"I'm just telling you the way it is...We can't write everything down" --> "an invitation for disaster."
What I mean is, everything needn't be written down. Some things are so standard, so protocol, with adverse reactions mild or rare enough, that there is no need to get elaborate permission to give someone cefazolin for cellulitis. We just do it. And I should add, it works just fine. See cellulitis discussion below.
"To purposely withhold information about medical procedures or drug therapy because the treating physician thinks the patient should have procedure A vs. procedure B, and not give the patient the option is clearly wrong."
I'm not talking about a doctor who does a C-section on some unwitting woman because s/he makes more money that way than in a vaginal delivery. Or not telling her the risks. Of course that would be wrong.
I'm talking about the impracticality of going over with a patient with cellulitis whether that person should get cefazolin or nafcillin or oxacillin, or levofloxacin, or gatifloxacin, or something else, and whether it's 1 or 2 grams, and the dosing frequency, and the duration of IV vs oral, the total length of therapy, the ideal time for followup, and the very low risk of hepatitis, or the serious but very rare anaphylaxis or interstitial nephritis, the possibility of c diff infection, or of an abscess at an IV site. This all pertains to about the simplest possible admission a medicine resident can get. Discussing these things with another doctor would take probably an extra hour at least; they could easily fill several hours or days of lecturing. If we really wanted to discuss every single detail of care with every patient--and of course their families too--when they have no medical training, this would take--well... you'd have to send them to med school. This would at least triple the time spent with patients, at least cutting admission numbers and reimbursements by a third, and closing every hospital in the country given the razor thin profits Gene mentioned earlier. It is not possible.
"The patient has a stone-cold right to make each test or therapy decision and maybe even make an awful decision."
To review the medical ethics that were bought up earlier, there are several major principles we try to further: benevolence (doing what we think is right for the patient), autonomy (allowing the patient to make their own decisions), and nonmaleficence (doing no harm). They're frequently conflicting; chemo may be the best thing but it has bad side effects; we may want a patient to get blood but they may refuse, etc. Patients MAY refuse ANYTHING they want in my book if they have capacity--the MD's make that call--but they do NOT dictate their care.
But I will NOT give demerol just because a drug addict wants it. I will not give them the wrong antibiotic because they want it due to poor judgment. I will not give them lethal doses of medications, or let them decide they need to have heart surgery. People could make fabulously bad decisions that could kill them, harm others (thru increased cost and antibiotic resistance, resource availability etc). As I'm sure Gene is aware, MD's are NOT required to do ANYTHING they feel is immoral (say, an elective abortion) or improper (a dangerous drug when a safer one is as good). We are required to provide emergency care and help people until they find a new doc; we are no more required to let them dictate care than the good sigma six people at GM are rquired to let their customers open the windows on their jets. If they disagree with how we are doing our best to help, they are free to leave at any time.
As an intern I faced a patient who was dying--inevitably--of a degenerative neurologic disorder in a matter of days, inhaling her own spit. She wanted "everything," including a trip to the ICU on a ventilator which would prolong her dying (not her life) a few days, and pounding on her chest, shocking her heart, etc. I pleaded with her / family from 10pm to 4:30 am to reconsider, which she did, dying peacefully at 5:30. As a junior resident I understood I did not HAVE to provide such a therapy when it would not help; I could refuse. As a senior resident I know not even to raise the issue. Simply discussing only the indicated therapies and omitting those which can only harm would have been the best thing for her. I mean, why offer her useless life support when we don't offer radiation or chemo, those things being useless themselves?? Yes, autonomy is key, and patients can refuse all--but they cannot demand all. I am not working at Burger King's counter and it would be a new and lethal, if utterly unworkable, precedent if physicians began taking orders from the patients. That said, there is a lot of negotiating with real world patients and things generally work out fine. Smart docs document liberally when uncooperative patients make bad decisions.
"But a lot of what you're talking about is just plain chilling."
No, I just think you have unrealistic expectations about how medicine is practiced. I'm describing nothing more than a day in the life of the world's best medical care, and it works great. I'm describing these things, not advocating them. Day in and day out we keep people informed about the right things, get consent about the right things, and respect their autonomy. It has never been realistic or advisable to do many of the things you ask.
"And just because no one's taken the good doctors at BI to task over it..."
Please! This has nothing to do with BI. Everyone, drop by... I have wroked at 7 hospitals, observed at 9 (did a more thorough count), as mentioned, and the communication, the compassion, the excellence, the respect for patient's privacy and autonomy, the nursing is all top notch at BI, and as a result, the patient satisfaction places us very well nationally.
"Could you give an actual example, Ian, of a case where you withheld information from a competant patient, and your reasons for doing so?"
This is an example of an unrealistic perception. I did not tell any of the people who got nafcillin for cellulitis that is very rarely causes hepatitis; that is so rare, we generally don't even have to survey for it. We cannot and should not list every single side effect a drug has ever had, that would be bewildering and harmful. Yet this is FAR from withholding information!!!! I would happily discuss this with anyone for whom it was relevant or who asked.
"And how do we reduce physicians work hours and give them time to practice good nutrition and allow for their comfort? Maybe these are also barriers to quality..."
No "maybe!" Bill's discussion of best efforts in a bad system needs no amendment.
"Ian is the one who talks about the lack of objective standards of care and the diversity of contradictory opinions, and how proper it is. If that indeed is as true and as prevalent as he says, then there clearly is work to do."
