April 2003 Bulletin

Communicating adverse outcomes

Be sensitive, honest, express emotional support

By Howard R. Epps, MD, and John R. Tongue, MD

An adverse outcome is a serious injury or death resulting from medical management— not the underlying condition of the patient. Patients and their families who experience feelings of fear, isolation and mistrust due to the incident itself often feel that communication of the incident was insensitive and inadequate.

While breaking bad news is always difficult and stressful, we believe that a systematic approach can improve the communication process and reduce the overall negative impact. Honest, timely disclosure of errors strengthens the physician-patient relationship and can reduce the risk of litigation.

Plan to disclose

We have been trained in a perfectionist medical model. However, we all have experienced sudden emotional shock—even nausea—following a medical mistake. Immediate feelings of anxiety and defensiveness are normal.

Discussing the incident with members of the patient’s health care team and other supportive staff members can ease the burden. It can also help prepare you for providing an appropriate response.

Consider which health care providers should be present and who should break the news. Include important family members and try to have both parents present, if the patient is a minor.

Eliminate possible interruptions such as pagers and phone calls. The exact content of the disclosure and the order [that a disclosure] is given should be carefully considered. All pertinent data and test results should be readily available.

Pitfall: Immediate, instinctive reactions to minimize a bad mistake have led physicians to naturally distance themselves from the affected person. Such reactions lead patients and their families to perceive those involved as arrogant and disinterested.

Begin a dialogue

Take sole responsibility by delivering bad news in person. Errors can be forgiven when the key issue of caring for the patient is fully addressed. Direct, clear statements are important, as well as how you say them—particularly the tone of your voice.

Communicate in a manner that is open, compassionate and timely. Give an accurate and clear statement with non-defensive explanations of what happened.

Speak in short statements. Frequently stop to ask the patient/family members if they understand. Avoid overly technical descriptions and vocabulary.

Expect and acknowledge emotional responses. Complex, even severe reactions of fear, anger, mistrust and hopelessness are common at this time. Acknowledge those responses: "You sound very upset with this news."

Apologize when appropriate: "We are sorry this has happened to you." Such an apology is not an admission of liability. (DO NOT SAY: "We are sorry that we did this to you.") The complication should be your focus.

Remember that communication is mostly nonverbal. Sit together in a quiet, private room. Avoid barriers such as desks and tables. Face the patient. Maintain eye contact.

Speak with an even tone of voice. Appear calm—not hurried or irritated. The content of the initial discussion may be less important than how it is said.

Provide ample time. Reschedule other commitments in order to properly organize and address the communication needs of the unexpected event—just as you would for a difficult emergency surgery.

Pitfall: Avoid offering initial beliefs or subjective opinions of possible causes of the event. Also, criticisms made by members of the health care team may plant misunderstandings and detract from the essential goal of caring for the patient.

Express emotional support

As orthopaedic surgeons, our most common deficiency in daily patient interviews is a failure to demonstrate an empathic response to our patients. It is all the more difficult to recognize the severe emotional reactions of patients and families to adverse outcomes. These situations are often sad and tense. Prepare to receive the patient’s emotional outpouring of fear, anger, disappointment and mistrust.

Tolerate silence as emotions are gradually sorted out—then expressed.

Reflect Acknowledge their emotions, let them know you feel [for them] and the patient is heard.

Listen for concerns you can clarify, and values you can confirm.

Offer to listen to other members of the family who could not participate in the initial disclosure.

Pitfall: Avoid defensive comments when confronted by fearful or angry patients: "I understand that you feel very sad and angry in this situation."

Repeat concise explanations blocked out by the patient’s initial emotional response to bad news. Repeat your commitment to helping the patient deal with the illness or injury.

Provide direction

After you have discussed the adverse outcome, tell the patient how you will address the situation.

Summarize an explicit, proactive plan for the care and support for the patient.

Negotiate. Check the patient’s understanding and acceptance of this plan.

Write down a list of tasks and instructions. A drawing can be helpful.

Avoid delays in the subsequent completion of tests and consultations.

Review progress of the care plan directly with the patient.

Recognize and respect shifting complex emotions as care continues.

Express hope in each encounter with the patient and family members.

Document your discussions and plan.

Pitfall: Failure to execute the care plan or to communicate effectively will possibly cause the patient or family to lose trust. Promises must be kept in a timely manner to assure the primary goal of providing appropriate care for the patient.

Howard R. Epps, MD, is a member of the AAOS Patient Safety Committee. He can be reached at (713) 799-2300 or at epps@fondren.com.

John R. Tongue, MD, is chair of the AAOS Communication Skills Mentoring Program. He can be reached at (503) 692-5483 or at JTongue.MD@verizon.net.

Communicate welcomes suggestions about future topics for the column on patient-physician communications. Send your suggestions to the Bulletin at AAOS, 6300 N. River Rd., Rosemont, Ill. 60018.


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