What is the risk of a lawsuit?

[SurferBoyMD]

What are the chances of a lawsuit after being involved in a case with a poor outcome (i.e. nerve damage, paraplegia, infection etc)? And how do you protect yourself in that situation besides good documentation? Granted no negligence on your part.

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[Planktonmd]

What are the chances of a lawsuit after being involved in a case with a poor outcome (i.e. nerve damage, paraplegia, infection etc)? And how do you protect yourself in that situation besides good documentation? Granted no negligence on your part.

There are many factors that determine if you are going to get sued and many of them have nothing to do with you being negligent or not.
First, there must be, as you said, some sort of bad outcome or injury either real or perceived by the patient or the family.
Second, the patient or the family must feel that the bad outcome was caused by someone making a mistake, it doesn't matter if a mistake was actually made, all it takes is a perception that a mistake happened, which is often triggered by staff behavior after the event. like acting defensive or evasive.
Third, there must be a motive to pursue legal action, and this could be simply retaliation against a provider who was perceived as being negligent, or financial gain, or both!
Then the case is presented to a malpractice attorney who will study the case, consult with experts, and determine if the case has merit and enough money can be made. That determination depends on how hungry or eager the lawyer is, and that varies greatly by geographic location. It also depends on the age of the patient, the life expectancy, the estimated lost wages and other damages, your insurance, the hospital's insurance and the insurance of the other providers involved.
The actual negligence or deviation from the standard of care is only a small factor in determining if a lawsuit is worthy, actually if you have no insurance and no attractive assets you might not get sued because the lawyer is not going to waste his time and resources if there is no money to be made.
If you are unlucky enough to have good malpractice insurance and/or assets, and the case is considered juicy enough for the lawyer you will get sued.
As for what you can do to prevent lawsuits, there is no simple answer, and even if you do everything perfectly you can still get sued.
The best thing to do is do your best to take good care of the patient and try to adhere to what is considered the standard of care where you practice.
Be brief and to the point in your documentation and always remember that every word you write on that chart can be dissected and taken out of context and used against you.
So, only document what happened, in brief and clear language, without any opinions or explanations.
If a negative event took place you need to resist the urge to over document or over explain things.
Excessive documentation can be portrayed as an attempt to hide something.
Also it is very important to communicate clearly with the patient or the family after a negative event, be compassionate without admitting guilt, be available, and answer all their questions.
many times people get sued simply for being a#s holes!
If you get sued, above all, don't take it personally, and focus on the positive things in your life.
It is a very tough experience and it will take it's toll on you, but you need to always remember that you are a good doctor and the lawsuit is a business transaction that a lawyer uses to make a living, nothing more.
Focus on your family, your hobbies, take more time off... it will pass and you will come out with very valuable knowledge.

 

[Baller MD]

There are many factors that determine if you are going to get sued and many of them have nothing to do with you being negligent or not.
First, there must be, as you said, some sort of bad outcome or injury either real or perceived by the patient or the family.
Second, the patient or the family must feel that the bad outcome was caused by someone making a mistake, it doesn't matter if a mistake was actually made or not, all it takes is a perception that a mistake happened, which is often triggered by staff behavior after the event. like acting defensive or evasive.
Third, there must be a motive to pursue legal action, and this could be simply retaliation against a provider who was perceived as being negligent, or financial gain, or both!
Then the case is presented to a malpractice attorney who will study the case, consult with experts, and determine if the case has merit and enough money can be made. That determination depends on how hungry or eager the lawyer is, and that varies greatly by geographic location. It also depends on the age of the patient, the life expectancy, the estimated lost wages and other damages, your insurance, the hospital's insurance and the insurance of the other providers involved.
The actual negligence or deviation from the standard of care is only a small factor in determining if a lawsuit is worthy, actually if you have no insurance and no attractive assets you might not get sued because the lawyer is not going to waste his time and resources if there is no money to be made.
If you are unlucky enough to have good malpractice insurance and/or assets, and the case is considered juicy enough for the lawyer you will get sued.
As for what you can do to prevent lawsuits, there is no simple answer, and even if you do everything perfectly you can still get sued.
The best thing to do is do your best to take good care of the patient and try to adhere to what is considered the standard of care where you practice.
Be brief and to the point in your documentation and always remember that every word you write on that chart can be dissected and taken out of context and used against you.
So, only document what happened, in brief and clear language, without any opinions or explanations.
If a negative event took place you need to resist the urge to over document or over explain things.
Excessive documentation can be portrayed as an attempt to hide something.
Also it is very important to communicate clearly with the patient or the family after a negative event, be compassionate without admitting guilt, be available, and answer all their questions.
many times people get sued simply for being a#s holes!
If you get sued, above all, don't take it personally, and focus on the positive things in your life.
It is a very tough experience and it will take it's toll on you, but you need to always remember that you are a good doctor and the lawsuit is a business transaction that a lawyer uses to make a living, nothing more.
Focus on your family, your hobbies, take more time off... it will pass and you will come out with very valuable knowledge.

