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Page 1
A journalist in the UK who died in 2001 of throat cancer expressed surprise that many doctors had not yet found a way to give bad news to patients that would serve them comfortably in the majority of cases.
There is substantial education and research data on the communication of bad, sad, and difficult news, but little evidence that such encouragement alone can substantially improve behavioural styles of health-care professionals.
Although many courses and workshops exist to help doctors improve their communication skills, few empirical data show that these improvements are sustained over time.
We reviewed research done in different parts of the world on how to communicate sad, bad, and difficult news effectively. We focus mainly on problems encountered from three areas of research involving parents, people in acute trauma situations, and patients with cancer.
What is bad news in medicine?
Information that alters a person's expectations about their present and future could be considered bad news. Bad news has gradations, which are dependent on an individual's life experiences, personality, spiritual beliefs, philosophical standpoint, perceived social supports, and emotional hardiness.
Search strategy
We searched several databases for relevant studies on receiving bad news, breaking bad news, and the effects of breaking bad news on patients, doctors, and hospitals.
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Doctors frequently censor information they give to patients about outlook, because they believe that what someone does not know cannot harm them. Such traditional paternalistic attitudes can still be seen despite moves towards increased autonomy and empowerment for patients.
Patients’ and families’ needs
Patients' and relatives' reactions to receiving bad news depend on many factors, including expectations, previous experiences, and general personality disposition. The way in which bad news is conveyed can substantially influence patients' emotions, beliefs, and attitudes towards the medical staff.
Although many personal and moving anecdotal reports have been published in the medical and lay press, few researchers have systematically assessed how patients or the families felt immediately after having received bad news. Although not impossible, asking the recipients of bad news questions immediately after the event can
be impractical.
Difficulties faced by health-care professionals
Table 1 shows that health-care professionals have different views on breaking bad news, and that inadequate training is a major factor contributing to their high rates of burnout and psychological morbidity.
In a study of videotaped consultations, doctors thought they performed worse when palliation was discussed than when potentially curative treatment was discussed.
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Bad news in different specialties Obstetrics and paediatrics
Parents hope for an uneventful pregnancy, a safe delivery, and a normal, healthy baby. When things do not follow the anticipated pattern and a baby is born damaged or dead, it is extremely distressing to all concerned.
Parents are often clear many years later about the communication that helped them deal with the sad and bad news that their child had died. Police officers were praised as being good informants.
In one US study, 16 of 18 families felt shocked and upset after being told their child had neurofibromatosis. This led to depression.
Although parents' complaints about poor communication surface in many other studies,31 the reports also show
some of the more positive experiences. The most important attributes for family members when receiving bad news are privacy, attitude and knowledge of the news bearer, and clarity of the message.
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A National Health Service Trust in Portsmouth, UK, developed a 1-day workshop for all professionals working with critically ill patients. It includes precourse reading, informal and interactive seminars, practical demonstrations, role play, and discussion.
The European Donor Hospital Education Programme was devised to address the problems that relatives report and to meet the training needs of clinicians and nurses who feel uncomfortable approaching bereaved relatives about donation. It consists of two parts: a hospital-based lecture and a 1-day grief response and donation request workshop.
In 1995, a programme was introduced to improve the communication skills of intensive-care unit doctors and nurses. The improvements were not maintained over time.
Consultations with patients and their relatives within oncology pose many difficulties. Parents appreciate doctors
who are confident, show concern, and are caring, but also allow them plenty of time to talk and ask questions. A severe breakdown in communication between health-care professionals and parents can lead to distressing and
stressful situations, and may result in long-term investigation. The Bristol Inquiry recommended improving communication between doctors and parents and between multidisciplinary team members.
SCOPE, a UK organisation that campaigns for equality in society for people with cerebral palsy, worked with other voluntary organisations and professional bodies to improve the way the diagnosis and disclosure of disability in children was presented to parents. The Right From the Start resource pack offers information and support for developing and training in the communication of a disabled child's needs. It includes a template for developing local policies and background reading materials, videos, and a website.
Staff in accident and emergency departments often have to tell families bad news. The experience can be stressful and the communication can be thwarted by time constraints and political imperatives to meet targets and contain costs.
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Patients' perceptions of the way doctors deliver bad news alter understanding, decisions about treatment options, and later adjustment.
