Poly pharmacy and falls

[meow1985]

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Long story short, I had an older patient on sedating meds which I had been working to minimize. Last time I saw her she was having poor PO intake and I focused on enhancing that and getting her to be medically evaluated in the ER because she is also diabetic on insulin (which she did not follow through on, and it was telemedicine so I could not arrange direct transport). In hindsight I should have probably lowered her meds because blood levels could have been going up. She then proceeded to have a bad fall a few weeks later. Family got involved and expressed concern about her being over medicated, saw PCP and sat down with in house pharmacist to review meds.

I feel horrible that I didn’t expedite lowering meds at that particular time and am of course paranoid that I will be sued again, and if you are sued too often your malpractice can drop you and there goes my otherwise good job. The first lawsuit was frivolous a couple years back but this won’t be. Patient saw me again and did not seem to cast any kind of blame on me, but who knows….

I was doing relatively well with my mental health and balancing work stress, and now this has set me back again. 🙁((( It’s like, the nothing lawsuit was still traumatic in that I’m now always worried it will happen again.

 

[wolfvgang22]

Could be worse. I had a patient die by suicide recently. I think the best thing you can do to avoid getting sued is have good rapport with the patient and their family. It's not to late to speak to them with your patient's consent. If you let them know your concerns and what you've done to help already, listen to their concerns, and let them know what the plan is that can give them relief knowing you are doing your best like you would for your own family.

 

[meow1985]

Could be worse. I had a patient die by suicide recently. I think the best thing you can do to avoid getting sued is have good rapport with the patient and their family. It's not to late to speak to them with your patient's consent. If you let them know your concerns and what you've done to help already, listen to their concerns, and let them know what the plan is that can give them relief knowing you are doing your best like you would for your own family.

Do you work at the VA or am I confusing you with someone? Are VA docs taken to task by the institution for suicide? I remember the VA has a zero suicide goal and there was a suicide of a vet at the VA affiliated with my residency, and there was some major grief at the institutional level.

 

[wolfvgang22]

Yes, I work mainly at a VA. Outside gross negligence, it is difficult but not impossible to successfully sue a VA physician directly. Typically a tort claim against the VA must be filed instead, but that isn't pleasant, either. I have reviewed such cases for the VA general counsel as an expert. Most of the time a review reveals that a psychiatrist (or multiple doctors nurses, and counselors) have gone above and beyond the standard of care to help a patient.

If you see enough patients with serious mental illness, particularly the highest risk patients, there will eventually be a patient die by suicide even if you've gone above and beyond standard of care and documented appropriately. There is a Morbidity and Mortality review but the goal is to identify any gaps in care and make improvements if possible, not assign blame to a physician and team that have done their best. The day that attitude changes I will seek other employment. Different VA hospitals can have different cultures care, though they are not supposed to. It mainly depends on leadership.

 

[calvnandhobbs68]

Eh, if you were actively trying to minimize medications and documented concerns that the medications were over sedating, sure someone could try to sue you but it'll go nowhere. Everything is a risk/benefit, risk of lowering meds too fast is that you destabilize her and cause other problems. You even recommended she go to the ED because of the poor PO intake, which of course could have also led to the fall. Sounds like you're covered.

Much more lawsuit risk if you dramatically INCREASED multiple sedating meds in an elderly patient with no clear documented reason for this and they had a fall.

 

[Bartelby]

Remember the four D's of malpractice: dereliction of duty leading directly to damages. Each element needs to be present to have a successful malpractice case. I don't know the details of your case, but from what you have mentioned:

Damages: seem minimal. Your patient is apparently still alive, and you did not describe any long-term disability, etc. I presume your patient ended up briefly hospitalized after a fall. Those are damages, but most attorneys would not be interested in pursuing such a small amount.

Dereliction: why didn't you lower the sedating medications? I bet you have a reason. If you exercised reasonable medical judgment and made what appeared to be the best call, I would argue that you did not fail to fulfill your duty to the patient. As was mentioned above, there are good and valid reasons you might taper slowly. If you find that going down on the medication was clearly and undeniably the right call and for some reason you didn't do it anyway, that would be different, but I doubt that's the case.

Directly: you haven't shared what sedating medications this patient was taking. It is likely they contributed to the fall, but would the fall have been prevented had you started a decrease sooner? I don't know based on what you've shared, but I'm not confident you are describing a situation with clear direct causation (going slower on tapering down sedating medications leading to the fall and resulting damage).

In addition, it sounds like your (competent) patient contributed to the bad outcome by failing to follow your advice (not presenting to the hospital for evaluation). This would also seriously undermine a liability case.

In short, all of us feel a little anxiety when we find out there has been a serious adverse outcome for one of our patients. What you describe, though, does not seem particularly egregious and does not sound like the kind of occurrence that would be likely to give rise to a malpractice suit.

