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Complicated Communication: Discussing Unexpected Outcomes with Patients

February 5, 2018

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Case Scenario

A 32-year-old woman underwent emergency cesarean section due to fetal bradycardia. Her C-section was complicated by an injury to her bladder which was repaired immediately by her obstetrician. Post-operatively, the patient was not informed of this complication as the obstetrician reasoned that this was included as a possible complication on the consent form. In addition, the obstetrician was of the opinion that the bladder repair was successful thus the patient was unlikely to experience any future problems related to this complication.

Ten days following delivery the patient presented to her primary care physician complaining that an increasing amount of fluid was draining continuously from her vagina. The patient’s primary care physician examined her and reviewed the records that had been faxed over by the obstetrician following her delivery. The discharge summary included documentation of the patient’s bladder injury and the fact that it was repaired. The primary care physician then explained to the patient that the fluid leaking from her vagina was likely due to a vesico-vaginal fistula that developed as a result of her bladder injury. To the primary care physician’s surprise, the patient had no knowledge that a bladder injury occurred during her C-section. The patient was very upset that her obstetrician failed to inform her of this complication and the possible sequalae. Following her discussion with her primary care physician, she promptly called her obstetrician’s office to voice her displeasure.

Discussion

Failure to disclose a complication not only breaches the code of professional ethics, but also destroys the trust in the physician-patient relationship and exposes physicians to an increased risk of litigation should the complication be discovered by the patient at a later point. Although many physicians fear that patients will become angry and sue once a complication is disclosed, honest communication about complications has been shown to avert anger and litigation. Communicating honestly with patients preserves the trust in the physician-patient relationship and enables patients to maintain a level of respect for their physician.

Recommended Steps for Communicating Following a Complication

  1. Disclose the facts. Be forthright in telling patients and their family members the facts. Physicians should bear in mind that facts surrounding the case will be made available to patients once their records are requested. Patients who discover information in their chart that was not disclosed, or realize that facts were misrepresented, will lose any remaining trust in their physician and become more inclined to seek legal action. Furthermore, as occurred in this case, if a patient finds out about the complication through another healthcare provider (not involved in the procedure) they are more likely to develop distrust and anger towards the provider who performed the procedure. Disclosing complications to patients allows them to feel informed and helps to sustain trust in their healthcare provider.
  2. Apologize using language that cannot be misconstrued as an admission of malpractice. Conveying your regret and empathy that a complication occurred is appropriate, but depending on the language used your statements may or may not be protected legally. Most apology laws only extend protection to expressions of empathy, but do not cover statements that could be interpreted as an admission of negligent conduct. That said, a physician should never fail to show care or empathy. Physicians who appear cold and indifferent about the event are more likely to experience a breakdown in the physician-patient relationship, thus making a favorable resolution less likely.
  3. Make things right. Most importantly, this involves recognizing and acknowledging how the unanticipated event has affected the patient. Identify specific needs or changes in treatment and discuss these honestly. Let the patient know that you will look into options that may help and continue to communicate with them. Consider offering assistance with out-of-pocket medical and other expenses that the patient would not have otherwise incurred.
  4. If applicable, explain the steps you will take in your practice to reduce the future likelihood of similar events.

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.

Footnotes