In an Australian survey, patients wanted to be given the diagnosis and prognosis honestly and in simple language, but not too bluntly. The difficulty for most doctors is getting the balance right, of being honest but at the same time encouraging, hopeful, and supportive.
Patients with head and neck cancer want their doctors to be truthful, caring, and compassionate, to speak in simple terms, and to use unambiguous language. However, ambiguity is common in cancer consultations, and health-care professionals are sometimes unaware that they have conveyed the wrong meaning.
Too much emphasis is placed on the communication of bad news by one individual. Multidisciplinary teams frequently have little awareness about each other's informational roles and responsibilities, and collusion with relatives to deceive patients about their situation is still evident.
Interventions to help communication Guidelines
There are many guidelines and recommendations for how doctors should prepare themselves before imparting bad news, and how difficult information should be given. The empirical basis for guideline development is important, in particular checking that guidelines have some face validity, are ethical, practical, and address patients' needs.
There is some congruence between guidelines and the views of patients and relatives as to how unpleasant news should be delivered, but significant evidence for their implementation in a clinical setting without further content and methods of courses aimed at improving communication in general should be assessed.
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Conclusion
The delivery of sad, bad, and difficult news to patients will always be an unpleasant but necessary part of medicine. Training health-care professionals how to do the task more effectively will produce benefits for them as well as their patients, but training is lacking.
Many training courses on breaking bad news have been reported, but most use self-report of confidence ratings
before and after course and acceptability of the training as their outcome measures. These measures provide little hard evidence of effectiveness for transfer of good skills into practice.
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Communication with cancer patients is important, but there are many factors to consider. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM, Fallowfield LJ, Clark AW, Chan A, Woodruff RK, Butow PN, Dunn SM, Tattersall MH. There are several studies that look at how doctors break bad news to patients, including Chapman K, Abraham C, Jenkins V, Fallowfield L, Poole K, Kirwan JM, Tincello DG, Lavender T, Kingston RE, Rabow MW, McPhee SJ, Cegala DJ, Lenzmeier Broz S.
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A pediatric department's evaluation of a simulated intervention to teach medical students to give bad news. Communication skills training for health professionals working with cancer patients, their families and/or carers (Cochrane Review) includes teaching physicians how to break bad news, using standardized parents, a 1-day workshop, experiential sessions with standardized patients, and a 12-month follow-up.
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In this article, we discuss how to improve health outcomes for multicultural U.S. society by reducing cross-
cultural miscommunication.
All ethnic minority populations in the United States lag behind European Americans (whites) on almost every health indicator, including health care coverage, access to care, and life expectancy.
Physicians and patients from different cultural backgrounds are becoming more common. However, most clinicians lack the information to understand how culture influences the clinical encounter and the skills to effectively bridge potential differences.
The authors provide an anthropological perspective of the fundamental relationship between culture and health, outline the clinical skills required to negotiate among potential differences, and indicate the structural changes needed in the health care setting to enable such practice.
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Maternal mortality is higher for African Americans, Vietnamese women and Hispanic women are at higher risk for cervical cancer, and diabetes and its sequelae are more prevalent in ethnic minority populations.
While not completely understood, health disparities are attributed to barriers to routine access to preventive care, low levels of cultural competence among health care professionals, and lack of proportional representation
of minorities in the health professions.
Theoretical models outside the traditional biomedical paradigm offer promising constructs to reduce the disparities in health care. By recognizing the integrity of each culture, the culturally-based systems approach fosters respect for diversity and optimal care for patients and families.
The function of any culture is to ensure the survival and well-being of its members within a particular ecologic niche. Cultures define health, determine the etiology of diseases, and prescribe the appropriate means to treat the disorder, both medically and socially.
Culture provides meaning and purpose to life by manipulating the environment, making cognitive and emotional sense of the chaos around them, and providing social support.
Culture is woven into an integrated whole fabric, and the symbols and metaphors used in the weavings express the ethos of each culture. Culture is analogous to the warp and woof or the perpendicularly woven threads of a tapestry, and provides individuals with the beliefs and values that provide meaning in life and a sense of identity,
and the rules for behavior that support an individual's sense of self-worth. In one study, Japanese Americans and European Americans experienced similar emotional responses to cancer, but the Japanese Americans
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experienced more distress than the European Americans, who used the idiom of fighting an external enemy.
Page 11
The Western European and U.S. belief system that human beings are made in God's image and are central to the meaning of the universe is fundamental to the Western health care system.
