Scenario: How and when should a doctor inform a patient of a treatment error?

A physician mistakenly orders a higher dose of chemotherapy drug than indicated. The overdose causes temporary acute renal failure in the patient. After the patient recovers from the renal complications, he is reluctant to continue chemotherapy and asks the oncologist why he became so sick. How does the oncologist respond?

Reply:

Our oncologist sits in a very uncomfortable seat that many, if not most, physicians are all too familiar with. To tell or not to tell? If to tell, how much, where, to whom? Did a mistake really happen?

How many people and decisions were involved in the mistake spilling through the system and potentially harming the patient? Did the incorrect dose really harm the patient? Will I help or harm the patient by informing him of the mistake? Will I help or harm myself, the nurse or pharmacist involved, or the system I work in by disclosing what I know?

Is the patient more likely to sue the hospital or me if I tell him what I think happened, or if I tell him he just had the usual complications? Will the patient be more or less likely to continue his needed chemotherapy if I disclose what I know? If he chooses to sue or go somewhere else for care, will that impact his potential for cure or improvement through unnecessary delay in therapy? Uncertainty around mistakes is common. Fear of disclosure is universal.

Let's assume our oncologist has decided to accept responsibility that the mistake was his alone. Our oncologist then must face the frightening questions: What will the patient think of me? What will the nurses think of me? What will my supervisors think of me? What do I think of me?

These are the unavoidable questions for a physician facing his or her own flaws in an environment that implies physicians must be perfect at all times and in all ways.

Putting the needs of the patient before one's own needs is a deeply held ethic of the patient-doctor relationship. Living out this ethic is the great challenge of disclosure.

Let us for a moment assume that the oncologist wrote the incorrect dose. Let us also assume that renal failure is a rare complication when the correct dose is given. In truth, temporary acute renal failure is a common complication of many chemotherapies given at the correct dose.

Even with the clarity provided in this scenario, one could argue honestly that the patient might have had renal failure regardless of the error. What if the patient went on to have an unusually good outcome? The oncologist may have given him a short-term, temporary harm as a trade-off for an unexpected, long-term benefit. At the moment of disclosure, however, these outcomes cannot be fully understood or appreciated. Withholding the potential harm, in my view, is not justified by the hope that perhaps some long-term good may come of it.

Ethical dilemmas are draped throughout the journey toward disclosure. When approaching the patient, our oncologist must face the "how to" aspect of disclosure. I see this moment as the "honesty vs. skillfull obscuration" dilemma of disclosure.

Honesty, though supported in the literature as "the best policy" against malpractice suits intent on "finding the cover-up" of errors, requires the physician to accept his or her imperfections and limitations -- a skill that is seldom even discussed, let alone mentored, during our long and arduous training.

Skillful obscuration, as I see it, is the ability to appear to disclose what happened yet cloak the truth in obscure or esoteric language that the patient is unlikely to understand. The complexity of health care makes the approach of skillful obscuration all too tempting for many of us -- particularly given the enormous vocabulary we have acquired through years of training. It is the tool of the ill-advised cover-up. So what will our oncologist choose?

He approaches the patient, offering his hand, looks the patient straight in the eye, sitting in an equal position and begins:

"Mr. Cancer Patient, I have some serious information I would like to share with you. Is this a good time?"

"Yes."

"Well, sir, I believe there has been a mistake in the dosage of your medication. From my initial review it appears I inadvertently wrote for a higher dose than required."

What follows is a painful, though ultimately powerful, dialogue. The patient asks questions, the oncologist listens and answers. How did this happen? Have you ever done this before? Is the damage permanent? Will other things happen to me? How come nobody caught the mistake? Are you sure no other medications were given to me incorrectly? How will you make sure this doesn't happen to me or anyone else in the future? Does this mean maybe I won't get so sick next time if the dose is given correctly?

Listening, empathy and apology are essential components of the disclosure moment. The only security for the oncologist who chooses to move beyond blame and fully disclose what he believes happened is the reinforcement of his relationship with the patient. An apology may be given even if it remains unclear what exactly happened. "I am sorry that you suffered kidney failure as a result of your chemotherapy. I am pleased that it was temporary and does not appear to have created any permanent damage" may be all that needs to be said at the conclusion of the disclosure.