This is great. Thanks.

 

[Ignatius J]

There are many factors that determine if you are going to get sued and many of them have nothing to do with you being negligent or not.
First, there must be, as you said, some sort of bad outcome or injury either real or perceived by the patient or the family.
Second, the patient or the family must feel that the bad outcome was caused by someone making a mistake, it doesn't matter if a mistake was actually made or not, all it takes is a perception that a mistake happened, which is often triggered by staff behavior after the event. like acting defensive or evasive.
Third, there must be a motive to pursue legal action, and this could be simply retaliation against a provider who was perceived as being negligent, or financial gain, or both!
Then the case is presented to a malpractice attorney who will study the case, consult with experts, and determine if the case has merit and enough money can be made. That determination depends on how hungry or eager the lawyer is, and that varies greatly by geographic location. It also depends on the age of the patient, the life expectancy, the estimated lost wages and other damages, your insurance, the hospital's insurance and the insurance of the other providers involved.
The actual negligence or deviation from the standard of care is only a small factor in determining if a lawsuit is worthy, actually if you have no insurance and no attractive assets you might not get sued because the lawyer is not going to waste his time and resources if there is no money to be made.
If you are unlucky enough to have good malpractice insurance and/or assets, and the case is considered juicy enough for the lawyer you will get sued.
As for what you can do to prevent lawsuits, there is no simple answer, and even if you do everything perfectly you can still get sued.
The best thing to do is do your best to take good care of the patient and try to adhere to what is considered the standard of care where you practice.
Be brief and to the point in your documentation and always remember that every word you write on that chart can be dissected and taken out of context and used against you.
So, only document what happened, in brief and clear language, without any opinions or explanations.
If a negative event took place you need to resist the urge to over document or over explain things.
Excessive documentation can be portrayed as an attempt to hide something.
Also it is very important to communicate clearly with the patient or the family after a negative event, be compassionate without admitting guilt, be available, and answer all their questions.
many times people get sued simply for being a#s holes!
If you get sued, above all, don't take it personally, and focus on the positive things in your life.
It is a very tough experience and it will take it's toll on you, but you need to always remember that you are a good doctor and the lawsuit is a business transaction that a lawyer uses to make a living, nothing more.
Focus on your family, your hobbies, take more time off... it will pass and you will come out with very valuable knowledge.

Bravo on the documentation part. I never understood people that write out the Grapes of Wrath about potential problems or complications that occurred.

 

[drrosenrosen]

A couple other notes:

If you use templates for procedure notes, make sure to amend it before signing if anything unusual or untoward happened. It seems obvious, but can be forgotten in the heat of a busy day, especially if you're catching up on documentation before going home. I agree with not overdocumenting, or especially editorializing.

Another one that should be obvious but bears mentioning: never change a note after the fact! Even if it's innocuous, it can be dissected by the plaintiff's attorney. Most EMRs don't even let you edit a note that's been signed, but especially if something happened, make sure the note is the way you want it before signing off on it. Looks much better than amendments made after the fact.

Apologizing after an untoward event or poor patient outcome has been identified in multiple studies to actually reduce the chance of litigation. It definitely does not increase your liability. Just be a human being and let the patient know that you're sorry that there was a bad outcome. If you actually did something wrong, apologize for that. This really makes a big difference in how the patient perceives you and the event.

 

[criticalelement]

Then the case is presented to a malpractice attorney who will study the case, consult with experts, and determine if the case has merit.

Every case presented to a plaintiffs attorney has merit according to them. That's what they do!

The best way to avoid a lawsuit is practice conservatively. Avoid Regional and spinals and epidurals when at all possible. Make sure informed consent is obtained and alternatives discussed with patient. If you didnt say bleeding around spinal cord before an epidural... you havent obtained informed consent. If you havent discussed the possibilities of death before a GA, informed consent was not obtained. When a partner takes over, document you spoke to him or her about case and she is taking over. If you are faced with a difficult airway, do a fiberoptic if you anticipate difficulty.Dont force regional on any patient. There are a lot more. You will start to get savvy as time goes on.

 

[drrosenrosen]

Interesting side discussion:
Who here includes death in the consent discussion with pts? Every time, every case? What if the patient hears that and says "I don't want to have this case!" for a cancer surgery, or a CABG?

