10) 4(0-10) NS
median (range)
Baselineparental anxiety 43-c 11 41 + 8 NS
(STAI), mean ? SD
Baselinechild anxiety 39 f 6 41 i- 11 NS
(VAS), mean i SD
Parental education (%)
Graduated high school 85 94 NS
and above
Grade school and 15 6
somehigh school
“Overall desire index”‘, 34 ? 7 33 -c 6 NS
mean -+ ss
EASI, mean ‘-’ SD~
Emotionality 11*3 13 ? 4 NS
Activity 15 ? 4 17 + 4 NS
Sociability 19 i- 2 18 i 2 NS
Impulsivity 12 5 4 14 i 4 NS
STAI = State-Trait-Anxiety Inventory; VAS = visual analog scale, range l-100; NS = not significant
’ Number of days between start of study and surgery.
“Overall desire index-see Phase 1 of study; range 14-42.
’ EASI = child’s temperament instrument.

information in that study, however, was determined

in the operating room, after the patients were premed-
icated with secobarbital. Furthermore, all previous in-
vestigations were conducted either the day before sur-
gery or on the day of surgery, and it is possible that, as
time passes between receiving detailed risk informa-
tion and surgery, rumination in patients will result in
increased anxiety (5). In addition, most patients now
receive their preoperative anesthesia evaluation either
on the morning of or several days in advance of sur-
gery and thus conclusions obtained from previous
investigations may be irrelevant for the present clini-
cal practice.
Pre Inter”entlon Post htervenhon PEOp3C3hW Separahon
(Tl) CT2 Holdmg to OR We have noted that in the analysis of Phase 1,
CT31 (T4) parents who were studied on the day of surgery indi-
STRESS POINT cated that they have a right to know about both all
Figure 1. Changes in parental anxiety over the four time points
possible complications and common complications
(Tl-4) are shown. The difference between groups was not signifi- less frequently than parents who completed the ques-
cant by one-way repeated-measures analysis of covariance [F(1,45) tionnaire one to three days prior to surgery. This
= 0.6, P = 0.41. The interaction between time and group assignment phenomenon may be related to a greater degree of
was also not significant [F(3,135) = 1.66, P = 0.181. For the control
group: *T4 is significantly different from Tl and T2, P < 0.01. For the situational anxiety experienced by parents on the day
study group: ““T3 is significantly different from Tl and T2, P < 0.01; of surgery. We also demonstrated that increased de-
#T4 is significantly different from T3, P < 0.01. STAI = State Trait sire for information was not related to variables such
Anxiety Inventory state subscale. OR = operating room. Data are
mean 2 sEM. as age, race, marital status, educational level, history
of previous hospitalizations, ASA status, and the sur-
gical procedure the child underwent. All parents stud-
analog anxiety scale and a single numerical estimate to ied had a consistently high desire for information. We
compare two groups of patients who either received should emphasize, however, that our study popula-
no information or information about eight significant tion for Phase 1 consisted of parents of children ASA
risks (16). The anxiety level after the provision of physical status I or II who were about to undergo
304 PEDIATRIC ANESTHESIA KAIN ET AL. ANESTH ANALG
PERIOPERATIVE INFORMATION: EFFECT ON PARENTS 1997;84:299-306