There is work being done--education, and research. It however is not instant. There are things we can never study, things that take a long time to study. I am not happy that medicine is imperfect; I am happy that it does amazing things and is improving at an astonishing rate. Believe me, I would rather know the 1 best thing to do in every situation. However, people who *require* that kind of security in their lives are not suited to medicine, as we deal with uncertainty when life is at stake. There is a reason our patients pray and frequently like us to pray with them... our art is (surprise!) not yet perfect.
"I refuse to believe, that as a matter of course, it is proper for the medical industry to hide behind such wild lack of precision as a means to protect themelves when they've done wrong."
This is getting rather disingenuous. You make it sound as if I'm covering up some sue-able error or something! There are things that can and should be precise--medication schedules, dosing, etc. There are things that cannot be precise no matter how practiced the doctor--determining the cause of a patient's pneumonia is frequently impossible. I am not advocating imprecision to hide behind it for when I do wrong; **I am noting that we are neither omniscient nor omnipotent and it is sometimes difficult to discern when we have done wrong**. It's like a chef's task--if the creme brulee is not to the patron's liking, and there are many right ways for an expert to make it, did he err? Do we accuse him of incompetence? The chef can no more guess a person's tastes ahead of time than we can know whether dopamine or vasopressin works best in a particular sick person.
"Ian and Bill both wax poetic about the need for physician judgement in treating the difficult patient, yet Ian agrees with the premise of having good, solid SOPs. Which is, as they seems to me to be contradictory opinions?"
I have already discussed the frequent need to deviate from protocol and predicted that the debates would only shift to whether the deviation was justified or not. I explained how they would be helpful but not perfect. Please see the above posts.
"My opinions here are based on my experience, education, training, participation, both as a patient and a provider, in health care, including participating on physician's rounds."
I'm curious as to what the provider / rounding experience was. For disclosure's sake, I took undergraduate and graduate medical ethics courses in college, went directly to med school, and am now in my third year of internal medicine residency. The last 4 years have been spent in clinical duties.
I'm going to drop the quote-response method from here on out, as it generates unwieldy posts and deviates from topic (Bill posted on caps, here we are talking about autonomy and hospital practice) but of course am happy to answer questions and will respond to big points and welcome replies. Perhaps there is a second or third thread starter here?
Political opinion - medical malpractice
Moderator: Available
-
Gene DeMambro
- Posts: 1684
- Joined: Sat Dec 12, 1998 6:01 am
- Location: Weymouth, MA US of A
I only use BI as an example, 'cause it's a hospital we're both familiar with. I don't know the names of the other hospitals you have trained in. I could just use a general statement from now on.
Yes, for many it all pertains to the simplest possible admission a medicine resident can get. Operative word being "possible", with the word "proper" understood to be somewhere in there as well.
Ah Ian, the devil is in the details, especially with prose!
To paraphrase, you maintain that it is not necessary to discuss with the patient, his wife, their 3 kids, their 6 grandkids, the dog and the 4 goldfish EVERY risk and EVERY option of EVERY therapy you, as the treating physician, think is in the patients best interests.
And you are completely, 100%, absolutely, unfathomably correct. But are we in agreement that a physician owes his patient a duty to disclose in a reasonable manner all significant medical information that is material to make an intelligent decision by the patient whether to undergo a proposed procedure?
Now, apply this mandate to the ICU woman you faced as an intern. Could you reasonably justify what you did or didn't tell this woman and her family regarding end of life care, and what to do when she codes? If so, then you acted properly. Nothing wrong with that.
Must you divulge the 1 in a million chance Mr. Nafcillin might get hepatitis? Probably not. Probably not material. Must you divulge the chance he might get an infection from the IV line? Probably not. Probably not material. So no, there is no need to divulge all risks of a proposed therapy or information the physcian reasonably believes the patient already has.
Must we divulge the choices of nafcillin vs. oxacillin vs. levofloxacin vs. gatifloxacin vs. something else, the dose and frequency, the duration, the route of administration? Probably not. But at the very least tell the patient what the hell we're doing, if you think he can handle it.
But skin necrosis due to Warfarin or liver damage due to Lipitor might be a good conversation to have.
But the other extreme is of course untenable, that of NOT disclosing information, as well. And, without any qualifiers, this is the direction you appeared to be leading. At least that was the impression I got. So are we therefore in agreement then that a physician is not priviledged to remain silent simply because divulgence might prompt the patient to forgo therapy the physician feels the patient really needs?
Patients free to leave? You bet. Happened to Reggie Lewis. But don't make it sound as if we say to patients, "I'm the doctor, and it's my way or the highway". Which I'm sure you don't.
Can't write everything down? I say take a lesson from the good docs who document liberally when uncooperative patients make bad decisions and take it one step further, even for cooperative patients:
"I discussed with the patient the significant medical information that is material to his decision to undergo or decline Nafcillin treatment. He elected to begin therapy immediately".
Multiple drugs ordered?
"I discussed with the patient the significant medical information that is material to his decision to undergo or decline drug treatment as ordered. He elected to begin therapy immediately".
Even if you lie, and never said a word, this might protect you. But since you had a duty to have some type of conversation anyway (and in the case of Nafcillin, the conversation most likely would be very short indeed), where's the harm in writing down a few short sentences, especially where it might protect you in the long run?
Do you make a record of the conversation you had with a patient regarding the significant medical information that is material to his decision to undergo or decline Warfarin treatment treatment, where more dangerous side effects are more commom? This might be a good one write down.
And what do the poor doctors do with documenting a difficult patient?