 

[Ignatius J]

Interesting side discussion:
Who here includes death in the consent discussion with pts? Every time, every case? What if the patient hears that and says "I don't want to have this case!" for a cancer surgery, or a CABG?

I don't and I fundamentally disagree with people that say you have to remind them of that. If I get sued, I get sued. But that isn't what I would want for my family members or myself. I have 5-10 minutes with a patient pre-op, and I try and utilize that little time to best ensure there comfort and relieve anxiety.

Now, if I ever feel like there's a disconnect, like patients and their families not understanding how their comorbities puts them at increased risk, I explain that. But oftentimes they know full well about the circumstances.

 

[epidural man]

Every case presented to a plaintiffs attorney has merit according to them. That's what they do!

The best way to avoid a lawsuit is practice conservatively. Avoid Regional and spinals and epidurals when at all possible. Make sure informed consent is obtained and alternatives discussed with patient. If you didnt say bleeding around spinal cord before an epidural... you havent obtained informed consent. If you havent discussed the possibilities of death before a GA, informed consent was not obtained. When a partner takes over, document you spoke to him or her about case and she is taking over. If you are faced with a difficult airway, do a fiberoptic if you anticipate difficulty.Dont force regional on any patient. There are a lot more. You will start to get savvy as time goes on.

Wow - avoid regional/neuraxial - sad but could be true. Because a spinal is the best anesthetic ever -- give me a spinal every time. Redgarding that large trial recently in Journal of Bone and Joint using propensity matching - regional was clearly the winner over general. I wonder with that kind of data if a patient could sue for NOT using regional. That will happen eventually.

Also, not sure you have to mention all that if it is written on the document they sign. I generally say something like "the nasty bad stuff that could possibly happen with your anesthesia is a list as long as my arm and listed on that paper I need you to sign. Please take a look at it. However, let me tell you the two most common problems that we have to deal with - sore throat and nausea" and I talk a little about that only unless they have specific questions about something else.

If you tell them to read a piece of paper that mentions bleeding around the spine - and are later questioned...did you inform them about the bleeding around the spine? I think the answer is probably - yes I did, and they even signed their name saying they understood it.

 

[nimbus]

Interesting side discussion:
Who here includes death in the consent discussion with pts? Every time, every case? What if the patient hears that and says "I don't want to have this case!" for a cancer surgery, or a CABG?

Death is included as a risk in our written anesthesia consent. I ask the patient if they read the consent and if they have any questions about it. Surprisingly they usually say they read it and have no questions.

 

[deleted171991]

Interesting side discussion:
Who here includes death in the consent discussion with pts? Every time, every case? What if the patient hears that and says "I don't want to have this case!" for a cancer surgery, or a CABG?

I don't mention death (it's extremely rare in my population), but I do mention brain damage.

 

[deleted171991]

Death is included as a risk in our written anesthesia consent. I ask the patient if they read the consent and if they have any questions about it. Surprisingly they usually say they read it and have no questions.

That does not qualify as informed consent, FYI.

If you read and explain it to them, yes. I actually know a surgeon who does exactly that with every patient.

 

[deleted162650]

That does not qualify as informed consent, FYI.

Then whats the point of even having a written and signed consent form??

 

[criticalelement]

But that isn't what I would want for my family members or myself..

Nobody cares what you want for yourself or you family. They just want you to obtain informed consent and having a patient sign a tiny consent form without their glasses and saying youll have a sore throat is not informed consent. You have to say the word DEATH, DEAD Brain Dead or something like it to be true informed consent. IF someone said DEAD or BRAINDEAD to joan rivers.. would she do it?


I do the same thing you do. I say something like do you want me to tell you all the bad things that can happen to you? Almost all of em say NO. Thats ok.

 

[drrosenrosen]

I don't and I fundamentally disagree with people that say you have to remind them of that. If I get sued, I get sued. But that isn't what I would want for my family members or myself. I have 5-10 minutes with a patient pre-op, and I try and utilize that little time to best ensure there comfort and relieve anxiety.

Now, if I ever feel like there's a disconnect, like patients and their families not understanding how their comorbities puts them at increased risk, I explain that. But oftentimes they know full well about the circumstances.

I agree completely.

 

[deleted171991]

Then whats the point of even having a written and signed consent form??

The point is to explain the consent in lay terms, in a standardized way. Also to prove that there was a discussion about the contents of the consent form. But if the patient proves in court that there was no discussion, that s/he just had to sign, the consent becomes really vulnerable. Especially a signature obtained in a stressful preop situation. It's a completely different story if the patient had the opportunity to study the consent at home for a week, and call with questions, for example, and the consent is very well-written and self-explanatory.

