What should doctors disclose to patients in the aftermath of adverse events? Does it matter if the adverse event was related to an error? Does it matter if it was preventable or not, anticipated or unexpected?
Recently, I was at the Carolina Refresher Course facilitating a session on adverse events in anesthesiology. We touched on a variety of issues, but spent the most time discussing the importance of disclosure conversations, as well as the challenges that we face.
What is disclosure?
Disclosure is really a process rather than an event, and is the series of conversations that convey information to the patient about an adverse outcome, and sometimes, a medical error (if one has occurred). Like many realms of professionalism, this is rarely given adequate attention in medical school or residency training, and as such, many doctors express uncertainty about what to say, how to say it, and sometimes, whether anything should be said at all.
An “adverse event” includes any untoward outcome, regardless of whether an error occurred. “Error” implies that a deviation from standard of care or best practice occurred, whether by an incorrect action (doing the wrong thing) or an omission (failure to do the right thing).
What are potential barriers?
Anesthesiologists face some unique, specialty-specific barriers, in addition to barriers that are present across the board in all medical circumstances.
- “Pay no attention to that man behind the curtain!” This quote from The Wizard of Oz sums it up — many patients do not view us as “their doctor” the way they view the surgeon, cardiologist, or primary care doctor who has spent time with them in an office setting, whom they’ve seen on multiple occasions, and whom they have researched and selected to care for them. Anesthesiologists are generally not pre-selected by patients, and have precious few minutes to meet patients and establish rapport prior to initiating medical care. This lack of relationship can make difficult conversations even more challenging.
- We’re still treating the patient when the surgeon leaves. Anesthesiologists are often still actually caring for the patient at the time that the surgeon or proceduralist might feel it is appropriate to speak to the family. If something dramatic has occurred, we may be continuing to resuscitate the patient, or stabilizing and ensuring safe transport to an intensive care unit, or engaging in a transfer of care conversation with the ICU doctors or other consultants. Because of this, we may not be present to clarify facts and answer questions. This absence can lead to misunderstandings, both of facts and of intentions (“Why isn’t the anesthesiologist here? Is he hiding something? Can’t he be bothered?”). As presented at the 2012 ASA Annual Meeting, one survey of anesthesiologists found that surgeons were present at 94% of initial disclosure conversations, while anesthesiologists were involved in only 57% of those discussions.
- Production pressure. Anesthesiologists face considerable production pressure to get the next case started. This may interfere with our ability to take time for a family meeting, particularly if our institutions and practices do not support this endeavor. Many folks in my session told me that their administrators would view these conversations as the surgeon’s responsibility and would indeed expect the anesthesiologist to be ready to get back to work on the next patient immediately.
- Fear and uncertainty. Some barriers that all doctors face include the challenge of breaking down complex medical events into understandable lay terms, and answering questions while avoiding speculation when a full root cause analysis has not yet uncovered all of the facts. Handling patient distress or anger can be hard, and patient responses may be more intense when an adverse outcome is not anticipated, as with a healthy patient undergoing a “simple” or “routine” elective case. We may be afraid of litigation, or damage to our professional reputations among colleagues or in public, even when no error was made. We often don’t know quite what to say or how to say it.
We want to do the right thing.
You may wonder why we should engage in disclosure at all, given the barriers described above. It turns out, we want to. Studies have shown that anesthesiologists feel personally responsible for adverse outcomes even when an error was not made, or the error was clearly surgical, and even when the adverse outcome is thought to be unpreventable.
For example, a study found that 3/4 of anesthesiologists felt personally responsible for adverse outcomes even when more than half of these were not anesthesia-related, and more than 60% still felt personally responsible if event was believed to be unpreventable. Anesthesiologists have a long history of leading patient safety initiatives. We strive to improve patient safety processes, and we view sentinel events as learning opportunities for ourselves as well as our institutions. We care about patients, even those we’ve only known for five minutes, and we work to foster trusting relationships with them.
So, what should be said? Below are some suggestions for the content of disclosure conversations.
- Facts. At the initial conversation, it is important to discuss known facts only, without speculating about causality. Gaining a complete understanding of an adverse event takes time, and this should be conveyed to the patient or family.
- Expectations. Reassure patients that they will be given all of the information when the analysis is complete, and offer a timeline for the process so they know what to expect. Of course, also explain the expected prognosis and need for any ongoing treatment related to the event.
- Error. At the conclusion of an investigation, it may be appropriate to disclose whether a medical error occurred, and what steps will be taken to prevent similar events from happening in the future.
- Apology. Some doctors wish to express sympathy whether or not a medical error has occurred, and many states have laws that protect caregivers who apologize to patients from having that apology be used against them in legal proceedings. In North Carolina for example, “statements by a health care provider apologizing for an adverse outcome in medical treatment, offers to undertake corrective or remedial treatment or actions, and gratuitous acts to assist affected persons shall not be admissible to prove negligence or culpable conduct.”
What work needs to be done to improve the process of disclosure after medical error or adverse outcomes?
Institutions and practice groups should invest in supporting anesthesiologists to appropriately deal with adverse events, including disclosure conversations with patients and their families. Professional development and residency education should focus on teaching these elements and communication skills. Risk managers and administrators should value our participation in these endeavors, because we as physicians think it is important, and patients appreciate it too.