Discussing Unexpected Outcomes with Patients

Executive Summary 

Failure to disclose complications that occur during the course of medical treatment breaches the code of professional ethics and breaks the trust in the physician-patient relationship. Honest communication about complications enables patients to maintain a level of respect for their physician and makes a favorable resolution more likely. 

Recommended Actions  

• When an unexpected outcome occurs, disclose all the facts to the patient promptly to preserve the physician-patient relationship. 

• Acknowledge a patient’s frustration with unanticipated outcomes and remain compassionate during the patient’s healing process. 
• Apologize in a way that patients cannot misconstrue as an admission of malpractice. 

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 her obstetrician repaired immediately. Post-operatively, the physician did not inform the patient about 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 faxed by the obstetrician following her delivery. The discharge summary included documentation of the patient’s bladder injury and repair. 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 consequences. Following her discussion with her primary care physician, she promptly called her obstetrician’s office to voice her displeasure. 

From the Patient’s Perspective   

Recently, we received the following comment from a patient: 

“The doctor was wonderful in how he handled this unexpected outcome. His bedside manner is wonderful. He even called me at home and on the weekend to check on how I was doing. He was truly compassionate and I felt he was truly sorry.” 

This feedback shows that the patient felt genuine concern and caring from the physician, which helps address the emotional impact of an unanticipated outcome. The physician demonstrates compassion by verbally expressing empathy, investing time and staying involved with the patient. 

Conversely, some comments alert us to a patient’s belief that the physician doesn’t care, typically occurring when there is no continued communication after an unexpected outcome. “We were very disappointed that it took one year to be able to sit down with the physicians and discuss this matter. That made us feel that there wasn’t much concern on the doctors’ part, especially after being told that it was impossible to sit down with a doctor to discuss this event.” 

Additional comments such as, “I haven’t heard from him (the doctor) since the surgery” and “I only saw him once after the bowel perforation” indicate that patients expect continued involvement from their physicians even if other healthcare providers have assumed primary care. 

Expressing empathy and concern often requires ongoing interaction with follow-up visits and phone conversations. Acknowledging the patient’s response to an unexpected outcome and promoting healing in all respects takes time. Empathetic listening and responding allows the patient to express his or her feelings and facilitates understanding between the provider and patient. In addition, this promotes trust and strengthens the physician/patient relationship.   

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 they disclose a complication, honest communication can 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. 

Part of the patient’s healing process following an unexpected outcome necessitates physician involvement by facilitating treatment to promote physical healing. Patients also report an associated financial burden. 

In addition, doctors need to recognize the patient’s emotional response to a complication. Patients and their families often have a variety of emotions that surface after an unexpected outcome, including fear, anger, frustration and loss of control. Compassionate care includes responding to these emotional responses to effectively facilitate the patient’s entire healing process. 

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 they weren’t aware of, or realize that facts were misrepresented, will lose any remaining trust in their physician and become more inclined to seek legal action. Furthermore, 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 a patient cannot construe as an admission of malpractice. Conveying your regret and empathy that a complication occurred is appropriate, but depending on your language, statements 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 likelihood of similar events. 

Lessons Learned 

• Contact your insurance provider immediately after an unexpected outcome occurs.  
• Consider offering training for providers to handle patient interactions when common complications do occur. 
• Offer the patient an explanation for what led to the complication and ways you will reduce the possibility of similar events. 

Potential Damages 

Patients are more likely to instigate legal action if they find out a physician failed to disclose a medical error than if the physician disclosed the issue immediately. Failure to disclose complications and unexpected outcomes with the patient can lead to claims for negligence. If the patient suffers further harm due to the provider’s failure to disclose, the provider can be required to compensate the patient for the injuries caused, auxiliary medical treatment needed, and pain and suffering. The patient can initiate further if the provider failed to inform them of risks associated with the treatment beforehand.