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High-Risk Anaesthesia Decision-Making — FRCA Final MCQ

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HardMedicolegal & EthicsHigh-Risk Anaesthesia Decision-MakingFRCA Final

A 75-year-old man with capacity has end-stage heart failure despite maximal tolerated therapy. He is ASA IV, has an ejection fraction of 15% and is breathless at rest. Debridement of a sacral wound is proposed solely to reduce pain, discharge and odour; it is not an emergency, and the probability and duration of symptomatic benefit are uncertain. The surgeon requests general anaesthesia. The anaesthetist estimates a substantial risk of perioperative death, but no structured discussion of the patient's goals, individualised risk or non-operative options has occurred. What is the most appropriate next step?

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Correct answer: C — Arrange a documented multidisciplinary discussion with the patient about goals, individualised risk, alternatives and no intervention

The correct answer is C. This is a non-emergency intervention with uncertain palliative benefit and a substantial risk of death. RCoA guidance recommends individualised risk estimation, shared decision-making and close collaborative discussion—ideally within a documented multidisciplinary process—when surgical risk is high. The discussion should establish the patient's goals and cover likely benefit, material anaesthetic and surgical risks, feasible alternatives and no intervention; palliative-care input is appropriate. Consent to the surgeon alone does not oblige the anaesthetist to proceed, so B is insufficient. A is premature before goals and alternatives have been explored. Local anaesthesia may be discussed but cannot be imposed regardless of feasibility, excluding D. E improperly transfers an unresolved clinical and ethical disagreement rather than addressing it through shared decision-making.

Reference: Royal College of Anaesthetists. Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients, recommendations 4.2–4.11 and 5.5–5.13, 2025. https://www.rcoa.ac.uk/gpas/chapter-2