Choose your words carefully with patients to reduce liability, improve safety
What you say/don’t say can influence how a patient responds to adverse events
Executive Summary
In addition to being part of good patient care, communicating clearly and effectively can reduce the chance of a patient seeking legal action. Better communication also improves safety and helps to avoid adverse events.
- A mnemonic device can help physicians remember the key discussion points.
- Never admit fault if you're not sure yet what happened.
- Avoid the tendency to become defensive.
With many healthcare providers adopting policies of full disclosure and apology, clinicians can be left wondering exactly what to say, how to say it, and what not to say to patients and family after an adverse event. With multimillion-dollar verdicts resting on what was said, even the best doctors can benefit from coaching on how to talk to patients at a critical juncture.
What clinicians say after an adverse event has been proven to be instrumental in determining whether the patient or family will pursue a malpractice case, says Peter Pronovost, MD, PhD, FCCM, a practicing anesthesiologist, critical-care physician, professor, and senior vice president of Johns Hopkins Medicine in Baltimore, MD, and senior vice president and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.
"If you look at why patients sue, it’s because they suffered a bad outcome and they lost trust in you," he explains. "There doesn’t have to be an error. The loss of trust is a big factor, and they are going to determine whether they trust you during that conversation after the bad outcome."
In many cases, it is wise to include the patient’s family members in the discussion, with permission, he says. Involving the family has been shown to improve patient safety overall, Pronovost notes, and it can be particularly important when discussing a poor outcome. (See the story on p. 100 for more on the benefits of including family members.)
Most physicians have no specific plan on how to talk to patients and family when there is an adverse event or when they are upset about the care provided, Pronovost says. "Most of them just shoot from the hip, with no structured way to do it," he says. "They may say they try to listen and explain, but when everyone is upset about what’s happening, that conversation can go downhill pretty quickly."
Pronovost advises risk managers to help educate physicians and nurses on the most effective way to have those conversations, using role-playing scenarios when possible. At Johns Hopkins, he trains physicians using a mnemonic that reminds physicians to anticipate, listen, empathize, explain, and negotiate.
Pronovost recalls one incident in which a woman was upset that her father had been given insulin to control his blood sugar level — the common and correct treatment for that condition. "The daughter starts screaming and gets really upset, saying insulin makes his blood sugar up and he can’t take it. That’s just not medically correct, but she certainly believed it," he says. "I let her unload a lot of emotions on me, empathized with her, and calmly explained how the insulin works and why we decided on that treatment. Then we talked about how we could decide when was the best time to give her father insulin."
By the end of the talk, the woman was calm and complimented the care team on their skills and how they wanted the best for her father.
One potential pitfall with this approach is that doctors can try so hard to empathize with the patient and family that they admit to more blame than is appropriate or state information that is not yet known to be fact. This situation can be the case especially if the doctor is feeling remorse after a poor outcome, Pronovost says.
An apology can be appropriate, but it does not have to include an admission of responsibility, he explains. The doctor can say, "I’m sorry this turned out the way it did and you’re suffering because of it" without also saying "and it’s because we made a mistake."
The apology coupled with the admission of guilt is most associated with lowering the risk of litigation, Pronovost notes. However, you sometimes do not know at that point if there was an error, and it is dangerous to suggest that there was an error until you are sure.
"Don’t go beyond the facts," he says. "If you know more later, you can go back and give a more detailed apology. Don’t fill in the blanks with what you don’t know. Be transparent and say you don’t know everything yet, but you’re going to find out."
Physicians might need to be reminded to speak in a way that the patient can understand the information, says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the American Society for Healthcare Risk Management (ASHRM). Some of the information might be complex, but it is important to avoid medical jargon and terms that the other person might not understand.
Remember that the other person might be reluctant to admit being confused by what you’re explaining. Make the information as clear as possible without talking down to the person, she says. "Have a discussion. Don’t talk at the patient," she says. "You have to have empathy for the person. This may be a situation you face every day, but this patient is scared out of his mind. For him, this is the most important thing in the world right now, and you can’t talk about it like it’s just another thing on your to-do list."
Kicklighter notes that many pieces of this advice applies just as much to informed consent and other discussions as it does to talking after an adverse event. The goal in all patient interactions should be clear and effective communication, she says.
As for what not to say to patients, Kicklighter says she has been astounded by the cavalier approach some physicians take when talking about devastating topics. When her sister was diagnosed with pancreatic cancer, she happened to be in the doctor’s office on her birthday. The doctor flippantly told her that he hoped he’d be able to wish her happy birthday next year. When Kicklighter heard of the comment, she told her sister to change doctors immediately because he was too insensitive.
"Sometimes I think doctors can try so hard not to get all caught up in the emotions of every patient that they go too far in the other direction and get callous," Kicklighter says. "A thoughtless comment like that colors the entire relationship and can make a difference if the patient is wondering whether to hold you responsible for a bad outcome."
ALEEN helps doctors remember key points of discussion
At Johns Hopkins Medicine in Baltimore, MD, Senior Vice President Peter Pronovost, MD, PhD, FCCM, uses a mnemonic device to train physicians on how to talk with patients or family members who might be upset.
The mnemonic is ALEEN:
• Anticipate. "When you're walking in to talk with an upset family, you have to know that they're going to be emotional and may yell at you. You can't take that as an affront on your self-worth," Pronovost says. "So many physicians go on the defensive and argue back about how good a doctor they are. That's not the right response."
• Listen. When people are upset, they need to speak, Pronovost says. If you don't allow them to get their feelings and concerns out, they grow more and more frustrated. Doctors tend not to be the best listeners, so they have to remind themselves to just stay quiet and not interrupt.
• Empathize. "Be human about it," Pronovost says. "You can say, 'Geez, if I thought someone was hurting my loved one, I'd be upset too.' You don't have to admit responsibility or agree with what they're alleging, but you can acknowledge that their feelings are normal and you get it."
• Explain. Tell them the facts as you understand the situation so far, and acknowledge any ongoing questions or uncertainties. Explain the reasoning behind certain decisions that were made, even if they prove to be the wrong move in the end.
• Negotiate. Involve the patient and family in crafting the solution so that they will buy into it. You can explain what steps you think are necessary at this point and ask if that sounds like a good plan. The doctor also should ask if there is anything else that they think should be done. The key is to involve the patient and family rather than just telling them what is going to happen.
Sources
- Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, The Kicklighter Group, Tamarac, FL. Telephone: (954) 294-8821. Email: [email protected].
- Peter Pronovost, MD, PhD, FCCM, Senior Vice President, Johns Hopkins Medicine, Baltimore, MD. Telephone: (410) 502-3231. Email: [email protected].
