Problematic cases I: Prototype-based reasoning
dementia, hyperactive
SAID, COMPLICATIONS
In the cases we discussed with interviewees, the single patient characteristic they most often flagged as a potential source of serious complications was any indication of dementia. Patients with dementia were of concern to anesthesiologists particularly when it came to the provision of spinal anesthesia, due to the possibility that they would not remain still and cooperative during the administration of the anesthetic or during the operation. In evaluating whether they were willing to give a spinal anesthetic to a given patient with dementia, anesthesiologists compared the case to the prototypical characteristics of what they called the “pleasantly demented” versus “non-pleasantly demented” patient. These characteristics were based on anesthesiologists’ prior clinical experience. Whether and how they manifested in the cases of specific patients eligible for REGAIN was inferred from behavioral signs picked up during interaction with these patients. For example, the below interviewee discusses a patient whom they withdrew from the trial due to a lack of willingness to administer spinal anesthesia.He was a non-pleasantly demented 96-year-old. […] When he was randomized initially, he was in his bed, in his room with a family member, and he was nice and still and pleasant. Once you got him out of that environment, he became agitated to the point that I thought it might not be safe for the patient and to risk the surgical team to have just a spinal. […] It didn’t become clear until he came to the [operating room] environment that the original randomization might not have been suitable for him. But before that moment, I think I would have been entirely comfortable randomizing the patient. (interviewee 4)“There are little clues,” said another interviewee about patients with dementia.Things like sometimes patients will arrive in restraints, and that tells you they’re vigorous enough to be a danger to themselves but disorganized enough to need to be restrained. Right? […] Other [times] patients are hyperactive, who just move around the whole time or are completely unable to cooperate, there’s no eye contact, there’s no verbal response. It’s very much just from experience knowing which ones cope and which ones don’t. (interviewee 18)Interviewees’ comfort performing the spinal anesthesia procedure in patients with dementia factored into how they considered which class a given patient represented. Said one anesthesiologist (interviewee 21) when recounting a patient with dementia whom he refused to randomization: “I mean, I have tried to do spinal anesthetics or epidurals in patients who have limited cognitive abilities and my success rate personally in doing these is usually very low.”Hesitation about how to proceed with randomization in these cases centered on indeterminacy about how they compared to the prototypic situations in which anesthesiologists thought spinal tended to go well or poorly in patients with dementia. Once the patient was aligned with one or the other prototype, this discomfort was resolved, as there were clear implications for care. For example, the interviewee above (interviewee 4) who had determined a patient was “non-pleasantly demented” and withdrew him from randomization explained, “I thought this guy was probably in that category. So I thought, well, I won’t even try to give you a spinal. You’re just going to sleep.” “Had he been pleasantly demented,” said the same interviewee, “he would have had a spinal, no question in my mind.” “That sort of patient,” another anesthesiologist said of an individual with dementia they refused to randomize, “I mean, you can’t even consider doing it.” (interviewee 18).