Standards of care do not call for giving Demerol just because a drug addict wants it, nor performing open heart surgery on demand. You give the significant medical information that is material to make an intelligent decision and than let the decision making process take its course. Patients may not dictate their care, but the buck stops with them. As long as the buck gets there in the first place...
And many of the things I ask, which may not be realistic or advisable, are legal mandates.
BI nurses are great, aren't they? The hospital, before all the financial problems went down, was even voted the #1 place to work for in America for nurses. The fact that many women from the far flung suburbs choose to have their babies there means the place is something else.
Here's an example of medical protocols, informed consent with drug therapy and documentation, all in one:
McLean Hospital has high dose limits on almost all of the drugs on its formulary. This list is reviewed annually. No physician may prescribe a drug above this high dose maximum without recording the following, more or less:
"Both the patient and the physician are aware the prescribed dose of Thorazine exceeds the hospital maximum. Both the patient and the physician are aware of the potential risks and the potential benefits of this, and elect to begin therapy as ordered". It is then signed by the doctor.
No note, no drug. Period.
If there is a potential drug-drug interaction, the note might look like the following:
"Both the patient and the physician are aware of the risks of continuing Zoloft therapy with Nardil. Both elect to continue therapy as ordered". It is then signed by the doctor.
No note, no drug. Period.
Is there a rigid protocol? Yes. Is there a reasonable way to violate protocol when medical necessity dictates? Yes. While there is an increased risk to the patient, are patient rights protected by informing him of the risks? Yes. Time it takes to write the note to record a conversation MD should have with patient anyway? Minimal.
Patients under guardianships and Rogers commitments are a separate case.
Justify the deviation (and the greater the deviation, the greater the justification in my view) and doctors can get whatever they want. But document document document. It will end up being a life-saver.
It may sound disingenuous, but it sounded like the wild imprecision in modern health care is used as a cover for certain types of care that is clearly incompetent. That was the impression I got.
Things that cannot be precise no matter how practiced the doctor? As I said before, give your best shot based on all those things medicos use to base their best shots on, fully document (there's that word again...) your rationale and the patient conversation if treatment is involved (in which you discussed those material things), let Mrs. Jones make up her mind, and go from there. We're in agreement on this, yes? This, in my mind, allows for the great variability of care and physician judgements that many feel are necessary.
My experience includes a successful undergraduate education in pharmacy, including undergraduate ethics courses, graduate level training in Nuclear Pharmacy, graduate level training in Epidemiology and Health Care Law, and a clinical educational rotation at Beth Israel Hospital, which included participation on physician rounds longer than the recommended week. Used to walk down Mission Hill every day for 8AM rounds!
Yes, for many it all pertains to the simplest possible admission a medicine resident can get. Operative word being "possible", with the word "proper" understood to be somewhere in there as well.
Ah Ian, the devil is in the details, especially with prose!
To paraphrase, you maintain that it is not necessary to discuss with the patient, his wife, their 3 kids, their 6 grandkids, the dog and the 4 goldfish EVERY risk and EVERY option of EVERY therapy you, as the treating physician, think is in the patients best interests.
And you are completely, 100%, absolutely, unfathomably correct. But are we in agreement that a physician owes his patient a duty to disclose in a reasonable manner all significant medical information that is material to make an intelligent decision by the patient whether to undergo a proposed procedure?
Now, apply this mandate to the ICU woman you faced as an intern. Could you reasonably justify what you did or didn't tell this woman and her family regarding end of life care, and what to do when she codes? If so, then you acted properly. Nothing wrong with that.
Must you divulge the 1 in a million chance Mr. Nafcillin might get hepatitis? Probably not. Probably not material. Must you divulge the chance he might get an infection from the IV line? Probably not. Probably not material. So no, there is no need to divulge all risks of a proposed therapy or information the physcian reasonably believes the patient already has.
Must we divulge the choices of nafcillin vs. oxacillin vs. levofloxacin vs. gatifloxacin vs. something else, the dose and frequency, the duration, the route of administration? Probably not. But at the very least tell the patient what the hell we're doing, if you think he can handle it.
But skin necrosis due to Warfarin or liver damage due to Lipitor might be a good conversation to have.
But the other extreme is of course untenable, that of NOT disclosing information, as well. And, without any qualifiers, this is the direction you appeared to be leading. At least that was the impression I got. So are we therefore in agreement then that a physician is not priviledged to remain silent simply because divulgence might prompt the patient to forgo therapy the physician feels the patient really needs?
Patients free to leave? You bet. Happened to Reggie Lewis. But don't make it sound as if we say to patients, "I'm the doctor, and it's my way or the highway". Which I'm sure you don't.
Can't write everything down? I say take a lesson from the good docs who document liberally when uncooperative patients make bad decisions and take it one step further, even for cooperative patients:
"I discussed with the patient the significant medical information that is material to his decision to undergo or decline Nafcillin treatment. He elected to begin therapy immediately".
Multiple drugs ordered?
"I discussed with the patient the significant medical information that is material to his decision to undergo or decline drug treatment as ordered. He elected to begin therapy immediately".
Even if you lie, and never said a word, this might protect you. But since you had a duty to have some type of conversation anyway (and in the case of Nafcillin, the conversation most likely would be very short indeed), where's the harm in writing down a few short sentences, especially where it might protect you in the long run?
Do you make a record of the conversation you had with a patient regarding the significant medical information that is material to his decision to undergo or decline Warfarin treatment treatment, where more dangerous side effects are more commom? This might be a good one write down.
And what do the poor doctors do with documenting a difficult patient?
