Standards of care and the ASA medical direction statement.

It should come as no surprise that malpractice attorneys are among the many people who do not understand what nurse anesthetists do or what their capabilities are. Recently, a newsletter directed to both anesthesia providers and lawyers, quoted several malpractice attorneys who were under the impression that the American Society of Anesthesiologists (ASA) Statement on the Anesthesia Care Team was a standard of care and that hospitals employed CRNAs only to save money. 1 When the makers of one brand of a soft drink say it tastes better than the others (or it opens the door to a fuller life or whatever), the public judges the statement with some skepticism and feels no hesitation in buying the other brands. But in healthcare, the public has been conditioned to believe that medicine is based on scientific principles. It assumes that when physicians make statements, they are based on scientific principles. Of course, there is no science behind the ASA Statement on the Anesthesia Care Team. Nonetheless, the Statement does not get the same scrutiny because of the respect the public gives to physicians. Where did the ASA Statement on the Anesthesia Care Team originate? In the late 1970s the ASA decided to develop a statement on the anesthesia care team, nurse anesthetists and anesthesiologists working together. ASA established a committee to develop the statement. Nurse anesthetists serving on the committee were surprised in 1982 to read a newly issued ASA Statement on the Anesthesia Care Team that had not been discussed with them. The statement is offensive to many nurse anesthetists because it requires that the Anesthesia Care Team has to be directed by an anesthesiologist. Even more difficult was that it sets forth a number of requirements that have to be fulfilled by the anesthesiologist directing the team. These requirements include: 1. Preanesthetic evaluation of the patient 2. Prescription of the anesthesia plan 3. Personal participation in the most demanding procedures in this plan, especially those of induction and emergence 4. Following the course of anesthesia administration at frequent intervals 5. Remaining physically available for the immediate diagnosis and treatment of emergencies 6. Providing indicated postanesthesia care Is the ASA Statement on the Anesthesia Care Team a standard of care? The ASA Statement is not required by law, has not been shown to have any impact on the quality of anesthesia care, and is not customarily followed. It is not a standard of care. Although there are some states that require that nurse anesthetists be supervised or directed by a physician, every state permits nurse anesthetists to work directly with physicians other than anesthesiologists. A requirement of anesthesiologist supervision or direction would substantially change the ground rules under which anesthesia is administered in this country. Even in states that require direction or supervision, substantial leeway is given to healthcare personnel to develop their own standards and the terms “supervision” and “direction” are undefined. No state restricts the performance of the elements contained in the ASA Statement to physicians. Most lawyers (including most judges and malpractice attorneys) do not have expertise in the healthcare area. To avoid interfering with what they do not understand, the courts put healthcare in a special category, a profession. Unlike other areas where people are expected to conduct themselves the way that courts and juries determine that a reasonable person should conduct himself or herself, a professional is required to conduct himself or herself with the same degree of skill, care, and diligence exercised by other members of the same profession. When something goes wrong and the courts require knowledge as to the standard of care, an expert is required to testify, or explain to the court or jury, the practices that other members of the profession would have followed in the same circumstances.