During informed consent for nasal intubation, how do you determine which risks must be disclosed to meet the standard of care?

Determining Required Risk Disclosure for Nasal Intubation

The standard for determining which risks must be disclosed during informed consent for nasal intubation is based on what the particular patient would regard as relevant when making their decision, not what the physician thinks is important—you must disclose all significant foreseeable risks from the patient's perspective, including both common complications and serious rare ones. 1

The Patient-Centered Standard

The 2017 AAGBI Consent Guidelines establish that information provided should be determined by asking: "What would this particular patient regard as relevant when coming to a decision?" 1 This represents a decisive shift from the paternalistic "doctor knows best" model to a patient-centered approach where disclosure is flexible according to what the individual patient wants to know 1.

Three Categories of Required Disclosure

You must discuss:

1. What procedures are intended and why (the nasal intubation itself and its indication)
2. What the significant, foreseeable risks are and their consequences
3. What the alternatives are, including having no treatment 1

Specific Risks for Nasal Intubation

Based on the guidelines, for nasal intubation specifically you should disclose:

Common/Significant Side Effects:

• Epistaxis (most common complication from damage to Kiesselbach's plexus) 2
• Sore throat
• Damage to teeth/lips 1

Serious Side Effects:

• Nerve damage 1
• Sinusitis (from oedema around maxillary sinus opening) 2
• Superficial necrosis of nasal ala 2
• Bacteremia (from nasal mucosa abrasion) 2
• Death 1

Procedure-Specific Considerations:

• Awareness during the procedure if performed awake 1
• Alternative techniques (oral intubation, alternative airway management) 1

Critical Pitfall: Patient-Specific Risks

You must make reasonable efforts to identify risks that would be particularly significant to your specific patient 1. For example:

• A professional singer needs to know about vocal cord damage risk
• A model or actor needs detailed discussion of nasal ala necrosis risk
• Someone with recurrent sinusitis needs emphasis on sinusitis risk

The guidelines explicitly state that "it is the anaesthetist's responsibility to make reasonable efforts to judge what would be particularly significant risks or complications to his/her patient" 1.

What Determines "Significant"

A risk is significant if:

• Any information that might lead a patient to cancel or defer the procedure should be considered significant 1
• It would be relevant from the patient's perspective in making their decision 1
• It is a typical risk specific to the intervention that is unknown to the patient and might have a lasting adverse effect on their lifestyle 3

Common practice pitfall: Research shows surgeons often fail to discuss complications they consider minor but patients regard as serious 4. For nasal intubation, this includes risks like changes in sense of smell or nasal cosmetic changes that surgeons may underestimate but patients find highly significant.

Documentation Requirements

You must document clearly both the patient's agreement and the discussions that led to that agreement, including the patient's questions and your responses 1. Where possible, provide estimates of the incidence of risks 1.

The Awake Tracheal Intubation Context

For awake nasal intubation specifically, the DAS guidelines mandate that "the risks of ATI and its alternative (induction of general anaesthesia before securing the airway) should be discussed" 5. This comparative risk discussion is essential—patients need to understand why you're choosing the awake approach and what would happen with the alternative.

Practical Algorithm

1. Start with the patient's concerns: Ask what they want to know
2. Disclose all common risks (>1% incidence): epistaxis, sore throat, nasal discomfort
3. Disclose all serious risks regardless of frequency: nerve damage, sinusitis, bacteremia, death
4. Identify patient-specific significant risks: based on occupation, lifestyle, medical history
5. Discuss alternatives: oral intubation, asleep vs awake technique
6. Provide incidence estimates where available
7. Document everything discussed, including patient questions

The key principle: When in doubt about whether to disclose a risk, disclose it. Information may only be withheld if providing it would pose a serious threat to the patient's health—not just because you think it might make them anxious 1.