This is not a contract. Signing it does not imply consent. Discussing (and signing) it does. You are supposed to assess the patient's comprehension; it's a two-way street. As usual, this is something particular to American malpractice jurisprudence.

I am really looking forward to the first lawsuit won on the basis that the patient was consented on the day of surgery (i.e. stressful situation). I think it is a truly bad idea, and yet most places keep doing it.

 

[Ignatius J]

Nobody cares what you want for yourself or you family. They just want you to obtain informed consent and having a patient sign a tiny consent form without their glasses and saying youll have a sore throat is not informed consent. You have to say the word DEATH, DEAD Brain Dead or something like it to be true informed consent. IF someone said DEAD or BRAINDEAD to joan rivers.. would she do it?


I do the same thing you do. I say something like do you want me to tell you all the bad things that can happen to you? Almost all of em say NO. Thats ok.

I operate on the Golden Rule. Sorry, but a lot of what I do is based on what I would think is ideal if myself or my family member were the patient.

If some suits want to predetermine that I am committing malpractice by not shaking the elephant's hand in the room that has made the patient 25% above their baseline BP already, so be it.

 

[pgg]

Then whats the point of even having a written and signed consent form??

To protect you from a battery charge. That's it.

 

[deleted126335]

A few other points:
-Informed consent statutes varies by state. One state that I practiced in was very doc friendly at the time.
-Whether a lawsuit has merit is irrelevant to a plaintiff's attorney. Whether he thinks he can recover is everything. A dramatic injury with a sympathetic plaintiff and a doc who has poor communication skills and makes a poor appearance who did nothing wrong is a better bet for a plaintiff's attorney than an average plaintiff, who is less than sympathetic with a slick defendant doc who committed malpractice.
-You can always find an expert who will say anything.
-Regional v. General for liability: The common wisdom is that a GA is a clean getaway. Don't know if there is any data to support. But when my legal ESP is up I also shy away from regional unless I feel that there would be a real advantage to the patient for doing regional. I used to follow IjnatiusJ's golden rule always. Now I do it almost always.
-Even otherwise honorable people will do dishonorable things when faced with a malpractice hit. I have seen surgeons who I totally respected throw anesthesiologists under the bus during deposition in a malpractice proceeding to save their a$$.
-A good bedside manner is the best defense against malpractice. I have seen terrible surgeons who have done lousy work that caused harm bond with the patient and family and not get sued.

 

[deleted171991]

I don't and I fundamentally disagree with people that say you have to remind them of that. If I get sued, I get sued. But that isn't what I would want for my family members or myself. I have 5-10 minutes with a patient pre-op, and I try and utilize that little time to best ensure there comfort and relieve anxiety.

Now, if I ever feel like there's a disconnect, like patients and their families not understanding how their comorbities puts them at increased risk, I explain that. But oftentimes they know full well about the circumstances.

Most patients don't understand what goes on during general anesthesia. For 99% of them it's not controlled coma, it's sleep. So it's useless to expect them to predict the risks involved.

You might make them feel good and like you, but don't fool yourself: you are not providing an informed consent, and you can be vulnerable if you make it to court. Just my 2 cents.

I agree that a truly informed consent might make the patient anxious preop, but that's why I have drugs. I seldom regret telling patients about frequent or grave complications; I almost always regret when I didn't and something happened.

 

[Ignatius J]

Most patients don't understand what goes on during general anesthesia. For 99% of them it's not controlled coma, it's sleep. So it's useless to expect them to predict the risks involved.

You might make them feel good and like you, but don't fool yourself: you are not providing an informed consent, and you can be vulnerable if you make it to court. Just my 2 cents.

Perhaps some day I will be and I will change my ways. It would be interesting to take a survey. I think most patients hear and see enough circumstantial stories to feel a little weary of the anesthesia. Nevertheless, "what will the court say" medicine is not the most satisfying way for me to practice.

I always get the "It's not the surgery that I'm worried about!" line. Or the "just please make sure I wake up." Maybe the occasional Joan Rivers joke now for some nervous humor.

Never really get the sense that the patient thinks they are going for some good R&R.

 

[deleted171991]

Perhaps some day I will be and I will change my ways. It would be interesting to take a survey. Most patients here and see enough circumstantial stories to feel a little weary of the anesthesia.

I always get the "It's not the surgery that I'm worried about!" line. Or the "just please make sure I wake up." Maybe the occasional Joan Rivers joke now for some nervous humor.

Never really get the sense that the patient thinks they are going for some good R&R.

I work mostly outpatient. Some of those patients behave like they came for a spa treatment. My consent is the wake up call in 25+% of the cases.

I get the "most important person in the room" line (or something similar) from less than 10%. I once had one who was texting while I was talking to him about GA. I bet he didn't try that with the surgeon.

