Disclosing adverse events to patients: strengthening the doctor-patient relationship
Of interest to all physicians
Adverse events and litigation
Patients and families litigate for a variety of reasons. Financial need is certainly a factor. Disappointment and anger over poor clinical outcomes or unfulfilled expectations also play significant roles. Surprise at unanticipated outcomes or the incidental discovery of important undisclosed details about an adverse event are also strong motivators. Surprise may quickly turn to mistrust and anger. Patients and families sometimes state that litigation is an attempt to find out what happened after other attempts at communication and enquiry have not successfully answered their questions. Litigation may also be an attempt to change the system for the better so that similar events do not occur to others.
Some patients and families have said they may even be forgiving of preventable adverse events but are less inclined to be so if they perceive that the physician or hospital is evasive or dishonest. Patients appreciate physicians who have a caring attitude and who support them through an adverse event.
Physicians react to unexpected complications and poor clinical outcomes for their patients in a variety of ways. All physicians are motivated to prevent, to the extent possible, the adverse event from happening again. Moreover, the majority of physicians have a profound sense of personal responsibility and are immediately self-critical when an adverse event affects their patient. Sometimes there is a tendency to attribute the cause of the harm to individuals even before all of the contributing circumstances and facts are known.
What is an adverse event?
An adverse event is one which results in unintended harm to the patient and is related to the care and/or services provided to the patient rather than to the patient's underlying medical condition (CPSI 2008).
Adverse clinical outcomes usually are not caused by negligence. In fact, most unanticipated injuries or outcomes that occur during the course of medical care are an inevitable part of clinical practice even with the best of care. In the courts, the medical standard of care to determine negligence is not one of perfection, but rather the standard of care that might reasonably have been applied by a colleague in similar circumstances. The courts rely heavily upon the testimony of other physicians working in a similar specialty in the same kind of practice to help establish the applicable standard of care.
Disclosure of adverse events to patients
The CMPA has for many years encouraged member physicians to disclose to patients the occurrence and nature of adverse outcomes as soon as is reasonable to do so after their occurrence. This is an ethical, professional and legal obligation. This recommendation sometimes is unfortunately confused with specific CMPA advice given to a specific physician related to limiting communications with a patient after a legal action has commenced. Prior to communicating directly with a patient who has commenced a legal action against them, members should consult the CMPA or their legal counsel.
Disclosure to patients soon after the adverse event is recognized
Ideally, the communication of adverse events should be done in a gentle, non-rushed manner in a private setting. Formulate a plan of communication prior to approaching the patient and/or family.
The CMPA suggests the following:
In summary, patients and their families want to understand what went wrong, as do their physicians. Patients do not want to feel abandoned by their physician after an adverse event has happened. The patient's most immediate concern is usually to know what needs to be done to improve the clinical situation. It is at this time that good communication may actually help restore or strengthen the doctor-patient relationship.
The bottom line
Communicating with your patient about harm: Disclosure of adverse events. This CMPA publication has suggestions to help members meet their patients' clinical, information and emotional needs after an adverse event.