Being the bearer of bad news

27-10-2014

Being the bearer of bad news

Talking to patients about adverse events is a grave responsibility, one that must be handled with care, writes Dr Dan Cohen, International Medical Director of patient safety and risk management software company Datix.

Caring for patients is fraught with hazard. Every time we come to the bedside we bring the potential for benefits, but also the potential for harm. Benevolent intentions do not necessarily translate into safe and effective outcomes. Problems with our systems and processes of care and personal lapses related to a range of human factors often result in preventable harm. 

The processes of diagnosis are complex and encumbered by numerous biases. Even if all the processes and human factors are aligned for success, achieving best outcomes can be challenging, as patients must be fully engaged for optimal outcomes. Healthcare is all about partnerships, patients and healthcare professionals partnering to achieve desired outcomes. Best and safe outcomes are all about trust, caring and mutual obligations, and we must never lose sight of how to achieve these goals.

The duty of candor

When something goes wrong it is important to remember that sustaining trust is a key element in discussions that should occur shortly after an incident has been identified. We are still responsible for the care and welfare of our patients, and most assuredly this applies to those we may have harmed. We have a duty to be honest and open with our patients and recently, in England, this paradigm has been encompassed in a legal statutory requirement titled the Duty of Candour. 

What we have been ethically obliged to do as part of our humanity and commitment to patients is now embedded in law. In my view this should never have been necessary.

Delivering bad news 

When patients are harmed, we need to focus on the aspects of trust and obligation that are appropriate for our profession. Discussing adverse events, any damaging outcomes, the remedies to treat these outcomes and the steps to prevent further harmful incidents is part of the fiduciary relationship with those we serve. We need to be open and honest and to build and sustain bridges of communication, and we need to apologize, yet we are often not adequately prepared to do so. 

Of course, individual circumstances should dictate seeking guidance from hospital administration resources beforehand, but that should not trump the ethics of honesty, communication and trustworthy behavior.

Unfortunately, most physicians and nurses are not specifically trained in delivering bad news, let alone bad news resulting from system or human errors or other mistakes. Nonetheless, it is the right thing to do and there is some evidence emerging that open disclosure actually decreases medical malpractice suits. Physicians and nurses need mentoring in how to talk with patients about adverse events, and institutions should have in place formal plans that address disclosure as part of an overall incident response plan.

The Institute for Healthcare Improvement in the USA has published Respectful Management of Serious Clinical Adverse Events, guidance on the management of serious adverse events and preparation for disclosure, which should be read and incorporated into local planning.

I was trained as a pediatric oncologist and I have had a lot of experience in sharing very bad news. To start with, I was not very good at this and, frankly, was highly intimidated by such discussions. Fortunately, I had good mentors who coached me through the process so that after few weeks into my training, I was much better. I have always been a compassionate guy but needed some help sharing facts and concern when the facts were sometimes very frightening. 

Case study 

Years ago I was involved in an incident where a patient under my care was administered 10 times the appropriate dose of chemotherapy for cancer. I had been called away from the bedside and I asked someone else to administer the medication on my behalf. An incorrect dose had been prepared by the pharmacy and had I been present this error would have been identified and the overdose avoided. 

My mistake was that I had been reluctant to call for oncology staff backup simply because of a scheduling glitch, and instead had relied upon someone without oncology qualifications to accomplish this simple but potentially very dangerous task. I was complacent and thought my work-around would suffice. After all, a schedule glitch is not usually an emergency. I have regretted this ever since, as this case still lingers with me.

Later that evening, when I realized what had happened, I became very alarmed. I was certain that the overdose would kill the patient, a little girl with Wilms’ tumor.

I called my attending physician immediately, and he advised that we meet together with the family to discuss what had happened. He also said that although the child had received a very high dose of medication, we did not know that she would die, but only that she was likely to become very ill. This distinction stuck with me because it is important to deal with what is known to be factual, not what may be mere conjecture.

The meeting was hugely challenging for all parties involved, but with honesty and compassion I explained what had happened, how this had happened and what steps we would take to care for their daughter going forward. I apologized for what had happened, promised to keep the parents updated and to share details of the subsequent investigation into this incident. The family was upset and very frightened but remained grateful and confident in our care. 

To make a long story short, the child recovered nicely, despite 10 days of severe bone marrow suppression and gastrointestinal toxicity. She was ultimately cured of her illness and my relationship with the family was strengthened and sustained. Although I became what we now refer to as a 'second victim', my longer-term relationship with this family restored my sense of value, confidence and purpose.

Of course, not all stories will end this way, but an honest, compassionate approach has served me well over the years. Institutions need to be prepared, and formal disclosure planning plus individual and team training in disclosure should be part of the safety culture.

The English Duty of Candour encompasses all the elements of communication that I and my colleague utilized when meeting with this family, long before the jargon of patient safety included words like disclosure, transparency, personal and system failures and 'second victims'. Perhaps, as a profession, if we had generally been more open to begin with, the Duty of Candour legislation would never have been necessary.

Caring for patients means sharing good and bad news in a balanced way, all with the goal of sustained engagement. The product of our ongoing efforts is safe and effective outcomes. In the absence of partnering with patients, all we have is a bunch of people working in hospitals and clinics - alone! Best and safe outcomes are all about trust and caring, communication and mutual obligations, and we must never lose sight of how to achieve these goals. 

Dr Dan Cohen writes a regular monthly blog post at http://blog.datix.co.uk/

 

About Dan Cohen

Dr Dan Cohen was formerly chief medical officer and executive medical director for the US Department of Defense health plan that provides or purchases healthcare services for more than nine million beneficiaries worldwide. As director, office of the chief medical officer, Dr Cohen was responsible for important aspects of oversight for clinical quality, patient safety, population health and medical management initiatives across this comprehensive system.

He trained in pediatrics and hematology/oncology at the Boston Medical Center, Boston University, and the Boston Children's Hospital, Dana Farber Cancer Institute, Harvard Medical School. He is a Senior Fellow of the Royal College of Paediatrics and Child Health and a Fellow of the American Academy of Pediatrics. He retains a faculty appointment in the Department of Pediatrics at the Uniformed Services University of the Health Sciences, F. Edward Herbert School of Medicine, Bethesda, Maryland, US, where he once served as dean for student development. 

Also available by Dr Dan Cohen: Late Night Reflections on Patient Safety - Commentaries from the Front Line; ISBN 978-0-9930573

Dan Cohen, Datix, US

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