 

[Stagg737]

Long story short, I had an older patient on sedating meds which I had been working to minimize. Last time I saw her she was having poor PO intake and I focused on enhancing that and getting her to be medically evaluated in the ER because she is also diabetic on insulin (which she did not follow through on, and it was telemedicine so I could not arrange direct transport). In hindsight I should have probably lowered her meds because blood levels could have been going up. She then proceeded to have a bad fall a few weeks later. Family got involved and expressed concern about her being over medicated, saw PCP and sat down with in house pharmacist to review meds.

I feel horrible that I didn’t expedite lowering meds at that particular time and am of course paranoid that I will be sued again, and if you are sued too often your malpractice can drop you and there goes my otherwise good job. The first lawsuit was frivolous a couple years back but this won’t be. Patient saw me again and did not seem to cast any kind of blame on me, but who knows….

I was doing relatively well with my mental health and balancing work stress, and now this has set me back again. 🙁((( It’s like, the nothing lawsuit was still traumatic in that I’m now always worried it will happen again.

Three things:

1. As others have said I don't think you realistically have anything to worry about. Sounds like you were focusing on a major problem that you felt was more urgent than decreasing the meds at that visit and that decreasing sedating meds has been a goal. Maybe blood levels went up, but how can you know that? Ordering levels in this situation was almost certainly unnecessary. You recommended she seek further care in the ER and she didn't, not your fault at all. Remember that you can't control most things that patients do, don't stress about the things that you cannot realistically control. They sat down with PCP and pharmacist, good. Sounds like this was necessary and in the hospital/immediate f/up is exactly when they should do this. Again, if this is what it took for family to get involved and pay closer attention, that's not something you can control.

2. This exact situation happens ALL. THE. TIME. Old people fall. Old people are on ridiculous medication regimens. Old people on ridiculous medication regimens fall. It happens. Here's evidence from the CDC: Keep on Your Feet.

Unless you're basically snowing/obtunding this patient with your meds, are grossly over-prescribing, or are ignoring black box warnings and not educating the patient, this would be a frivolous lawsuit. Additionally, you've seen the patient and they don't seem to blame you. Sounds like you've at least got decent rapport and that your patient is reasonable. Realize you had good reason for what you did, be happy your patient is okay, and move on. Sounds like the patient already has.

3. Your usual neuroses are showing. Close your eyes, take a deep breath, etc. Imo the bolded is more concerning than anything that happened with the patient at this point and sounds like you may have some actual ongoing PTSD. Not medical advice, but if you're still seeing your therapist (which I would assume you are), talk to them about it.

 

[hallowmann]

You'll be fine. We see something like this on an almost weekly basis. If those community psychs and NPs aren't getting sued, you definitely won't, especially if you were in the process of deprescribing/weaning to prevent the exact thing that happened. Chalk it up to a sucky situation that now demonstrates to the patient why its so important to get them off of at least some of those meds.

 

[Merovinge]

You'll be fine. We see something like this on an almost weekly basis. If those community psychs and NPs aren't getting sued, you definitely won't, especially if you were in the process of deprescribing/weaning to prevent the exact thing that happened. Chalk it up to a sucky situation that now demonstrates to the patient why its so important to get them off of at least some of those meds.

Absolutely, this happening without significant consequences (e.g. no mention of a hip fx) is actually a good thing and likely to improve long-term morbidity AND mortality in this patient as they/family understand the need to reduce polypharmacy. I think the initial post is much more a trauma response of the poster than a particularly negative clinical outcome.

 

[meow1985]

Absolutely, this happening without significant consequences (e.g. no mention of a hip fx) is actually a good thing and likely to improve long-term morbidity AND mortality in this patient as they/family understand the need to reduce polypharmacy. I think the initial post is much more a trauma response of the poster than a particularly negative clinical outcome.

So I could have been more specific. Patient broke their humerus and is in rehab for a few weeks. Still, my internist friend told me that those kinds of fractures typically heal fine, though they are a drag. The reason why I think I was to blame was because the pharmacist mentioned my meds as a potential reason for the fall. But of course it’s not the only issue that led to the fall. Falls are often quite multi factorial. For instance, it was later discovered the patient was taking liberal amounts of an OTC antihistamine and no one knew.

 

[Merovinge]

So I could have been more specific. Patient broke their humerus and is in rehab for a few weeks. Still, my internist friend told me that those kinds of fractures typically heal fine, though they are a drag. The reason why I think I was to blame was because the pharmacist mentioned my meds as a potential reason for the fall. But of course it’s not the only issue that led to the fall. Falls are often quite multi factorial. For instance, it was later discovered the patient was taking liberal amounts of an OTC antihistamine and no one knew.

Ah okay, that makes a bit more sense. I do still think given an ignored active recommendation for ED visit and actively working to reduce these medications that there is essentially zero liability. I can imagine some concern since there was a fx though. Bad things happening to our patients is the burden of being a physician, we stand with those at their darkest times and serve as vanguards. One does not join the Avengers and not expect to see combat with the forces of evil.