Abstract
Case study
Patricia was a 40-year-old nurse working in a large hospital in a Southern European country at the time of this incident. She had been married to Peter, also a nurse, for 3 years.
Patricia was diagnosed with malignant melanoma in her right eye. Her initial treatment included two operations: first to place a radioactive plate and then to remove it. It was hoped that this would stop the neoplasm from growing allowing her to keep the eye. Even if successful, she would require close monitoring for the rest of her life.
Patricia and Peter were apprehensive yet hopeful with this unexpected event. As nurses, they knew that this type of malignancy had the potential for further problems, such as liver metastasis, and that risk of sequelae continues for many years.
Eighteen months after the surgery, follow-up examinations showed good response to the therapy and no recurrence. In response, Patricia became pregnant, bringing the couple great joy. However, they remained aware that her illness could still recur.
The pregnancy went well until the seventh month when, following her regular ocular examination, her oncologist said that the most recent ocular ultrasound showed a recurrence of the neoplasm, now larger than before. Her oncologist advocated surgery to excise part of the eye, but out of concern for her pregnancy she opted to wait until after the birth of the baby to reassess the tumor. Patricia understood that the partial removal of the eye meant a total loss of vision in that eye, a new risk of metastasis, and might jeopardize her pregnancy.
However, Patricia was concerned that the ultrasound was poorly done and so the results might be unreliable. Instead of the usual expert physician, the subtle procedure was carried out and interpreted by a very young doctor with little experience in the area. It would be revealed later that the interpretation was in error and that Patricia’s oncologist, as the supervising physician, did not review the interpretation which is the standard of care at their institution.
Shortly afterward, the gynecologist’s abdominal examination revealed that the fetus was not gaining weight. As a result, it was decided to deliver her baby by cesarian on short notice. The happiness at the birth of their daughter comforted Patricia and Peter, despite their continued fear of the cancer.
A month after the birth, Patricia was now ready to consider further eye surgery. This time the ultrasound was carried out by a physician with more experience in ocular ultrasound.
Later, her oncologist invited Patricia to sit down and take a long breath. With little embarrassment, this physician who had been caring for Patricia for several years at this point told her that the interpretation of the previous ocular ultrasound was mistaken and that the further surgery was not needed. The correct interpretation was that her eye was responding well to treatment and she should continue close monitoring. Although relieved, Patricia and Peter were angry and offended about the unnecessary worry and suffering caused by the physician’s earlier inattention.
Reflective questions
How might this clinician have responded on discovering that her patient suffered because standard of care was not followed? What ethical approach would best guide the clinician’s response to Patricia? Relational? Principlist? Other? Are there any aspects of organizational culture that may have led to this mistake? How might the culture be changed for the better?
Comment: Helen Chan
Introduction
This case brings up issues on disclosure of medical error to patients and the ethically appropriate response of health professionals to mistakes.
Background
Patricia, a 40-year-old lady, was threatened with neoplasm recurrence while she and her husband were expecting a baby. It was later revealed that they have suffered from unnecessary worry out of the misinterpretation of the ultrasound by an inexperienced physician. Indeed, they might have made wrong decisions, such as undergoing unnecessary surgery causing total vision loss, due to the misjudgment. Despite this, Patricia’s oncologist who had not fulfilled his duty as supervisor had not apologized for the mistake.
Alternatives
Clearly, disclosure of medical errors to patients is based on the obligation of veracity in support for the trusting relationship between health professional and patient, and this act has been considered as the standard of care since the report To err is human: building a safer health system by the Institute of Medicine. 1 In this case, the oncologist had told the couple that the interpretation of ultrasound made by the junior physician was inaccurate. The resentment of the patient, however, lies in the way the oncologist responded to the mistake. One may argue that the oncologist did not need to apologize for the mistake as there is no apparent adverse outcome. Concern may also arise about whether an apology would be evidence malpractice litigation. In fact, limited attention has been given in the field on the ethically appropriate response of health professional to medical error as there are rarely any specific ethical guidelines on medical error disclosure and the issue has not been touched upon explicitly in the codes of professional conduct. Hence, the responses of individual health professional may be largely based on the ethics of care.
Resolution
To avoid this kind of incident, the oncologist should have undertaken his supervisory duties in due manner to ensure patient safety. As for this case, the oncologist should apologize to the couple for his omission, regardless of whether harm resulted.
Recommendation
The medical error disclosure framework (MEDF), which highlights the importance of apologize, demonstrate empathy, and plan for preventative steps (such as corrective action and compensation), proposed by Boyle et al. 2 could serve as a framework for guiding health professionals on communicating medical errors with patients. Allen et al. 3 have conducted a study to compare the effects of different approaches of apology and found that apology which comprises elements of acknowledgment, remorse, and reparation would be more effective as it has taken the patients’ perspectives into account and recognized their needs. Yet, they also noted that any basic apology that comprises an admission of responsibility, expressing regret and offering restitution, could already bring more positive than negative impact. 3
Author response
We want to thank the commenters for their thoughtful consideration of our case and suggestions for guidance regarding error disclosure. We would also suggest the work of Mary Beth Foglia, RN, PhD, for ethical guidance and evidentiary support for disclosure.
Advocating frank disclosure of errors by healthcare professionals has become a central tenet of ethical practice. Providing an informative explanation of how the error occurred, expressing empathy, explicitly apologizing and taking steps to remedy any consequential damages must be inscribed in a relational ethics that constitutes the basis of fiduciary relationships with patients. Furthermore, a veracious and reliable rapport between professionals and patients prevents rather than cultivates malpractice lawsuits. Regrettably, obstacles such as superior attitude, fear of a damaged reputation, and lawsuits hold back providers from speaking to patients about errors. These lamentable comportments that tend to cover up mistakes happen worldwide but are especially rampant in cultures where physician domination, still anchored in a directive model of clinical relationships, is strong, as it is in Southern Europe. The prevailing cultural context, in this case, may have influenced the non-disclosure of the error by the oncologist. However, these inimical behaviors happen far too frequently, are ethically deplorable, threaten the quality of care, and harm the public’s trust in the healthcare system.
Such cases of untrustworthy communication must be addressed by culture change to one which values transparent communication including openness to patient concerns as well as disclosure of possible errors. Sincerity and veracity should be encouraged as essential aspects of care including a norm of error disclosure that was lacking in the case’s environment.