Standards of care do not call for giving Demerol just because a drug addict wants it, nor performing open heart surgery on demand. You give the significant medical information that is material to make an intelligent decision and than let the decision making process take its course. Patients may not dictate their care, but the buck stops with them. As long as the buck gets there in the first place...
And many of the things I ask, which may not be realistic or advisable, are legal mandates.
BI nurses are great, aren't they? The hospital, before all the financial problems went down, was even voted the #1 place to work for in America for nurses. The fact that many women from the far flung suburbs choose to have their babies there means the place is something else.
Here's an example of medical protocols, informed consent with drug therapy and documentation, all in one:
McLean Hospital has high dose limits on almost all of the drugs on its formulary. This list is reviewed annually. No physician may prescribe a drug above this high dose maximum without recording the following, more or less:
"Both the patient and the physician are aware the prescribed dose of Thorazine exceeds the hospital maximum. Both the patient and the physician are aware of the potential risks and the potential benefits of this, and elect to begin therapy as ordered". It is then signed by the doctor.
No note, no drug. Period.
If there is a potential drug-drug interaction, the note might look like the following:
"Both the patient and the physician are aware of the risks of continuing Zoloft therapy with Nardil. Both elect to continue therapy as ordered". It is then signed by the doctor.
No note, no drug. Period.
Is there a rigid protocol? Yes. Is there a reasonable way to violate protocol when medical necessity dictates? Yes. While there is an increased risk to the patient, are patient rights protected by informing him of the risks? Yes. Time it takes to write the note to record a conversation MD should have with patient anyway? Minimal.
Patients under guardianships and Rogers commitments are a separate case.
Justify the deviation (and the greater the deviation, the greater the justification in my view) and doctors can get whatever they want. But document document document. It will end up being a life-saver.
It may sound disingenuous, but it sounded like the wild imprecision in modern health care is used as a cover for certain types of care that is clearly incompetent. That was the impression I got.
Things that cannot be precise no matter how practiced the doctor? As I said before, give your best shot based on all those things medicos use to base their best shots on, fully document (there's that word again...) your rationale and the patient conversation if treatment is involved (in which you discussed those material things), let Mrs. Jones make up her mind, and go from there. We're in agreement on this, yes? This, in my mind, allows for the great variability of care and physician judgements that many feel are necessary.
My experience includes a successful undergraduate education in pharmacy, including undergraduate ethics courses, graduate level training in Nuclear Pharmacy, graduate level training in Epidemiology and Health Care Law, and a clinical educational rotation at Beth Israel Hospital, which included participation on physician rounds longer than the recommended week. Used to walk down Mission Hill every day for 8AM rounds!
Warning: mostly about consent and disclosure issues not malpractice caps:
"Are we in agreement that a physician owes his patient a duty to disclose in a reasonable manner all significant medical information that is material to make an intelligent decision by the patient whether to undergo a proposed procedure?"
Documentation of consent for procedures has been the norm at every practice site I've ever worked at or heard of, and of course I support it; however the fact is the number of potentially risky things we do exceeds our ability and time to hold consent conversations.
Your mention of warfarin skin necrosis is notable. (This is a blood thinner which has a slightly procoagulant action early in use, and rarely, causes clotting of an area of skin, like the necrosis of a large chunk of breast of thigh. This can be an awful complication and amputations and fatalities have been reported. Yet, there are about 300 reported cases in the literature. Meanwhile 3% of our population over 60 has atrial fibrillation, for which warfarin is indicated to prevent stroke; it is also widely used for those blood clots discussed on Bill's site earlier, which are also common. In other words this is a very widely used drug, yet I have never met a person who's had this reaction, or known a doctor that has had a patient with it, and I've read articles disputing its existance)
I understand that having a patient's breast die off would be classic fodder for a malpractice suit ("You may to say you didn't even TELL this woman her whole breast might DIE if you used this drug???"). So let's say in practice I start to tell everyone who might need warfarin about this risk. I can assure you that it will scare people away from taking the drug, people who will then face a much higher risk of injury and death from NOT taking it, as they will have strokes and disabling or fatal pulmonary emboli.
PERHAPS I wouldn't be responsible legally for these bad outcomes ("You mean you dwelled on this very rare occurence and failed to sufficiently emphasize her OVERALL risk would be higher off the drug?) if I write it all down, and I understand quite clearly people's right to make informed decisions for themselves. I don't view that as something that's "in the way" of me doing what I want; rather I view what the patient wants as the goal and I try to help them within their framework. I've never lost any sleep about not giving blood to a Jehovah's witness, for example. I value my autonomy and I value everyone else's.
However, we again see a clash of values here as I believe beneficience (in not discussing a rare side effect which could but shouldn't sway a patient's decision) outweighs autonomy here. And by that I do not mean forcing therapies on people, I actually mean it isn't that autonomous to refuse warfarin for fear of skin necrosis. Only a fraction of those refusers would really understand the relative weight of costs and benefits; they would not be making a true informed choice because their backround knowledge often isn't informed enough to guide the choice.
For patients in general, mentioning skin necrosis will cause more harm than good in my opinion, and so if I change my practice and start discussing it for legal reasons, I will be harming the patients because of the litigious climate in this country, which is precisely the kind of damage I've been referring to in this thread.
I should also note that writing down that we talked about risks and benefits doesn't really CYA that much. With warfarin, the primary risk to discuss is bleeding, which IS common, and CAN be very serious. That's something I absolutely would discuss with everyone on it, as well as it's teratogenicity--when dealing with a fertile woman. "Bleeding risk, need for frequent folloup tests and teratogenicity understod by patient.." The rule is if you didn't write it down it didn't happen, so I would have to write down each and every other detail we talked about. Otherwise I might have done nothing more than said I thought the benefits outweighed the risks--that wouldn't be sufficient.