I was trained abroad, where even the expression "defensive medicine" did not exist, so imagine how I feel.

 

[Ignatius J]

I work mostly outpatient. Some of those patients behave like they came for a spa treatment. My consent is the wake up call in 50% of the cases.

I get the "most important person in the room" line (or something similar) from less than 10%.

Yesterday, I had one who was texting while I was talking to him about GA. I bet he didn't try that with the surgeon.

You are smart. Not to say I won't give a reality check if I get a flippant vibe at all.

By the way, could not agree more about regional from who said it above. It's interesting to note the nerve damage lawsuit numbers in the Closed Claims Database.

Had an attending in residency who was sued for nerve damage after an ISB and never did them again.

 

[dhb]

-A good bedside manner is the best defense against malpractice. I have seen terrible surgeons who have done lousy work that caused harm bond with the patient and family and not get sued.

this

 

[deleted171991]

+2

 

[criticalelement]

Interesting side discussion:
Who here includes death in the consent discussion with pts? Every time, every case? What if the patient hears that and says "I don't want to have this case!" for a cancer surgery, or a CABG?

I operate on the Golden Rule. Sorry, but a lot of what I do is based on what I would think is ideal if myself or my family member were the patient.

If some suits want to predetermine that I am committing malpractice by not shaking the elephant's hand in the room that has made the patient 25% above their baseline BP already, so be it.

Not everyone wants the same thing as you or me. You cannot assume that because you want something, thats what patients want. They dont want to be scared but the law requires that you obtain informed consent and you aint doing it because you feel you are above that.

 

[criticalelement]

-A good bedside manner is the best defense against malpractice. .

A good bedside manner is not going to save us from a malpractice lawsuit. Maybe the surgeons who have a relationship with the patient, but not us

 

[urge]

Wow - avoid regional/neuraxial - sad but could be true. Because a spinal is the best anesthetic ever -- give me a spinal every time.

Pent sux tube for me. I wouldn't let anyone do a spinal/epidural on me.

 

[kazuma]

I know how some of you feel about doing regional under GA in kids and adults. Some argue that u/S has taken most if the guesswork out of regional anesthesia and think That someday regional under general Anesthesia might be more common due to patient comfort and generally low risk of complications. To be honest it seems to me that sometimes the patient might be less likely to have an injury from flinching and contracting muscles during the needle insertion under GA.

We do it with the "right" candidates a few times a week. But I definitely agree about not pressuring people into regional and I've been told by a wise old anesthesiologist "never needle a nut."

 

[deleted171991]

Pent sux tube for me. I wouldn't let anyone do a spinal/epidural on me.

Aren't you worried about the little grey cells, mon ami?

 

[pgg]

A good bedside manner is not going to save us from a malpractice lawsuit. Maybe the surgeons who have a relationship with the patient, but not us

C'mon, don't let your self-loathing and disappointment in our specialty get in the way of acknowledging this well known and obvious truth. Poor rapport with patients raises the odds of getting sued if something goes awry. Good rapport lowers those odds.

We may only get 10 minutes with a patient before they're unconscious, but that's plenty of time for them to decide if we are jerks going through the motions, or compassionate attentive doctors. After an event, interaction with the family and the patient matters too.

 

[powermd]

C'mon, don't let your self-loathing and disappointment in our specialty get in the way of acknowledging this well known and obvious truth. Poor rapport with patients raises the odds of getting sued if something goes awry. Good rapport lowers those odds.

We may only get 10 minutes with a patient before they're unconscious, but that's plenty of time for them to decide if we are jerks going through the motions, or compassionate attentive doctors. After an event, interaction with the family and the patient matters too.

This.

The relationship is everything. The patient has to believe you're a good egg whose looking out for them.

I've heard of some truly egregious malpractice thwarted by the doc's relationship with the patient/family.

Patients have limited ability to truly comprehend anesthesia/pain risks. If you really lay it out, you frighten them off. I think it's important to drive home the difference between the POSSIBLE and the PROBABLE. Before interventional pain procedures I tell patients in all likelihood their procedure will be completely uncomplicated and any complaints will be minor, but there is a very, very low risk of bad things like paralysis and death. I give them the statistics if they press on that. Once I say 1:50,000 or less most are happy at that.

 

[drrosenrosen]

So no one has addressed the specific question I brought up. What if you scare the patient by mentioning death as a possible outcome, even if you mitigate it appropriately and explain how small the risk is, and they decide that they don't want to have a necessary surgery? Do you really feel good about that?

I'm also astounded to hear that people are bypassing regional anesthesia, which has demonstrated benefit over GA in certain circumstances, solely to reduce their own liability.