outpatient surgery, and it is unclear from these data by Inglis and Farnill(5). According to the Flesch Read-
how parents of sick children, ASA III or IV, undergo- ability formula, the control script was in the fairly easy
ing major nonelective surgery would respond. category, equivalent to six years of education, and the
For anesthesiologists, the issue of informed consent intervention script was in the standard range, equiv-
poses a special dilemma. Although we recognize the alent to seven to eight years of education (5). In our
legal and moral need for informed consent, we must study population, however, 85% of the control group
consider the effects of extensive information disclo- and 94% of the intervention group parents had more
sure on patients, specifically with respect to increased than 12 years of education (Table 3). Further, even
anxiety. Increased preoperative anxiety in adults has after we excluded all parents with less than 12 years of
been shown to correlate with postoperative outcomes, formal education, our findings persisted. Finally, all
such as increased postoperative analgesic require- children involved in Phase 2 of this investigation were
ments and prolonged recovery and hospital stay (17). of ASA physical status I or II who underwent elective
Further, increased parental preoperative anxiety has outpatient surgery and it is unclear from this investi-
been shown to result in increased preoperative anxiety gation how parents with a history of previous surgery
in their children, which in turn may lead to immediate or hospital experience, or parents of sick children,
postoperative negative psychological changes, such as ASA III or IV, undergoing major nonelective surgery
sleep and eating disturbances and new onset enuresis would respond to different levels of anesthetic risk
(18). We should, however, recognize that anxiety is information. However, nonelective or major surgery
only one of the issues that needs to be considered shares most of the anesthetic risks associated with
when discussing informed consent. Indeed, the pri- elective outpatient surgery.
mary rationale of informed consent is to support and In conclusion, this study demonstrates that most
respect the autonomy of the patient, and not to de- parents prefer to have comprehensive information
crease anxiety. That is, some patients may want to concerning their child’s perioperative period. Further,
know all possible risks of anesthesia and surgery, even very detailed anesthetic information of what might go
though it makes them exceedingly anxious. wrong does not increase parental anxiety and has the
Currently there is a considerable debate in the an- advantage of allowing parents a fully informed choice.
esthesia literature, and in medical literature generally,
regarding how far the anesthetic disclosure should
extend. Gild (19) in his review article recommended Appendix I
that “it would not be unreasonable to mention all
material risks, i.e., those risks which the average, rea-
EASI (Emotionality, Activity, Sociability,
sonable patient would regard as significant.” More Impulsivity) Instrument of Child
recently, Litman et al. (20) recommended that an in- Temperament (10)
formed consent should include mention of any risk
Temperament refers to individual patterns of behav-
that “would result in permanent severe injury.” In
iors and responses to daily events and is closely akin
contrast, Waisel and Truog (21) recommended that the
to personality in adults. This instrument includes 20
information provided should be tailored to fit the
items in four behavioral categories: emotionality, ac-
special needs of each individual. The findings of our
tivity, sociability, and impulsivity. The ratings are
study do not support the use of therapeutic privilege
made by the parent on a five-point scale, and a score
in withholding information about the risks associated
ranges from 5 to 25 for each category with higher
with general anesthesia. We therefore believe that in-
scores indicating higher baseline emotionality, activ-
formed consent should strike a balance between pro-
ity, sociability, or impulsivity. The instrument has
viding the patient with details regarding significant
good validity (Y = 0.77) when compared against other
risks while considering the individual needs of each
measures of temperament for preschool children. Test-
patient.
retest reliability of the EASI was 0.83 when mothers
It is important to note several methodological issues
were rating their preschool children on adjacent
concerning this investigation. First, there is no gold
months.
standard to measure preoperative anxiety. However,
we have used the STAI, developed by Spielberger, State-Trait Anxiety Inventory (STAI)’
which is the most widely used anxiety instrument in
the medical literature. In fact, the STAI was referred to This is a widely used self-report instrument that esti-
recently in a major anesthesia journal as the gold mates situational and baseline anxiety in adults on the
standard for measuring preoperative anxiety (22). Sec- basis of responses to 40 statements’. Parents were
ond, this investigation was based on the assumption asked to respond on a four-point scale; total scores for
that information given to the patients was understood. situational and baseline questions separately range
The script used for the present investigation (Appen- from 20 to 80 with higher scores denoting higher
dix II) was adapted from a previous Australian study levels of anxiety. Test-retest correlations for the STAI
ANESTH ANALG PEDIATRIC ANESTHESIA KAIN ET AL. 305
1997;84:299-306 PERIOPERATIVE INFORMATION: EFFECT ON PARENTS