NB: just 3 weeks ago I had someone who refused warfarin for a deadly condition because he didn't like the idea of... frequent blood draws. No big deal--we documented and did what he allowed.
-------------
You're right, we don't tell anyone "my way or the highway." We tell them they should stay, we tell them we want them to stay, and what the risks of leaving are, then we have them sign the release, document the discussion, and sign them out with as much followup as they allow.
-------------
"Where's the harm in writing down a few short sentences, especially where it might protect you in the long run?"
1) No time to do this. Too many interventions to discuss / document.
2) **documenting the little things takes away from doing the big things**
3) makes me work in an environment that is more CYA than directed toward helping people. I'd rather get another job.
4) not needed. I don't need to discuss our imperfection in diagnosing pneumonia. We know how to respond best with a drug regimen that covers the likely pathogens, and going into the various types of bacteria that could be at work will do nothing more than scare hell into patients who already have enough stress. Again, again, we should and I do, always answer questions when they arise. However instilling fear in a patient merely so I can CYA in a note is not a practice I can support.
----------
For those who are interested, BI had identified several major areas it could improve patient care:
1) 24-7 staffing by critical care specialists (not just residents) in the ICU
2) all procedures to be supervised where possible
3) computer order entry.
All have been enacted. Our computer order entry system automatically checks every medication ordered for side effects and cross reactions and where indicated has the MD specify in the electronic order why a warning is overridden. I have never seen or heard of a better or safer one.
-----------
"it sounded like the wild imprecision in modern health care is used as a cover for certain types of care that is clearly incompetent."
"Wild imprecision" is not fair. No matter how much we learn, until we gain immortality with perfect health there will always be a limit to our skills and there will be disagreements over what to do at those limits. It's a fundamental part of medicine... people who cannot deal with uncertainty, failure, and most pointedly, their own errors, should rethink medical careers.
"Are we in agreement that a physician owes his patient a duty to disclose in a reasonable manner all significant medical information that is material to make an intelligent decision by the patient whether to undergo a proposed procedure?"
Documentation of consent for procedures has been the norm at every practice site I've ever worked at or heard of, and of course I support it; however the fact is the number of potentially risky things we do exceeds our ability and time to hold consent conversations.
Your mention of warfarin skin necrosis is notable. (This is a blood thinner which has a slightly procoagulant action early in use, and rarely, causes clotting of an area of skin, like the necrosis of a large chunk of breast of thigh. This can be an awful complication and amputations and fatalities have been reported. Yet, there are about 300 reported cases in the literature. Meanwhile 3% of our population over 60 has atrial fibrillation, for which warfarin is indicated to prevent stroke; it is also widely used for those blood clots discussed on Bill's site earlier, which are also common. In other words this is a very widely used drug, yet I have never met a person who's had this reaction, or known a doctor that has had a patient with it, and I've read articles disputing its existance)
I understand that having a patient's breast die off would be classic fodder for a malpractice suit ("You may to say you didn't even TELL this woman her whole breast might DIE if you used this drug???"). So let's say in practice I start to tell everyone who might need warfarin about this risk. I can assure you that it will scare people away from taking the drug, people who will then face a much higher risk of injury and death from NOT taking it, as they will have strokes and disabling or fatal pulmonary emboli.
PERHAPS I wouldn't be responsible legally for these bad outcomes ("You mean you dwelled on this very rare occurence and failed to sufficiently emphasize her OVERALL risk would be higher off the drug?) if I write it all down, and I understand quite clearly people's right to make informed decisions for themselves. I don't view that as something that's "in the way" of me doing what I want; rather I view what the patient wants as the goal and I try to help them within their framework. I've never lost any sleep about not giving blood to a Jehovah's witness, for example. I value my autonomy and I value everyone else's.
However, we again see a clash of values here as I believe beneficience (in not discussing a rare side effect which could but shouldn't sway a patient's decision) outweighs autonomy here. And by that I do not mean forcing therapies on people, I actually mean it isn't that autonomous to refuse warfarin for fear of skin necrosis. Only a fraction of those refusers would really understand the relative weight of costs and benefits; they would not be making a true informed choice because their backround knowledge often isn't informed enough to guide the choice.
For patients in general, mentioning skin necrosis will cause more harm than good in my opinion, and so if I change my practice and start discussing it for legal reasons, I will be harming the patients because of the litigious climate in this country, which is precisely the kind of damage I've been referring to in this thread.
I should also note that writing down that we talked about risks and benefits doesn't really CYA that much. With warfarin, the primary risk to discuss is bleeding, which IS common, and CAN be very serious. That's something I absolutely would discuss with everyone on it, as well as it's teratogenicity--when dealing with a fertile woman. "Bleeding risk, need for frequent folloup tests and teratogenicity understod by patient.." The rule is if you didn't write it down it didn't happen, so I would have to write down each and every other detail we talked about. Otherwise I might have done nothing more than said I thought the benefits outweighed the risks--that wouldn't be sufficient.
NB: just 3 weeks ago I had someone who refused warfarin for a deadly condition because he didn't like the idea of... frequent blood draws. No big deal--we documented and did what he allowed.
-------------
You're right, we don't tell anyone "my way or the highway." We tell them they should stay, we tell them we want them to stay, and what the risks of leaving are, then we have them sign the release, document the discussion, and sign them out with as much followup as they allow.
