Cite as: Arno CD, Krakowski JC. The consent conundrum in regional anesthesia . ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra050126.012.

Introduction

Informed consent is a fundamental prerequisite for performing medical procedures, including those commonly performed in anesthesiology. Ensuring that patients, families, or surrogates fully comprehend the nature of the procedure, the associated risks, and the potential outcomes, and explicitly authorize its performance is vital to the safe delivery of anesthesia care. As proceduralists, regional anesthesiologists must routinely obtain informed consent, a process that is among the most time-intensive aspects of their clinical workflow. There remains significant variability among regional anesthesiologists regarding the specific risks and complications disclosed during the consent process.¹ This article defines the informed consent process, highlights challenges unique to regional anesthesia practice, identifies frameworks for improvement, and applies best practices to a common acute pain management scenario.

Definition of Consent

The Joint Commission defines informed consent as “a process of communication between a clinician and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention,” culminating in documentation of this authorization in the patient record.² In addition to providing the risks, benefits, alternatives, and nature of a treatment or procedure, the Joint Commission further recommends the need to also ensure patient understanding of these core elements.² Patients have expressed a preference to be informed of both frequently encountered, low-risk complications and infrequent but potentially serious adverse events.³ Once these four essential components of the informed consent process have been addressed, the patient or surrogate may then accept or refuse the proposed treatment or procedure.²

Unique Considerations in Regional Anesthesia

For regional anesthesiologists, the informed consent process is further complicated by the wide range of procedures performed, each involving distinct anatomic considerations, risk profiles, and implications for patient decision-making. Significant variance exists when describing risks based on the anatomical location of block performance. For example, neuraxial anesthesia differs markedly from peripheral nerve block techniques in terms of indications, equipment, side effects, and associated risks. Peripheral nerve blocks may be further subdivided into myriad categories, including truncal, fascial plane, targeted nerve or plexus, single-shot or catheter placement, and superficial versus deep needle insertion. The choice of local anesthetic introduces an additional variable that influences both systemic toxicity risk⁴ and anticipated block duration.⁵ The choice of regional anesthetic technique thus impacts important safety areas, such as risk to neuronal tissues⁶ as well as the patient’s anticoagulation status and potential for hematoma formation.⁷ Despite the procedure-specific nature of regional anesthetic risks, certain complications persist across techniques, including bleeding, infection, pain at the site of needle insertion or injection, and the possibility of block failure.

Application in Clinical Practice

Although the essential components of informed consent are well defined, applying these principles consistently in regional anesthesia practice may prove challenging. The following vignette illustrates a potential clinical scenario in which such challenges might arise.

Clinical Vignette

A post-anesthesia care unit (PACU) nurse reported that a patient recovering from upper extremity surgery under general anesthesia was experiencing severe, uncontrolled pain. Multimodal analgesia, including intravenous acetaminophen and opioids, was administered but failed to provide relief. The on-call anesthesiologist evaluated the patient and determined that a supraclavicular brachial plexus block would likely provide effective analgesia.

Upon evaluation, the patient appeared somnolent and intermittently responsive, likely due to residual sedative and analgesic medications administered intraoperatively and in the PACU. As a result, the patient's capacity to provide informed consent for a regional nerve block was unclear. Contact was made with the patient's designated surrogate decision-maker, who stated, “Do whatever you think is necessary.”

This situation raises several ethical and practical questions: Does surrogate consent in this context constitute valid informed consent? Can an impaired but responsive patient adequately understand and authorize an invasive procedure such as the proposed peripheral nerve block? What criteria should guide anesthesiologists in determining decision-making capacity during the immediate postoperative period?

While the minimum elements of informed consent may be satisfied with a succinct explanation of the procedure, risks, and alternatives, the practical application of this process often falls short of its intended goal. Each of the aforementioned factors, including specific block technique, anatomical considerations, individual risk modifiers, alternatives, and procedural context, should be incorporated into the discussion to enable truly informed decision-making. Yet, how often do our pre-procedural conversations fully encompass this breadth of information?

Consider the earlier clinical scenario. During the consent process, the following explanation may have occurred:

“I want to perform what’s called a nerve block as I feel it will be the best option to help control your loved one’s pain. I will use an ultrasound to find the nerves that go to the arm and then use a needle to inject numbing medicine around the nerves so that your loved one gets pain relief for at least several hours. It is a very safe procedure; the main risks are bleeding, infection, and damage to nearby structures. How does this sound?”

While technically sufficient in meeting the basic requirements of informed consent, this dialogue represents the bare minimum. Important patient- or procedure-specific nuances may be omitted, and questions regarding block duration, failure risk, and systemic effects may remain unaddressed. Questions posed by the patient or surrogate may remain unanswered. As regional anesthesiologists, we have both the opportunity and responsibility to elevate this process.

Frameworks For Improved Consent

Emphasizing the importance of a thorough discussion, frameworks have been developed at both the national and institutional levels to assist with the informed consent process. The American Board of Anesthesiology (ABA), through its Applied Exam Objective Structured Clinical Examination (OSCE) content outline, defines a successful consent discussion as one that explains in plain language the indications, procedural steps, benefits, and both common and severe risks, along with strategies to mitigate those risks. The outline further emphasizes the importance of inviting questions, responding appropriately, and ultimately confirming the authorizing representative’s voluntary agreement.⁸ At our institution’s anesthesia residency program, the ABA OSCE outline has been further adapted into the following CONSENT acronym for ease of use: Comprehension (assessing patient understanding), Options (reviewing indications and benefits), Novice (explaining who will perform the procedure in accessible terms), Stratify (describing risks by frequency and severity), Explain (discussing risk mitigation strategies), any questions (inviting and addressing inquiries), and Thumbs up (confirming patient agreement). These examples offer a structured framework that regional anesthesiologists can adapt into a thorough yet efficient model for obtaining consent for anesthesia.