are reported to be high, ranging from 0.73 to 0.86.i injury; these events occur commonly but do not cause
Validity was examined in two studies in which the permanent damage. For instance, nausea and vomit-
STAI was given under high- and low-stress conditions ing occurs in 1 in 4 patients; sore throat or hoarseness
to large samples of students. The Y value ranged from occurs in 1 in 3 patients, and abrasions or bruising of
0.83 to 0.94, suggesting very good va1idity.i lips and intravenous sites occurs in 1 in 10 patients. In
addition, anesthesia can make your child feel disori-
Stressful Situation Coping ented or sluggish afterward.
Instrument (SSCI) (9) Other complications are more serious but occur
much less frequently. Because your child is healthy, I
Adult subjects and parents of children undergoing do not expect any serious complication to occur. How-
surgery indicate a recent stressful life event and then ever, breathing difficulty from aspiration of stomach con-
answer 19 yes/no items probing how they dealt with tents occurs in 1 in 10,000 patients; damage to teeth or
the event. This instrument was developed by Billing
dental work occurs in 1 in 30,000 patients; and remember-
and Moos (9) and consists of three major coping ing events while under anesthesia occurs in 1 in 200,000
categories: active-cognitive, active-behavioral, and patients.
avoidance. The most devastating complications of anesthesia are the
Visual Analog Scale (VAS) (12,12) most rare. Brain damage occurs in 2 in 80,000 patients;
death occurs in 1 in 200,000 patients. These complications
This scale is widely used as both a self-report and generally occur when a patient has a severe reaction to a
observational measure of anxiety. The VAS rating sys- drug or when blood flow or oxygen delivery is insufficient.
tem consists of a loo-mm line that pictorially repre- Again, these events happen rarely and every precaution will
sents two behavioral extremes at either end of the be taken to ensure that your child will remain healthy.
continuum, i.e., “not anxious” (score of 0) and “ex-
tremely anxious” (score of 100). For the purpose of this The authors would like to thank Paul G. Barash, MD, for his critical
study, the VAS was used as an observational measure review of this manuscript.
to rate the children and as a self-report measure for the
parents. Test-retest reliability of the VAS ranges from
0.61 to 0.73 when measured on adjacent days (12,23).
Also, when used to measure anxiety, the VAS has References
good validity against a self-rating depression scale 1. Williams 0. Patient knowledge of operative care. J R Sot Med
(Y = 0.64-0.67) (12). 1993;86:328-31.
2. Bruster S, Jarman B, Bosanquet N, et al. National survey of
hosnital uatients. BMT 1994;309:1542-6.
3. Cleary P:Edgman-Levitan R, Roberts M, et al. Patients evaluate
Appendix II their hospital care: a national survey. Health Aff (Millwood)
1991;winter:254-67.
The highly detailed information group received the 4. Miller S, Mangan C. Interacting effects of information and cop-
full script, including the italicized sections. The rou- ing style in adapting to gynecologic stress: should the doctor tell
tine information group did not receive the italicized all? J Pers Sot Psycho1 1983;45:223-6.
sections. 5. Inglis S, Farnill D. The effects of providing preoperative statis-
tical anaesthetic-risk information. Anaesth Intensive Care 1993;
I would like to discuss what will be done by the 21:799-805.
6. Elsass I’, Eikard B, Junge J, et al. Psychological effect of detailed
anesthesiologist during your child’s operation and preanesthetic information. Acta Anaesthesiol Stand 1987;31:
give you information about anesthesia and its risks. 579-83.
During the entire procedure, the anesthesiologist 7. Kerrigan DD, Thevasagayam RS, Woods TO, et al. Who’s afraid
of informed consent? BMJ 1993;306:298-300.
will measure heart rate, blood pressure, oxygen level,
8. Arellano R, Cruise C, Chung F. Timing of the anesthetist’s
and temperature. This allows us to give the proper preoperative outpatient interview. Anesth Analg 1989;68:645-8.
amount of anesthesia so that your child does not feel 9. Billings A, Moos R. The role of coping responses and social
or remember the operation. An intravenous line will resources at attenuating the stress of life events. J Behav Med
1981;4:139-57.
be inserted to give fluids and medicines. A breathing 10. Buss AH, Plomin R. Temperament: early developing personality
tube will be placed into the windpipe/trachea to allow traits. Hillsdale, NJ: L Erlbaum Associates, 1984.
oxygen and anesthesia to be delivered. After the op- 11. Cella DF, Perry SW. Reliability and concurrent validity of three
eration, your child will be taken from the operating visual analogue mood scales. Psycho1 Rep 1986;59:827-33.
12. Folstein MF, Lauria R. Reliability, validity and clinical applica-
room to the recovery area so that we can continue to tion of the visual analogue mood scale. Psycho1 Med 1973;3:
monitor her/him. We will give any medicine neces- 479-86.
sary to keep your child comfortable. 13. Lonsdale M, Hutchison GL. Patients’ desire for information
about anaesthesia. Scottish and Canadian attitudes. Anaesthesia
Although the monitors and medicine we use today 1991;46:410-2.
make anesthesia very safe, it is not without risks. 14. Farnill D, Inglis S. Patients’ desire for information about
Some risks are associated with minor discomfort or anaesthesia: Australian attitudes. Anaesthesia 1994;49:162-4.
306 PEDIATRIC ANESTHESIA KAIN ET AL. ANESTH ANALG
PERIOPERATIVE INFORMATION: EFFECT ON PARENTS 1997;84:299-306

15. Alfidi R. Informed consent: a study of patient reaction. JAMA 20. Litman RS, Perkins FM, Dawson SC. Parental knowledge and
1971;216:1325-9. attitudes toward discussing the risk of death from anesthesia.
16. Lankton JW, Batchelder BM, Ominsky AJ. Emotional responses Anesth Analg 1993;77:256-60.
to detailed risk disclosure for anesthesia, a prospective, random- 21. Waisel D, Truog R. The benefits of explanation of the risks of
ized study. Anesthesiology 1977;46:294-6. anesthesia in the day surgery patient. J Clin Anesth 1995;7:
17. Mathews A, Ridgeway V. Personality and surgical recovery: a 200-4.
review. Br J Clin Psycho1 1981;20:243-60. 22. Moerman N, van Dam F, Muller M, Oosting H. The Amsterdam
18. Kain Z, Mayes L, O’Connor T, Cicchetti D. Preoperative anxiety Preoperative Anxiety and Information Scale (APAIS). Anesth
in children: predictors and outcomes. Arch Pediatr Adolesc Analg 1996;82:445-51.
Med 1996;150:1238-45. 23. Wewers ME, Lowe NK. A critical review of visual analogue
19. Gild W. Informed consent: a review. Anesth Analg 1989;68: scales in the measurement of clinical phenomena. Res Nurs
649 -53. Health 1990;13:227-36.