-------------
"Where's the harm in writing down a few short sentences, especially where it might protect you in the long run?"
1) No time to do this. Too many interventions to discuss / document.
2) **documenting the little things takes away from doing the big things**
3) makes me work in an environment that is more CYA than directed toward helping people. I'd rather get another job.
4) not needed. I don't need to discuss our imperfection in diagnosing pneumonia. We know how to respond best with a drug regimen that covers the likely pathogens, and going into the various types of bacteria that could be at work will do nothing more than scare hell into patients who already have enough stress. Again, again, we should and I do, always answer questions when they arise. However instilling fear in a patient merely so I can CYA in a note is not a practice I can support.
----------
For those who are interested, BI had identified several major areas it could improve patient care:
1) 24-7 staffing by critical care specialists (not just residents) in the ICU
2) all procedures to be supervised where possible
3) computer order entry.
All have been enacted. Our computer order entry system automatically checks every medication ordered for side effects and cross reactions and where indicated has the MD specify in the electronic order why a warning is overridden. I have never seen or heard of a better or safer one.
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"it sounded like the wild imprecision in modern health care is used as a cover for certain types of care that is clearly incompetent."
"Wild imprecision" is not fair. No matter how much we learn, until we gain immortality with perfect health there will always be a limit to our skills and there will be disagreements over what to do at those limits. It's a fundamental part of medicine... people who cannot deal with uncertainty, failure, and most pointedly, their own errors, should rethink medical careers.
--Ian
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Gene DeMambro
- Posts: 1684
- Joined: Sat Dec 12, 1998 6:01 am
- Location: Weymouth, MA US of A
I'm not trying to put you on the spot, but do you mean to say that at times no consent converstion is held with a competant patient in a medical case where one usually is called for, solely because there is no time? Incapacitated patients excepted of course. That's a whole other area entirely.the fact is the number of potentially risky things we do exceeds our ability and time to hold consent conversations.
Ok, so maybe you don't mention skin necrosis with warfarin, and focus the conversation solely on biggies like the risk of bleeding, and the necessity of maintaining the appropriate diet. It's your call as to what's material to the patients ability to make an intelligent decision. But to not disclose material information, solely because Dr. wants the patient to make the "right" choice is not good at all. There's no need to discuss every risk or instill fear. There's just a necessity to discuss those things that are material. And for good portion of therapies, the conversation might be very short or even non-existant indeed. A patient's background may not be up to snuff to comprehend the info you think is material? This just means the bar is set that much higher. But to not mention something that is material because the Dr. thinks the patient is an idiot (which you don't mean at all), then the doctor deserves to be sued. Intelligent decisions by patients trump beneficience, that's my view. And we both chose our professions because of beneficience.
As to recording every detail in every conversation? Again, that's a decision of the part of the medical records honchos as to what's needed. More is better in practically every case I can think of, though. But, at a minimum, do what is required.
Only 10% of hospitals in the country use computerized physician order entry. As to why there aren't more, I have no idea - probably cost. Some even use a system where the order is then printed out in the pharmacy, and re-entered into the pharmacy computer again! Foolish. But CPOE is great when is works.
Since we're talking about Med-Mal: If I were a plaintiff Med-Mal lawayer, I'd not take this case. You did everything you were supposed to do. If I were a defense lawyer, assigned by your insurance company to defend you, the note you made would be Exhibit A as to why this case ought to be kicked.just 3 weeks ago I had someone who refused warfarin for a deadly condition because he didn't like the idea of... frequent blood draws. No big deal--we documented and did what he allowed.
So if you had a really bad angina attack patient, and you wanted to keep him overnight to work him up for a heart attack, and his admission medication orders were about 10 meds strong, a note like "I discussed with the patient the material information relating to the risks and benefits of the ordered medication regimen. The patient elected to begin therapy" isn't sufficient? Just wondering.I should also note that writing down that we talked about risks and benefits doesn't really CYA that much....The rule is if you didn't write it down it didn't happen,
Since we are talking about Med-Mal, are there things you think physicians can do to make themselves as liability-proof as they can, but aren't doing now?
CYA means (to me) doing those things that I'm supposed to do (no less), and being able to prove it if something goes down.
Lest anyone get the wrong idea, the reason I'm going on and on about patient's rights and such is because these are the biggest cases that have gone to high appellate courts, and doctors/hospitals have pretty much always lost (including a case where a Jehovah's Witness refused a blood transfusion). So obviously, this may be an area that might need improvement. Improving this area, might improve the precarious situation we find ourselves in regarding the insurance mess today.
Gene
"Do you mean to say that at times no consent converstion is held with a competant patient in a medical case where one usually is called for, solely because there is no time?"
Nope, I'm just saying even if I thought it was necessary to document as thoroughly as you ask, it would not be possible.
"But to not disclose material information, solely because Dr. wants the patient to make the "right" choice is not good at all."
This is all subjective because it's usually the experts disseminating the info (the doctors) who decide what's "material." I would never, say, conceal from a Witness that some drug actually had a blood product in it. That would be horrific. I limit what I disclose to a patient to what is relevant and I feel they would want to know / benefit from / be able to understand; this means, other than saying other side effects are rare or negligible, I won't bring usually up skin necrosis.
"But to not mention something that is material because the Dr. thinks the patient is an idiot (which you don't mean at all), then the doctor deserves to be sued."
