Clinical Ethics Framework for Last-Minute Pediatric Refusal of Anesthesia Induction

Induction of anesthesia is one of the most distressing moments for pediatric patients during their perioperative experience. They may consequently refuse induction at the last minute. Anesthesia providers are then placed in a challenging ethical dilemma: they must seek to gain the child's cooperation, force the child to undergo induction using restraint, or delay the case. In the moment, it can be difficult to parse the relevant clinical and ethical factors to determine the most appropriate course of action. The purpose of this perspective paper is to provide a clinical ethics framework to support anesthesia provider decision making during instances of last-minute pediatric refusal of anesthesia induction. Three prominent pediatric ethics concepts support this framework, including the harm principle, best interests, and emerging autonomy. This framework uses the criteria of (1) urgency of intervention, (2) decision-making ability of the patient, and (3) harms to the patient from a forced induction. Each of these criteria is discussed in depth as it relates to last-minute pediatric refusal. Case illustrations are provided to demonstrate the clinical utility of this framework in everyday practice.