The evaluation, conducted at the Royal National Orthopaedic Hospital in Stanmore and published in Frontiers in Anesthesiology, was carried out in the shadow of a landmark legal ruling. Since the UK Supreme Court’s 2015 decision in Montgomery v Lanarkshire Health Board, informed consent in Britain has been judged by what a reasonable person in the patient’s position would want to know, not by what doctors customarily disclose. That standard, reinforced by the General Medical Council and the National Institute for Health and Care Excellence, treats consent as an ongoing dialogue rather than a signature on a form. Valid consent for an anaesthetic intervention therefore requires that patients not only hear about the procedure but genuinely perceive it as elective.

Peripheral nerve blocks pose a particular challenge to that ideal. Unlike general anaesthesia or a spinal injection, a nerve block is usually an adjunct — an additional technique layered onto the primary anaesthetic plan to deliver targeted postoperative pain relief. It carries its own technique-specific risks, from nerve injury to local anaesthetic toxicity, and its success depends on the operator’s skill and the patient’s anatomy. Professional bodies including PROSPECT and the American Society of Regional Anesthesia and Pain Medicine recommend regional analgesia for many orthopaedic operations, which can make the conversation feel more like a recommendation than an offer. The Stanmore team wanted to know whether patients, after all the disclosures were complete, actually registered a choice.

The study took the form of a prospective service evaluation between June and July 2024. Every adult scheduled for elective orthopaedic surgery who was offered a peripheral nerve block was eligible, and investigators independent of the patients’ clinical care administered a standardised 19-item bedside questionnaire on the first morning after surgery. Sixty-three of the 68 eligible patients took part, a response rate of 92.6 percent. The questions mapped onto recognised domains of shared decision-making — information provision, presentation of options, deliberation, and decision — and covered whether patients saw the block as optional, what they recalled receiving, what information they had engaged with before surgery, and how satisfied they were with the consent process.

The headline numbers were sobering. Although 59 of 63 patients remembered being offered a block, only 25 perceived it as completely optional. Twenty-six believed it was simply part of the anaesthetic, and 12 were unsure. Fifty-one patients — 81 percent — accepted the block, most citing the anticipated pain relief, and satisfaction was uniformly high: 82.5 percent were very satisfied and none reported any dissatisfaction. On the surface, then, a compliant pathway and happy patients. Beneath it, a consent process that had failed to transmit the one fact the law cares most about.

The most dramatic finding concerned memory. When asked an open-ended question — what anaesthetic do you recall having? — not a single one of the 63 patients who received a nerve block spontaneously mentioned it, even though most blocks were performed while the patient was awake before the general anaesthetic began. By contrast, 15 of the 16 patients who received neuraxial anaesthesia, such as a spinal injection, recalled it without prompting, an absolute difference of nearly 94 percentage points. The dissociation was sharpest within individual patients: of six people who received both a spinal technique and a nerve block in the same anaesthetic, all six spontaneously recalled the spinal, and none identified the block — including two who had received sedation, which argues against sedation as an explanation for the gap.

The team’s interpretation is that patients categorise the two techniques differently. A spinal injection presents itself as a discrete event, often involving visible preparation and a distinctly felt procedure, whereas a peripheral nerve block seems to be assimilated into the patient’s broader mental category of ‘the anaesthetic’. This echoes earlier research showing that fewer than half of patients can recall any block-related risk shortly after surgery, that knowledge scores are weakest in the regional anaesthesia domain on validated instruments, and that fewer than 40 percent of patients feel sufficiently informed to choose between regional and general techniques. Consent documentation, too, is frequently written above recommended reading levels, compounding the problem.

Two of the study’s comparisons carry practical weight. Receipt of a written information leaflet made no measurable difference to whether patients recognised the block as optional — 41.7 percent of leaflet recipients versus 39.2 percent of those without, a null result with a p-value of 1.00. But prior personal experience of regional anaesthesia nearly quintupled the odds of recognising optionality: 62.5 percent of patients who had experienced a regional technique before perceived the block as elective, against 26.3 percent of those without such experience (odds ratio 4.67, p = 0.009). In other words, lived experience taught patients what leaflets could not. Passive disclosure, the authors suggest, is not enough; understanding appears to come from something closer to dialogue and demonstration.

The findings are a caution against the reflex to treat patient satisfaction as proof of valid consent. Satisfaction, prior work shows, reflects trust and rapport with clinicians far more than the cognitive content of the consent conversation. The authors are careful about what their data do and do not show: the three-category measure of optionality is a simplification, a strongly recommended intervention can be part of good shared decision-making, and some patients legitimately prefer to delegate decisions to a trusted expert. But they argue that even delegation presupposes awareness that a choice exists, and that under Montgomery even a strongly recommended treatment must be understood to be declinable. A pathway in which fewer than half of patients recognise the elective nature of an intervention, they conclude, is unlikely to be delivering the dialogue that guidance requires.

The response at Stanmore has been concrete. The perioperative consent pathway now includes a standardised opening phrase that explicitly frames the nerve block as one of several options the patient may accept or decline, and a mandatory teach-back step in which patients describe, in their own words, the option they have chosen and an alternative. The changes align with the Association of Anaesthetists’ newly issued 2026 consent guidelines, which require anaesthetists to actively confirm that information has been understood rather than rely on disclosure alone. Re-measurement is planned. The authors acknowledge the limits of a single-centre, descriptive evaluation — no pre-specified primary outcome, an unvalidated instrument, potential recall and social-desirability biases, and the exclusion of non-English speakers, arguably the group most at risk of comprehension gaps. Yet they argue the underlying failure mode, patients failing to categorise a nerve block as a distinct elective intervention, is unlikely to be confined to one specialist hospital, and they invite replication elsewhere. With the UK’s forthcoming Eighth National Audit Project expected to deliver fresh data on serious regional anaesthesia complications and reshape how risks are communicated, the timing of this quiet audit of the consent conversation could hardly be better.

Subject of Research: Patient perception of optionality in informed consent for peripheral nerve blocks in elective orthopaedic surgery

Article Title: Do patients perceive peripheral nerve blocks as optional interventions for elective surgery? An evaluation of informed consent at a UK specialist orthopaedic centre

Article References: Do patients perceive peripheral nerve blocks as optional interventions for elective surgery? An evaluation of informed consent at a UK specialist orthopaedic centre. (n.d.). https://doi.org/10.3389/fanes.2026.1956429

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1956429

Keywords: informed consent, peripheral nerve block, regional anaesthesia, shared decision-making, patient autonomy, Montgomery v Lanarkshire, orthopaedic surgery, perioperative medicine, teach-back, risk communication, patient satisfaction, service evaluation