I hope this isn't what you mean, and I'm not defending the badly characterized doctor here (if the patient is that confused they may lack capacity and you might be better off talking to a proxy and giving them the details), but look at what this says: not mentioning material info about a drug, which can be even when its the best one indicated, and works marvelously, is grounds for suing. My understanding is there must be BOTH negligence AND harm to have grounds. Or can we sue people who just have bad interpersonal skills?
"If I were a plaintiff Med-Mal lawayer, I'd not take this case."
My gawd, I hope not! It had never occurred to me that there would be one until now! He didn't want it, we didn't give it, everything was written out--I was just illustrating my / our perfect willingness to accomodate patient goals / limits / wishes lest you think I believed in anything less.
"So if you had a really bad angina attack patient, and you wanted to keep him overnight to work him up for a heart attack... a note like "I discussed with the patient the material information relating to the risks and benefits of the ordered medication regimen. The patient elected to begin therapy" isn't sufficient?"
There's always room for someone to wonder WHAT risks... bleeding? Did you specify that could include stroke? Or needing blood? Or did you mention the risk of x, y, z, etc? The note would be helpful if incomplete. But drop by any ER... if someone comes in with bad angina the first order of business is to get them better!!!!! We are running around getting EKGs, giving aspirin, giving beta blockers every five minutes till the heart rate is at goal, titrating nitroglycerin drips, starting heparin, calling the cath lab if needed, and many other things. If we stopped in the middle of this to ask permission to start each drug, THAT would be malpractice as far as I'm concerned. We tell them what's going on... only TWICE in 3-4 years of dropping by the ER have I had someone whose presentation justified suspending their care to talk about med risks. We DO get consent for nonemergent procedures... This would be more frequent if I was a cath fellow, or on the stroke response team ever ready with the clot busters... but trust me, we're following that good ole standard of care by NOT getting bogged down in documentation and discussion when people are acutely ill.
"Since we are talking about Med-Mal, are there things you think physicians can do to make themselves as liability-proof as they can, but aren't doing now?"
Absolutely. It's been shown over and over that doctors who don't communicate, demonstrate care, answer questions, apologize when there are bad outcomes, and generally are aren't likable to their patients get sued more--and being a doctor who screws up is NOT as risky. Patients love doctors who love them, and so they don't sue. There have been only a few very antagonistic patients over the years (say, throwing a chair at my 4'11" intern for no reason; being inappropriate / hostile for no reason). Communicating the medical news AND your personal dedication is crucial to keep yourself lawsuit free--more importantly, it makes my job much more enjoyable to be the guy who managed to get his rabbi patient a kosher birthday cake in hospital on Sabbath, and got a formal blessing and weeks later, a call late at night at work over Christmas holiday--he found out when I was on call and thought he'd let me know he didn't feel better after his stent was placed, but he was still glad he came in!
Gene, re: patient's rights, search this page for my 22 page ethics project on women's rights to determine their own medical care, pregnant or not. That was prompted by a case in which the OB's I was working with tried to get a court to order compulsory surgery on a patient. I've always been the guy at ethics conference livid that anyone would even RAISE the idea of, say, forcing blood on a witness regardless of the circumstances.
Nope, I'm just saying even if I thought it was necessary to document as thoroughly as you ask, it would not be possible.
"But to not disclose material information, solely because Dr. wants the patient to make the "right" choice is not good at all."
This is all subjective because it's usually the experts disseminating the info (the doctors) who decide what's "material." I would never, say, conceal from a Witness that some drug actually had a blood product in it. That would be horrific. I limit what I disclose to a patient to what is relevant and I feel they would want to know / benefit from / be able to understand; this means, other than saying other side effects are rare or negligible, I won't bring usually up skin necrosis.
"But to not mention something that is material because the Dr. thinks the patient is an idiot (which you don't mean at all), then the doctor deserves to be sued."
I hope this isn't what you mean, and I'm not defending the badly characterized doctor here (if the patient is that confused they may lack capacity and you might be better off talking to a proxy and giving them the details), but look at what this says: not mentioning material info about a drug, which can be even when its the best one indicated, and works marvelously, is grounds for suing. My understanding is there must be BOTH negligence AND harm to have grounds. Or can we sue people who just have bad interpersonal skills?
"If I were a plaintiff Med-Mal lawayer, I'd not take this case."
My gawd, I hope not! It had never occurred to me that there would be one until now! He didn't want it, we didn't give it, everything was written out--I was just illustrating my / our perfect willingness to accomodate patient goals / limits / wishes lest you think I believed in anything less.
"So if you had a really bad angina attack patient, and you wanted to keep him overnight to work him up for a heart attack... a note like "I discussed with the patient the material information relating to the risks and benefits of the ordered medication regimen. The patient elected to begin therapy" isn't sufficient?"
There's always room for someone to wonder WHAT risks... bleeding? Did you specify that could include stroke? Or needing blood? Or did you mention the risk of x, y, z, etc? The note would be helpful if incomplete. But drop by any ER... if someone comes in with bad angina the first order of business is to get them better!!!!! We are running around getting EKGs, giving aspirin, giving beta blockers every five minutes till the heart rate is at goal, titrating nitroglycerin drips, starting heparin, calling the cath lab if needed, and many other things. If we stopped in the middle of this to ask permission to start each drug, THAT would be malpractice as far as I'm concerned. We tell them what's going on... only TWICE in 3-4 years of dropping by the ER have I had someone whose presentation justified suspending their care to talk about med risks. We DO get consent for nonemergent procedures... This would be more frequent if I was a cath fellow, or on the stroke response team ever ready with the clot busters... but trust me, we're following that good ole standard of care by NOT getting bogged down in documentation and discussion when people are acutely ill.
