Key Considerations for Obtaining Informed Consent for Tracheostomy
Informed consent for tracheostomy must include a multidisciplinary discussion of goals of care, patient selection criteria, procedural risks, and post-procedure care requirements to optimize both patient safety and quality of life outcomes. 1
Medical Indications and Benefits
- Tracheostomy should be considered when prolonged mechanical ventilation is anticipated, particularly when ventilation is expected to be needed for more than 10-14 days 2, 3
- Benefits include increased patient comfort, potential for earlier ICU discharge, and shorter hospital stays compared to prolonged endotracheal intubation 3
- Either open surgical tracheostomy (OST) or percutaneous dilatational tracheostomy (PDT) can be performed based on patient factors and provider expertise 1
Risks and Complications
- Immediate complications include bleeding and loss of airway 2
- Short-term complications include tube blockage or displacement 2, 4
- Long-term complications include tracheomalacia, tracheal stenosis, and stoma-related problems 2, 4
- Risk of infection to healthcare workers must be discussed, especially in patients with infectious respiratory diseases 1
- Potential for impaired swallowing and increased risk of aspiration 1
- Risk of airway occlusion by mucus plugs requiring vigilant monitoring 1
Communication and Quality of Life Considerations
- Impact on speech and communication must be discussed, including potential need for speaking valves 1
- Many patients are concerned about cosmetic implications and potential communication difficulties, which must be addressed sensitively 1
- For many patients, communication may be restored using a relatively small tracheostomy tube allowing a "leak" around the airway and a speaking valve 1
- Speech therapy consultation should be included in the consent discussion as an essential part of post-procedure care 1
Procedural Details
- Explain the technique to be used (OST vs PDT) and why it's appropriate for the patient 1, 2
- Discuss the setting where the procedure will be performed (ICU, OR) and safety measures in place 1
- Explain the need for experienced providers to perform the procedure to minimize risks 1
- Discuss anesthesia considerations and perioperative management 5
Post-Procedure Care Requirements
- Explain the need for specialized care and monitoring after tracheostomy placement 1, 6
- Discuss the need for caregiver education if discharge with tracheostomy is anticipated 1, 6
- Explain the potential need for long-term care and follow-up appointments 6
- Discuss the possibility of eventual decannulation if the condition improves 7
Special Considerations for Pediatric Patients
- For pediatric patients, discuss the need for specialized care and monitoring 1
- Explain the need for two trained adult caregivers before discharge home can be considered 1
- Discuss the impact on speech development and communication strategies 1
- Address swallowing evaluation and management needs 1
Patient Autonomy and Decision-Making
- Patient autonomy must be respected after appropriate education has been provided 1
- Discuss alternative options to tracheostomy when appropriate (e.g., noninvasive ventilation) 1
- Include palliative care consultation in discussions about goals of care when appropriate 1
- Consider the patient's cognitive status and ability to participate in care decisions 1
Common Pitfalls in Obtaining Informed Consent
- Failing to involve a multidisciplinary team in the consent process 1
- Not addressing long-term implications for quality of life 1, 6
- Inadequate discussion of communication challenges and solutions 1
- Insufficient explanation of caregiver training requirements for discharge planning 1, 6
- Not discussing the potential need for repeat procedures or tube changes 7