 

[pgg]

So no one has addressed the specific question I brought up. What if you scare the patient by mentioning death as a possible outcome, even if you mitigate it appropriately and explain how small the risk is, and they decide that they don't want to have a necessary surgery? Do you really feel good about that?

I mention death to everyone and have yet to ever see anyone decide not to have surgery because of my preop consent spiel.

If an adult of sound mind chooses not to have a "necessary" surgery and instead decides he'd rather die on his own terms minus a surgery, I'd score that a win for patient autonomy.

I'm also astounded to hear that people are bypassing regional anesthesia, which has demonstrated benefit over GA in certain circumstances, solely to reduce their own liability.

I never try to talk patients into truly elective regional (eg most patients who are offered blocks for postop pain control). I do usually offer it. For patients who don't have a compelling reason to get a block (eg severe OSA prompting a low/no opiate technique) I always emphasize the optional nature of the procedure and reassure them that if they don't want it, I'll give them IV pain meds with some confidence that they'll still wake up comfortably.

For patients who appear unreliable I won't offer such elective regional. I think that's a totally reasonable medical and psychological assessment of a patient's risk factors and likelihood to perceive benefit from a good block, and it has little to do with any risk I perceive to myself.

 

[Ignatius J]

Not everyone wants the same thing as you or me. You cannot assume that because you want something, thats what patients want. They dont want to be scared but the law requires that you obtain informed consent and you aint doing it because you feel you are above that.

No, but philosophically the Golden Rule should make for a better world. The only thing I want is a patient that is healthy and satisfied with their experience.

As for what is informed consent, that's a contentious debate and is just as much subjective as it is objective. As for "breaking the law" tag, please remember that the next time you come to a rolling stop, forget to turn on your blinker, or go just a hair over the speed limit.

Enjoy scaring your patients. To each his own.

 

[deleted171991]

@Ignatius J, nobody "enjoys" scaring their patients. But not doing it is more serious, by far, than a rolling stop. It's more like running a red light.

The US is not a paternalistic medicine country. You cannot withhold information from the patient just because it might provoke anxiety or would paint you as the bearer of bad news, no offense.

 

[Ignatius J]

@Ignatius J, nobody "enjoys" scaring their patients. But not doing it is more serious, by far, than a rolling stop. It's more like running a red light.

The US is not a paternalistic medicine country. You cannot withhold information from the patient just because it might provoke anxiety or would paint you as the bearer of bad news, no offense.

Who says I withhold information? As far as how serious it is to do give a death schpeel, I would argue a traffic violation is more dangerous than not telling a patient they could die. There is zero paternalism in regards to my approach with patients unless they make a request that I feel is dangerous to their health and would compromise my ethics.

I've mentioned it already, if I feel like there is a disconnect in the patient's understanding, I clarify anything I feel I need to. All opportunities are given to read the consent and ask questions and all patients demonstrate some capabilities of understanding, much like riding in a car, that bad things can happen.

 

[epidural man]

@Ignatius J, nobody "enjoys" scaring their patients. But not doing it is more serious, by far, than a rolling stop. It's more like running a red light.

The US is not a paternalistic medicine country. You cannot withhold information from the patient just because it might provoke anxiety or would paint you as the bearer of bad news, no offense.

That's a little dramatic

No one withholds info. Not telling every crazy thing that might happen is not witholding.

Our hosptial bought these new fancy hospital bed sheets -but they were really slick and we had not ONE but TWO(!!!!) patients slide of the bed and hit the floor while in steep trendelenburg. Crazy right?

We fixed the problem - but should we inform every patient that this happened years previous? I saw a case report where the ET tube was placed through the soft palete - should I mention this to everyone as a possiblity?

I agree that this topic is a hot one....but unclear to me why.

Actually, isn't there a legal definition? if it happens less than 1% of the time then doesn't need to be discussed? I swear I read something like that.

 

[criticalelement]

Are you guys serious? What is wrong with telling a paient there is a rare chance that death/braindeath happens, it is exceedingly rare and we dont think it will happen to you but there is that chance.... We will do everything in our power to not let that happen ever. IF you dont say death/ braindeath in my opinion it is NOT informed consent. DO i say it every time? Nope. BUt i think it is important. IM tired of people coming into the OR as if the risk is as low as being in the barbershop chair.

 

[epidural man]

@Ignatius J, nobody "enjoys" scaring their patients. But not doing it is more serious, by far, than a rolling stop. It's more like running a red light.

The US is not a paternalistic medicine country. You cannot withhold information from the patient just because it might provoke anxiety or would paint you as the bearer of bad news, no offense.

