Talking to Patients About the Unexpected

Patients today are better informed consumers than ever before. They expect to be fully informed of their condition and the results of treatment. This expectation goes beyond just receiving information about good outcomes or even medical errors. It begins with a comprehensive informed consent process, includes an understanding of any expected — or unexpected — occurrences, and ends with information on the final result. It is more than a regulatory or accreditation requirement to notify patients about unexpected outcomes; it is an ethical obligation.

The purpose of this article is to raise awareness of the issues that can arise when talking to patients after the unexpected has occurred. This article also aims to provide tips on how to prepare for a disclosure conversation and how to avoid common pitfalls, particularly when there has been a patient injury. Practically speaking, ambulatory surgery centers (ASCs) may rarely be in situations where disclosing unanticipated outcomes is necessary.

This rarity underscores the importance of developing a stepby- step process for staff and providers to follow when the unexpected does happen. Well-designed disclosure policies emphasize effective communication and proper documentation as pivotal components of the disclosure process. Effectively communicating and educating both the ASC staff and providers about the policy (and how to execute it) are integral to its success.

Developing Disclosure Policies

The following points should be addressed when developing disclosure policies and contemplated when discussing unanticipated outcomes with patients.

• Decide who should be involved in the conversation. A healthcare provider who has an established relationship with the patient should be present along with anyone else that was involved with the event. Not all healthcare providers are good at this. Some may need significant support and coaching. Be careful not to include so many people that the patient is overwhelmed.
• Select an appropriate setting. It should be quiet, provide the necessary privacy, and be free from interruptions. All participants should sit down and turn off all cell phones, pagers, etc.
• Decide when to speak to the patient. Depending on the severity of the event and the patient’s condition, engage in the initial discussion before the patient is discharged.
• Review the facts before beginning the discussion. Determine what is known and what is not known about the event and its cause.
• Present the facts as they are known at the time. Do not speculate about causes or results.
• Express empathy. In the event of a medical error or patient injury, offer a sincere acknowledgment of the patient’s condition. It may be appropriate to say you are sorry that this has happened. However, immediately following events, apologies should not include admissions of negligence or fault. Rather, they should be a communication of compassion. Such admissions may come later, after thorough investigations, determinations of root causes, and with guidance from competent counsel and the center’s insurer.
• Establish a follow-up plan and stick to it. Explain when additional information will be available and when the patient can expect more information. Be sure to contact the patient at the established time, even if the expected information is not available. If this occurs, inform the patient and establish another time line.
• Describe next steps. Inform the patient of any necessary further treatment. Offer support and resources as the situation warrants. (For example spiritual support, transportation, a place to stay, etc.) Later, after the cause of an event is known, explain what the ASC is doing to prevent a reoccurrence.
• Document the conversation. This should be a factual accounting of the participants and conversation. It should not include opinions.
• Take care of the discloser and caregiver. A significant patient injury resulting from an error can be a life-altering event for the caregiver as well as the patient. Offer support and resources to them as well.

The question of the effect of disclosure on litigation frequently arises. While admittedly few studies have been conducted, there has not been a flurry of lawsuits after disclosure discussions, as some predicted. Both distrust and frustration are often identified as reasons patients sue healthcare providers. Effective disclosure provides patients and their families with an opportunity to obtain information to deal with their pain and to work through issues of distrust and frustration inside, rather than outside of the healthcare system.

ASCs should contemplate how and when to disclose unanticipated outcomes in advance of having to do so. There are numerous resources available to assist in developing policies. Among them are monographs available on the American Society for Healthcare Risk Management Website, www.ashrm.org. ASCs should also seek support and guidance from their insurer and/or counsel in developing disclosure policies. Remember that while talking to patients about the unexpected is the right thing to do, if you are unsure about how to proceed following a patient injury, it is prudent to seek advice before speaking to the patient.

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