Informed consent for the regional anesthesiologist represents both an essential prerequisite and an opportunity to engage patients and surrogates in shared decision-making.

Assessing Capacity

A critical component of the informed consent process is assessing the patient’s capacity to make medical decisions. Determining decision-making capacity has been described as the most difficult aspect of the consent process.⁹ The fundamental tenets of capacity include the ability to comprehend the medical situation, appreciate the risks, benefits, and alternatives, reason through a choice, and communicate that choice.⁹ Some scholars recommend the optimal manner to ensure patient capacity is to utilize a continuous approach with reassessment throughout the discussion.⁹

Addressing Health Literacy

The consent discussion may require modification when the patient or surrogate possesses limited health literacy, as understanding may be impaired by unfamiliar terminology, ineffective communication, and limited literacy or numeracy.¹⁰ When the patient lacks capacity, and a surrogate must authorize care, the information should be presented in understandable terms that facilitate meaningful consideration rather than merely obtaining assent.¹¹ The anesthesiologist should thus avoid specialty terminology, use short, concrete explanations, and provide simplified documents at an accessible reading level when written material is provided.^10,12 Contemporary evidence suggests that interactive consent strategies, such as test-feedback and teach-back techniques, improve comprehension more consistently than passive written or audiovisual materials alone.¹² Because patients tend to overestimate their own comprehension, self-report of understanding may not reliably reflect an adequate grasp of the information discussed.¹⁰ Asking the patient or surrogate to restate the proposed block, expected benefits, major risks, alternatives, and remaining questions may better confirm understanding and help prevent perioperative discussions from becoming overshadowed by technical details and logistics rather than patient-centered decision-making.^10,12,13

Applying Best Practices

Returning to the example patient above, and applying the frameworks described, the following script provides an outline to guide the discussion with the goal of facilitating a more comprehensive informed consent process.

Introductory Remarks

“Hello, I’m Doctor ________, the attending anesthesiologist currently in charge of the PACU. I’d like to discuss performing a nerve block to help control your loved one’s pain.”

These introductory statements clearly identify the physician’s role in the patient’s care and specify that the physician will be performing the procedure in question.

Specifics of the Procedure

“The block is called a supraclavicular block because it is performed above the collar bone. I will use an ultrasound machine to look just above the collar bone, near the neck, and see under the skin to find the nerves that provide feeling in the arm. The ultrasound will also help me carefully guide a needle to place numbing medicine around these nerves. While the medicine is working, the arm may feel weak or difficult to move because the same nerves control both feeling and movement. I expect this block will usually provide pain relief for 8 to 10 hours, but the exact duration can be shorter or longer depending on the patient.”

Here, the anesthesiologist explains, in plain language, which peripheral nerve block is proposed and how it will be performed.

Benefits and Risks

“The benefits of receiving this block may include improved pain control with less need for opioid or narcotic class medications that may cause their own side effects. This is considered a low-risk category procedure. Any time we break skin, there is a risk of bleeding, infection, or pain at the site of the injection. We use disinfectant solution to minimize the risk of infection. Major but rare risks can occur, such as nerve injury, injection of medication into a blood vessel, or an allergic reaction to the medication. We do not expect these events to happen, and we will monitor you closely both during and after the block. There is also a possibility that the block does not work as we expected.”

“This block is not mandatory, and if you choose not to have it, we will still treat your pain to the best of our ability using pills and medications through your IV. You will still receive these medications even if you receive the block, but you may not need as many of them.”

“Do you have any questions?”

Having a frank discussion of the benefits and risks of any planned procedure serves as the foundation of informed consent. Providers must ensure that the patient or surrogate thoroughly understands the potential benefits and risks of the proposed intervention. Explicitly acknowledging the possibility of block failure is essential, as no procedure achieves a 100% success rate, even in experienced hands. During the discussion, the physician may consider pausing between sections to allow the patient or surrogate adequate time to process the information. Equally important is allocating sufficient time to invite questions and provide thorough responses.

Affirmative Consent

“I would like to take a moment to confirm that you give consent and would like to proceed with the planned nerve block?”

The final step is to obtain the patient’s explicit consent, thereby providing authorization for the procedure.

The preceding clinical scenario and script provide one example of how informed consent may be obtained, while recognizing that numerous acceptable approaches exist. Challenges often arise when no next of kin is available, a language barrier exists, or the patient is a minor. In these situations, it is important for anesthesia providers to understand the requirements for valid consent and to communicate them clearly and confidently with patients or their surrogates.

Conclusion

Informed consent for the regional anesthesiologist represents both an essential prerequisite and an opportunity to engage patients and surrogates in shared decision-making. The diverse array of block techniques, procedure- and patient-specific risk factors, and the need to assess capacity underscore the complexity of this process in regional anesthesia practice. Variability among physicians and across institutions may lead to technically sufficient consents yet fall short of addressing block-related specifics and ensuring patient understanding. Structured frameworks may facilitate comprehensive, patient-centered discussions while maintaining clinical efficiency. The informed consent process should be regarded as dynamic rather than transactional, requiring continual reassessment of comprehension and capacity. By investing in the quality of consent discussions, regional anesthesiologists can enhance patient safety, foster trust, and advance the specialty’s standard of care.

References

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8. American Board of Anesthesiology. APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline. [cited 24 Sep 2025] https://www.theaba.org/wp-content/uploads/pdfs/OSCE_Content_Outline.pdf
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