"Since we are talking about Med-Mal, are there things you think physicians can do to make themselves as liability-proof as they can, but aren't doing now?"
Absolutely. It's been shown over and over that doctors who don't communicate, demonstrate care, answer questions, apologize when there are bad outcomes, and generally are aren't likable to their patients get sued more--and being a doctor who screws up is NOT as risky. Patients love doctors who love them, and so they don't sue. There have been only a few very antagonistic patients over the years (say, throwing a chair at my 4'11" intern for no reason; being inappropriate / hostile for no reason). Communicating the medical news AND your personal dedication is crucial to keep yourself lawsuit free--more importantly, it makes my job much more enjoyable to be the guy who managed to get his rabbi patient a kosher birthday cake in hospital on Sabbath, and got a formal blessing and weeks later, a call late at night at work over Christmas holiday--he found out when I was on call and thought he'd let me know he didn't feel better after his stent was placed, but he was still glad he came in!
Gene, re: patient's rights, search this page for my 22 page ethics project on women's rights to determine their own medical care, pregnant or not. That was prompted by a case in which the OB's I was working with tried to get a court to order compulsory surgery on a patient. I've always been the guy at ethics conference livid that anyone would even RAISE the idea of, say, forcing blood on a witness regardless of the circumstances.
--Ian
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Gene DeMambro
- Posts: 1684
- Joined: Sat Dec 12, 1998 6:01 am
- Location: Weymouth, MA US of A
I ask that we adequately document that which is necessary. This is partially determined by our legal duties. The Brigham just lost on appeal a heartbreaking case regarding improper medical records; but due to charitable immunity cap, damages were capped at $20,000.Nope, I'm just saying even if I thought it was necessary to document as thoroughly as you ask, it would not be possible.
And yes, it's the expert's decision to decide what is material information. We include or exclude whatever we wish. But when required, we give enough material information for a patient to make an intelligent decision. If you do this, you're probably liability proof.
There are people who think that doctors get sued and loose all the time, for willy-nilly stuff. I am trying to dispel that myth, by pointing out that when we do what we are supposed to do, like you did then, we are protected. And I now firmly believe, as I did before, that you don't believe in anything less!I was just illustrating my / our perfect willingness to accomodate patient goals / limits / wishes lest you think I believed in anything less.
If something goes down (like a lawsuit), would someone be able to gleen this from the medical record the next day, the next week, the next month or the next year? If so, then you're probably liability proof in this regard.We tell them what's going on
Three years ago, Mass. General won an appeal over a case where IC was questioned. The documentation was there, and the order of dismissal was affirmed.
Informed consent in the ER is a whole other issue, and has been used as the basis for successful suits. This can be a whole topic onto itself. Take a look at Shine v. Vega and see where Massachusetts stands on IC in the ER. After reading it, ask yourself this question: Does what we do in the ER comply with these mandates? If you can answer yes, then you're liability proof - from a patient autonomy standpoint.
I was advised a few years into my career that those people who talk to their patients don't get sued as much as those who don't. A person could have the interpersonal skills of the robot in the first Terminator movie. But as long as they meet their legal duty, they're covered.
This has all been a very long, roundabout way to point out that when we act, at the very least, the way we are required, we can't be touched.
Now we gotta work on getting Ian his much needed lunchbreak!
Gene
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Gene DeMambro
- Posts: 1684
- Joined: Sat Dec 12, 1998 6:01 am
- Location: Weymouth, MA US of A
Harm is an element used to prove negligence. The four elements that must be proved in order to win a malpractice suit are a duty existed, a breech of duty occurred, the breech of duty caused damages, and the damages (or harm) themselves.not mentioning material info about a drug, which can be even when its the best one indicated, and works marvelously, is grounds for suing. My understanding is there must be BOTH negligence AND harm to have grounds
Does not disclosing material information necessary for an informed opinion result, in and of itself, malpractice or negligence? Let's work it out...
- Duty - As for IC and drug therapy specifically, it is well established that a physician has a duty to inform themselves about the drug and warn their patients as they deem necessary. Physicians, after considering the history and needs of their patients and the qualities of the drug, are required to inform their patients of those side effects they determine are necessary and relevant for patients to know in making an informed decision. This is the standard of care.
- Breech of duty - Not informing the patient of the skinny regarding side effects of the prescribed drug which are necessary and relevant to an informed decision is clearly a breech of this duty.
- Causation - Is whatever harm the patient suffers caused by the physician's non-diclosure?
- Damages - We can go several different ways here. If a disclosable side effect occurs (like priapism with trazodone), the plaintiff may be able to successfully argue that if he was told about the side effect, he would have elected to decline the drug. In other cases, patients have successfully argued that even though they still would’ve taken the drug if informed, the fact that he was not warned of the dangers (such as untreated priapism), and therefore delayed treatment of a potentially disabling, damaging or deadly side effect resulted in damages/harm. If a non-disclosable side effect occurs (such as hepatitis with nafcillin), then the case might fail regarding the duty to warn, because there was no duty to warn of this side effect, as it is not necessary and relevant for an informed decision.
However, patients have been successful in proving damages under battery and emotional distress doctrines when given drug therapy without the required informed consent, even if no side effect occurs. In these cases, the physician has violated the patient's fundamental right to be free from invasion of bodily integrity. In other words, non-disclosure of that which is necessary and relevant, may be evidence, in and of itself, of harm. The law, however, is not clear if most drug therapies fits this bill. Some do, though.
Gene