Are you guys serious? What is wrong with telling a paient there is a rare chance that death/braindeath happens, it is exceedingly rare and we dont think it will happen to you but there is that chance.... We will do everything in our power to not let that happen ever. IF you dont say death/ braindeath in my opinion it is NOT informed consent. DO i say it every time? Nope. BUt i think it is important. IM tired of people coming into the OR as if the risk is as low as being in the barbershop chair.

Nothing is wrong with telling them. But many of us are voicing the opinion that nothing is wrong with NOT telling them. Let me ask you this...what do you think you are gaining or preventing or helping by making sure ...out of the seriously thousands of horrible horrible things that could POSSIBLY go wrong...that you mention that one thing? Will the surgery go better? Will the patient feel better about now having a "cleared up" idea? Will it change outcomes? Will it prevent a lawsuite? Will a SINGLE patient decide not to have his gallbladder removed because you happen to mention death as a possiblity?

Maybe it might change something.

But I bet you don't teach the patient a thing. They all know the bizare can happen. They all know because the surgeon tells them.

Also, of course it changes for fat people. They should know that they have really made it difficult for us.

 

[BLADEMDA]

Each surgery has its own set of risks. For example, a long, complicated back case involves the risk of blindness. Total Shoulder surgery involves the risk of brachial plexus injury (and it won;t be your block that causes it).

If the chance of something happening is less than 1% (in your opinion) then it doesn't need to be discussed. For example, an ASA 2 34 year old undergoing a knee scope doesn't need the "death speech" as the odds of dying or brain death are less than driving their car. I don't see how discussing the subject with someone who shouldn't die or be brain dead (as opposed to an 85 year old ASA 4 undergoing emergency AAA surgery) alters the odds for a lawsuit.

We are an outcome driven society which doesn't tolerate bad outcomes on reasonably healthy people; as such, you can expect to be sued if there is a bad outcome regardless of your spiel to the patient in the holding area. Lawsuits aside we have an obligation to discuss real risks to our patients

For 99% of my patients I spare them the "death speech."

 

[BLADEMDA]

20 THINGS THAT ARE STATISTICALLY SAFER THAN YOU THINK


http://www.kenneymyers.com/blog/20-things-that-are-statistically-safer-than-you-think/

Anesthesia – There’s something scary about going under the knife, especially when you know you’re going to be anesthetized. AnesthesiaWeb.org places the risk of dying as a result of general anesthesia alone at .01% to .0016%, though.

 

[urge]

Aren't you worried about the little grey cells, mon ami?

I'm more worried about one of you guys harpooning my back repeated times.

 

[deleted171991]

That's a little dramatic

No one withholds info. Not telling every crazy thing that might happen is not witholding.

Our hosptial bought these new fancy hospital bed sheets -but they were really slick and we had not ONE but TWO(!!!!) patients slide of the bed and hit the floor while in steep trendelenburg. Crazy right?

We fixed the problem - but should we inform every patient that this happened years previous? I saw a case report where the ET tube was placed through the soft palete - should I mention this to everyone as a possiblity?

I agree that this topic is a hot one....but unclear to me why.

Actually, isn't there a legal definition? if it happens less than 1% of the time then doesn't need to be discussed? I swear I read something like that.

You (all) seem to misunderstand me.

I am not at all for disclosing every single stupid complication that can occur, even death (which only has a chance of 1 in 200.000 ASA 1-2 patients). No law requires that. But I don't think that handing the patient a piece of paper to read is informed consent. Neither is chatting about the weather and sports, without mentioning the risks of anesthesia, or minimizing them (as in not mentioning the risk of blindness for a spine surgery).

My own speech is usually pretty short, detailing my plan, mentioning (relatively) frequent risks related to the specific patient, surgery or type of anesthesia, suggesting that usually it's pretty safe (when it's the case), but also that a bunch of things can go wrong unpredictably (when it's the case), including a very low risk of heart attack or brain damage (which makes them understand that absolutely anything could go wrong, despite the probabilities being low). If the patient wants more info, s/he gets more info. It's not about preventing lawsuits, or scaring the patient, it's about giving the patient enough data to assume risks rationally. I tell the patient exactly what I would tell a friend; I don't exaggerate, but neither do I minimize things.

Regarding the malpractice side, there is a new tactic among lawyers who cannot prove malpractice (dereliction of duty, directly causing damages to the patient) to focus on the lack of informed consent. As in the patient was not informed about a specific frequent or major complication, and had s/he known about it s/he would have refused the type of anesthesia or the surgery. Again, risk of blindness after spine surgery is the perfect example.

