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̶=
0;Delivering
Bad News”
Professionalism and Ethics
=
H. Colleen Silva, MD
Dept. of Surgery Grand Rounds&=
#13;
April 22, 2009
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Acknowl=
edgements
nAmerican
College of Surgeons 2007 DVD: Communicating with Patients about
Surgical Errors and Adverse Outcomes.
nACS
Handbook: Ethical Issues in Clinical Surgery for
Instructors and Practicing Surgeons, 2007.
ACGME/ABMS
Core Competencies<= /span>
Core Competencies<= /span>
nPatient Care
nMedical Knowledge&#=
13;
nPractice-based
Learning & Improvement
nInterpersonal &
Communication Skills
nProfessionalism
=
;
nSystems-based Pract=
ice
ACGME =
Core
Competencies
nResidents are
expected to communicate effectively
with patients, families, and the public
across a broad range of socioeconomic
and cultural backgrounds.
nResidents must
demonstrate a commitment to
carrying out professional responsibilities and an adherence to ethical principles
Texas
Medical Board
nPhysicians
are required to complete 24 hours of continuing medical educati=
on every
12 months.
nIncluding
1 hour of ethics and/or professional responsibility&nb=
sp;education
Definit=
ion
Medical Error
n“Failure
of a planned action to be completed as intended, or the use o=
f a wrong
plan to achieve an aim.”
Definit=
ion
Adverse Event
n“Injury
that was caused by medical management and that resulted in measurable
disability.”
![](3D"slide0011_image006.gif")
Relationship of Errors & A=
dverse
Events
Adverse Events&=
#13;
(Complications=
)
Medical Errors<=
/b>
Preventable AE’s
![](3D"slide0011_image007.gif")
![](3D"slide0011_image008.gif")
Non
preventable AE’s
AMA
Definition
n“It is a fundamental ethical requirement tha=
t a physician should at all times deal honestly and openly with patients…Situations occasionally=
occur
in which a patient
suffers significant medical complications
that may have resulted from the physician’s
mistake or judgment. In these situations,
the physician is ethically required to inform the patient of ALL the facts necessary to <=
/span>ensure understanding of what has occurred…Concern regarding legal liability w=
hich might result following truthful disclosure should =
not affect the physician’s honesty with a patien=
t.
The Soc=
ial
Contract
n“The
complete, unavoidable, albeit temporary transfer of
autonomy to the physician inherent in surgical therapy <=
span
style=3D'position:absolute;top:51.25%;left:16.29%;width:85.95%;height:6.75=
%'>makes
it imperative that the surgeon fully appreciates the mor=
al
obligation implicit in the surgeon-patient relationship.”
Axelrod, Goold; Arch Surg 2000:135:55-61
The Social Contract: A Fiducia=
ry Relationship
<=
span
style=3D'font-size:31%;visibility:hidden'>n
nA fiduciary duty is an obligation to act in the best interest of another party… the <=
/span>relationship with the client involves a special trust…A person acting in a fiduciary capacit=
y is held to a high standard of honesty and full disclosure in regard to the client…
<=
span
style=3D'font-size:38%'>n=
http://definitions.uslegal.com
nThe surgeon incurs a moral obligation to strengthen and deserve that trust.
Axelrod; Goold: Arch Surg 2000;135:55-61.
Patient
Expectations
nOnce
trust has been established, patients hold several
expectations:
n1. Goodwill and
beneficence
n2. Competence and g=
ood
outcome
n3. Honesty and open=
ness
Axelrod, Goold; Arch Surg 2000;135:55-61.
Error
Disclosure
Excerpted from ACS '07,
Communicating w/ Patie=
nts
about Surgical Errors & Adverse Outcomes,
Vincent 1994, Witana 1996
Disclos=
ure
Disconnect
nPatients want
disclosure.
n98%
expect MD to acknowledge error regardless of severity.&#=
13;
nAs
severity increases, patients expect more substantial
explanations.
n
Physician Barriers to Disclosure
nHarmful to the pati=
ent.
Induce anxiety.
nDisruptive to the
relationship
nAwkward and
uncomfortable
nPersonal failure=
3;
nFear of lawsuits
Physici=
an
Response
nApproached
from the perspective of informed consent.
nPatient’s
who want more information will ask.
Patient
Perceptions
nDisclosure
indicates respect for them as a person.
nPatient’s
want to know what happened.
nWhy it happened.=
3;
nPrevention in the
future.
nApology.
n<=
span
style=3D'mso-special-format:lastCR;display:none'>
̶=
0;Feelings,
Not Facts”
Physician risks appearing uncaring and distant
Disclosure Disconnect -=
Minimization
n
nNatural
urge to distance ourselves from the error. Protect against the=
painful
feelings.
nLoss of
self-esteem.
nPersonal failure.&#=
13;
nFear of lawsuit.
Disclosure Disconnect - Maximization
nThe patient/family
feels bewildered.
nAnger
increases over lack of information or quality of communication.
nThe
more resistance from the health care professional, the
greater the anger.
Reta=
ined
Sponge Scenario
Clini=
cal
Vignette
When I am speaking, how is wha=
t I am saying affecting the listener?<=
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Skilled
Communicator
nPatient feels
respected
nPatient senses your
concern
nThe
communicator tries to put himself in the place of the liste=
ner.
Skilled
Communicator
nDoes
not unnecessarily shift blame to a resident, an assistant,=
a
nurse, a referring physician, or the institution =
itself.
nInadvertent
or common mistakes should not be a touchstone for vilifying other
individuals.
Burn
Scenario
Clini=
cal
Vignette
A surgeon must be able to admi=
t to unwanted events in an honest and compassionate manner.
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‹#›
The balanc=
e of
power lies with the surgeon, the patient “trusts” the surgeon =
with
his life, well-being, and private information.
10
On accepta=
nce
(implicitly or explicitly) of a patient’s trust by the surgeon, he i=
ncurs
a moral obligation…
11
Deception,=
even by
omission, is a powerful betrayer of trust.
12
Unskilled
communicator, shattered, too preoccupied with his own feelings, the defens=
e of
me
18
How is the
listener understanding what I am saying, interpreting what I am saying, and
feeling.
22
While case=
s of
negligence or misconduct occur, inadvertent or common mistakes should not =
be a
touchstone for vilifying other individuals.
24
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