Safety of care
Cautionary tales: telephone advice
An article for physicians by physicians
Originally published Spring 1998 / Revised May 2008
Carefully document telephone advice even if a patient rejects it.
Of interest to all physicians
When physicians are governed by a patient's demands rather than their own medical judgment, the results are not always satisfactory for the patient and can be difficult to explain.
A family physician had a woman in her practice who had had sporadic episodes of chest pain for several years. On at least four occasions, the patient was investigated with ECG, x-rays and blood work, all of which turned out to be normal. The last visit to the emergency department had been about six months previously.
One evening, the physician received a telephone call from the patient's husband who reported that his wife was having chest pain. The physician advised the patient be taken to the emergency department, and it is the physician's position that she was advised that the patient did not want to go to the emergency.
The physician then spoke directly with the patient who reported flu-like symptoms for a period of days including nausea and vomiting as well as aching pain in the centre of her chest. Again, the physician advised the patient to go to the emergency department; the patient responded that she felt this would be a waste of time in view of the negative results of her previous visits.
The physician remained concerned and so arranged to call a pharmacy with a prescription for nitroglycerine. She instructed the patient over the phone as to how to use the medication. Shortly afterwards the husband left the house to obtain the nitroglycerine. On his return, he found his wife dead. An autopsy revealed the presence of significant coronary arteriosclerosis.
The husband's recollection differed from that of the physician's. He stated that he had simply been advised by the physician to pick up the nitroglycerine spray and flatly denied there had been any advice to go to the emergency department or that he and his wife had refused to go.
When the physician's decision came under scrutiny, there was difficulty understanding why the patient's symptom was managed over the phone, particularly since ordering the nitroglycerine implied that the symptoms could well be of cardiac origin. However, in view of the fact that her death occurred so soon after the time of the telephone call, the plaintiffs were unable to show that the physician's decision had caused the patient's death and the litigation was discontinued.
In addition to illustrating the dangers of the telephone and the need for consistent and full documentation of the discussion, this case points out the pitfalls when a physician's actions appear to endorse the patient's choice of a course of management directly opposite to that which the physician just recommended.