How much information is considered "adequate"?
How do you know when you have provided enough information about a proposed intervention? Most of the literature and law in this area suggest one of three approaches:

• • Reasonable physician standard: what would a typical physician say about this intervention? This standard allows the physician to determine what information is appropriate to disclose. However, this standard is often inadequate, since most research shows that the typical physician tells the patient very little. This standard is also generally considered inconsistent with the goals of informed consent, as the focus is on the physician rather than on what the patient needs to know.
  • Reasonable patient standard: what would the average patient need to know in order to be an informed participant in the decision? This standard focuses on considering what a typical patient would need to know in order to understand the decision at hand.
  • Subjective standard: what would this particular patient need to know and understand in order to make an informed decision? This standard is the most challenging to incorporate into practice, since it requires tailoring information to each patient.

Most states have legislation or legal cases that determine the required standard for informed consent.

https://depts.washington.edu/bioethx/topics/consent.html

 

[deleted171991]

But I bet you don't teach the patient a thing. They all know the bizare can happen. They all know because the surgeon tells them.

Many patients are not told about stuff that might scare them away, such as the world of pain after certain plastic surgeries (or even the size of the incision for a liver transplant donor). Some surgeons lie by omission all the time, and the more money they make the more they forget to tell. They just don't want to lose any customers. Usually these are the same guys who are too lazy to inject local anesthetic, not even at the end of the surgery.

They minimize anesthetic risks all the time, they present the patient a fairytale version of anesthesia, they promise everything the patient wants to hear, almost like used car salesmen. Then, when you come and actually have an honest discussion with the patient (like with a friend), you are the bad guy who gets to tell them the truth, and correct all the false information they have been given.

 

[jl lin]

They minimize anesthetic risks all the time, they present the patient a fairytale version of anesthesia, they promise everything the patient wants to hear, almost like used car salesmen. Then, when you come and actually have an honest discussion with the patient (like with a friend), you are the bad guy who gets to tell them the truth, and correct all the false information they have been given.

Loads of respect for what you are saying here.

 

[criticalelement]

If the chance of something happening is less than 1% (in your opinion) then it doesn't need to be discussed.



We are an outcome driven society which doesn't tolerate bad outcomes on reasonably healthy people; as such, you can expect to be sued if there is a bad outcome regardless of your spiel to the patient in the holding area. Lawsuits aside we have an obligation to discuss real risks to our patients

For 99% of my patients I spare them the "death speech."

Interesting that you think if a complication occurs 1 % of of the time it doesnt need to be discussed even one as catastophic as death/brain death
I beg to differ on the folks who say that all the patients know they can die. I would contend that it is a lower number than most of us believe. Having said that, I still dont tell everyone there is that possibility but the folks that i havent discussed this with are not informed.[/quote][/QUOTE]

 

[criticalelement]

So no one has addressed the specific question I brought up. What if you scare the patient by mentioning death as a possible outcome, even if you mitigate it appropriately and explain how small the risk is, and they decide that they don't want to have a necessary surgery? Do you really feel good about that?

I'm also astounded to hear that people are bypassing regional anesthesia, which has demonstrated benefit over GA in certain circumstances, solely to reduce their own liability.

If after i have tactfully told them the issues and they walk, not my problem. This is serious business.

Plaintiff's attorneys can sue you faster and easier and it is harder to defend yourself after a complication from regional anesthesia.
Persitent numbness, numb vaginas, persitent paresthesia weakness quad weakness.. all that junk.

The words incompetent, chose the wrong anesthtic, damage the nerves, doesnt know how to do a block. They will blow up your u/s image that you put in the chart with the needle and the plaintiffs expert will swear that needle is intra neural. IT is clear. Who needs that? ALL in one block.. (GA)

 

[Ignatius J]

If after i have tactfully told them the issues and they walk, not my problem. This is serious business.

Plaintiff's attorneys can sue you faster and easier and it is harder to defend yourself after a complication from regional anesthesia.
Persitent numbness, numb vaginas, persitent paresthesia weakness quad weakness.. all that junk.

The words incompetent, chose the wrong anesthtic, damage the nerves, doesnt know how to do a block. They will blow up your u/s image that you put in the chart with the needle and the plaintiffs expert will swear that needle is intra neural. IT is clear. Who needs that? ALL in one block.. (GA)

If you tactfully tell an ASA 1 and they walk away from their knee scope, to me that's a problem and I understand why a surgeon would be pissed as well as my group that saw me send a thousand bucks out the front door because I think a patient needs reinforcement that they can die.

They can go get in their car and have just as good of a chance of getting in a very serious accident on their way home.

 

[drrosenrosen]

So, if a patient dies, do you think that your having told them that they might will reduce your chance of being sued (what if you and they were the only witnesses to the informed consent discussion?)