Does not remembering a procedure make it OK?

Going all the way back to my training in gastroenterology, I have been disturbed by one aspect of conscious sedation. For the most part, it works very well. Patients are relaxed, and pain free. If they have discomfort, we give them more medication as we go along. The vast majority of patients are very satisfied with this. But there are a small number of patients who don’t do well with it. There are a variety of medical reasons why this might happen, and the use of certain medications interferes with the activity of midazolam, the cornerstone of conscious sedation.

Why is a midazolam so popular? It has an amnestic property, so even if people are a little aware of the test, the whole thing becomes a blur. There is its greatest benefit, but also potentially its major ethical issue. During my training, many of my attending gastroenterologists would tell me to push through with a colonoscopy even though the patient was clearly uncomfortable. “It’s fine, they won’t remember anything.” Is that okay? Just because you don’t remember pain, does that make it okay that you felt it?

The experiences referenced below, from the New York Times, discusses the possibility of PTSD resulting from unremembered medical procedures using medications like midazolam. Is this possible? I believe it is. If people can be traumatized by injury, sexual assault, and childhood abuse that they have repressed from their memories completely, then why not?

Anesthesia assistance (MAC), using something like propofol, has obviated many of the issues related to the lack of efficacy of conscious sedation. However, it is not always available, not always covered by insurance, and Medicare frowns on it. In fact, Medicare has started to track who utilizes anesthesia assistance during colonoscopy, and there is widespread belief that gastroenterologists will be financially penalized for this in the future.

So aside from the potential ethical issues of inflicting pain and relying on people not remembering it, there is a relative divergence between the availability of MAC and the demand for it. The aging population in America has many more complex medical problems, there are more people on sedatives than ever before, many young people talk about their anxiety disorders openly, and the use of sleep agents and other drugs which interfere with midazolam is much more mainstream. My experience has been that over the years people need much higher doses of conscious sedation than they did 20 years ago. I also much more frequently encounter patients with more complex medical problems, who insist that they be “completely knocked out”, despite the best safety practice being to use lighter doses with the more medically fragile patients.

How to reconcile the personal and medical demands of patients to be adequately sedated in a world where payors are less willing to pay for anesthesia assistance, is a battle being fought by our professional organizations on behalf of our patients every day. Add to this, the ethical issues surrounding using conscious sedation and relying on patients simply not remembering what might be a bad experience, and we reinforce the rationale for using a professional anesthesiologist to deliver MAC.

For colon cancer awareness month, we of course recommend that you get screened if you have not already done so. Encourage your family and friends to do the same. Make sure you find an experienced gastroenterologist in a setting with high quality standards. And be sure to ask what type of anesthesia or sedative is utilized.

See the New York Times article by Kate Johnson here.

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