There is no question that done properly, disclosure of even harmless errors increases the level of trust in the patient-doctor relationship and probably reduces the risk of subsequent malpractice suits. I have experienced the forgiveness, trust and confidence of my patients after disclosing my own mistakes in their care. Some have expressed that disclosure may be the only way a doctor can find forgiveness and healing after a mistake, particularly if the harm to the patient is serious. Moving beyond blame is a risk we must face and transcend.

So, we are asked, how does the oncologist respond? Gentle honesty is my best answer to this challenging question. Honesty, because it enhances trust and relationship. Gentleness, because the truth is often painful and must be brought to the patient with careful listening and empathy so as not to overwhelm him or her with what has occurred.

--Jeremy M. Fish, MD Assistant clinical professor of family medicine, Contra Costa Regional Medical Center, Martinez, Calif., University of California, Davis, Family Practice Residency Program

Reply:

Direct disclosure to the patient, by the individual responsible for the error, is crucial. This is the prime consideration, but there are hospital risk-management rules that should be noted and followed.

The disclosure to the patient has two parts. The first portion involves individual internal analysis. The second portion is the actual discussion with the patient. One may not proceed with the second step without processing the first. The spirit of this approach is not to devise a method of deceit or culpability denial. The point is that the physician must first decide the root cause and his or her bias about the consequences of noting the error before beginning a realistic dialogue with the patient. Patients deserve to know that unexpected outcomes are possible before any procedure, but after the fact, they deserve honesty and assurances about steps to prevent future errors.

The evaluation of the internal milieu begins with an examination of the critical question -- Why?

The error in this case may have several explanations. A first step is for the physician to identify the reason for the dosage error, as the things needed to prevent a reoccurrence differ based on this information.

The next step is for the physician to acknowledge his or her own feelings about having made the mistake.

The presence of guilt, irritation, remorse or the lack of these emotions will have a profound effect on the body language and word choices used in communicating about the event. These feelings must then be juxtaposed to those that might be present if the physician in question, or his or her loved one, was the patient. Balancing these perspectives is key in formulating the appropriate blend of humility, compassion and sincerity to communicate misfortune or medical error.

The discussion, the next step, is arguably the most important. However, the groundwork for any discussion of a complication turns on the foundation of informed consent. This means that the possibility of renal failure after using the chemotherapeutic in question already should have been presented to the patient. If this is not the case, this disclosure may be more problematic.

The goal of the conversation with the patient is to provide information, demonstrate compassion and remorse, and address questions that surface. The discussion is essential to maintaining trust, the basic tenet of the patient-doctor relationship. The patient views the physician as a professional and an expert. Following this assumption, the patient trusts that the expert is advising him or her to the highest available standard. In return for this trust, the patient must be guaranteed doctor accountability.

In recognition of the trust placed in him or her, a physician should offer the patient an earnest, straightforward and complete conversation about a medical error. Time should be taken to allow the patient to process the information. Excuses and mitigation should be minimal, but it is important to present the situation in a context that reflects the level of professionalism and respect due such a difficult situation.

The fact that an error occurred obviates the need to balance multiple forces. The duty to serve the patient, the duty to self and the duty to the larger medical environment may be in conflict.

However, one is less likely to suffer ethical, legal and professional repercussions if all discussion is addressed proactively and honestly. One must be prepared to take the responsibility for the error as much as for the credit for future successes.

Doing the right thing may prove difficult. However, the doctor is more likely to find an ally in the patient and achieve the best possible clinical outcome via standing accountable for any intervention, especially those that produce less desirable results.

Patients do not expect doctors to be superhuman. Nevertheless, they do expect physicians to match technical competence with the highest ethical standard of behavior.

The oncologist in error in this scenario must respond honestly and personally. This response should come after careful consideration of the circumstance and the potential reaction of the patient.

--Maurice G. Sholas, MD, PhD Fellow, Pediatric Rehabilitation Program, The Rehabilitation Institute of Chicago

Opinions expressed in Ethics Forum reflect the views of the authors and do not constitute official policy statements of the American Medical Association. Readers are encouraged to submit questions and comments to the Ethics Standards Group, AMA, 515 N. State St., Chicago, IL 60610; or by fax at (312) 464-4613. Actual names, addresses and affiliations of individuals whose queries are used will not be published.