The Office of Management and Budget designated six racial/ethnic categories to monitor political allocation of resources, not as scientific evidence of genetic differences. Genetic studies indicate greater within-group variation among members of these six categories than between groups, thus rendering these categories as social/ political constructs.
Each of the six OMB-defined racial/ethnic categories contains many distinct national groups and multiple ethnic groups within each national group, each with its own culture or subculture. The clinician must assess the strengths of and potential conflicts with individual patients and their families.
Cultures are not homogeneous or monolithic, and each cultural group is contemporaneously undergoing modifications and mixtures that render it different from the cultural group of origin, and uniquely American.
Most research focuses on the vulnerabilities of non-Western/European-American cultures, rather than the protective and health-promoting beliefs and practices of these cultures. This bias in research clouds our ability to see equal validity among different cultural strategies to meet life's adversities.
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Culture is a multidimensional and dynamic concept that is vaguely conceptualized and inaccurately used in medical training and practice. If physicians attended to the influence of culture on health behavior, outcomes of medical care might well be improved.
The fundamental unit of medical care is the doctor/patient-family dyad. However, doctor-patient communication pedagogy in biomedicine and Western bioethics is based upon monocultural Western European-American concepts, values, and beliefs, which are rarely seen as culturally bound and therefore seen as unnecessary.
The new paradigm for practice would support cross-culturally expert practitioners with the ability to differentiate culturally dependent from culturally independent normal and abnormal beliefs and behaviors. The outcome would indicate that patients and families are able to promote, maintain, and regain mutually desired health.
Culturally competent medical practice is the ability to make an accurate diagnosis and negotiate mutually satisfactory goals for treatment.
The culturally-based systems approach is a template for culturally competent practice, and it is based upon the proposition that an individual must be sufficiently knowledgeable about both his or her own culture and other cultures.
Human behavior is geared toward fulfilling the three universal human needs of safety and security, integrity and meaning, and a sense of belonging. Distress and disease are experienced in a sociocultural context that can both potentiate and/or ameliorate the condition.
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In a cross-cultural encounter, the physician and patient have four alternatives for communication: the physician could work exclusively within the biomedical paradigm, the patient could work within his/her cultural framework, or they could negotiate between their concepts.
After providing adequate information to patients and families to make informed choices, clinicians are often challenged to honor individual choice and patient autonomy when the decisions of the patient's family counter the clinician's best judgment.
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Miscommunication is likely when a physician uses his or her Western biomedical template of treating disease and illness as the right way, rather than one of several options. The essences and rationalities of other cultural patterns are lost, and the prescribed intervention would probably fail.
The culturally-based systems approach requires the practitioner to acknowledge his or her own cultural beliefs and values, and to evaluate the patient's responses objectively. The practitioner can use knowledge about
particular cultural beliefs, values, and practices as hypotheses about an individual patient's beliefs and practices.
Understanding the patient as an individual in the context of culture helps to prevent conflicts over differing values, beliefs, or practices.
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Culture of the Patient/Family—Whose ‘‘Gold Standard’’ Should Be Used?
Anthropologists make an important distinction between disease and illness, which provides physicians with a way to tease out the influences of culture on the disease experience.
Biomedicine views most diseases as natural mechanistic errors that can be corrected with interchangeable or repairable parts. The spiritual or metaphysical causes of disease have little credibility in Western biomedicine, and the efficacy of treatments for these diseases has yet to be widely tested.
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The effect of ethnic minority status on American groups of color is essential to understand the phenomenon of differential treatment in medical care and the necessity for culturally competent practice.
Culture of the Organization and Institution
Most mainstream health care agencies are structured within the European-American cultural model. They will need to make major structural and process changes to transform themselves into multicultural agencies that will
provide optimal care to all segments of the U.S. society.
Hospitals are associated with problems in terms of the intensity and quality of care, and minority patients have more trouble getting appointments and waiting longer to see the physician even with insurance.
Culturally competent practice requires institutional commitment and the creation of infrastructure to promote and
support patient and employee diversity, and responsiveness to cross-cultural issues. Specific interventions include recruiting ethnically diverse faculty and attending medical staff.
An internal quality improvement project team comprised of multidisciplinary staff from all levels of the organization, reflecting the diversity of the populations served, could guide and lead the initiative to develop a cross-cultural education curricula based on the values and principles outlined in numerous theoretical models for health care practitioners.
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Evaluation
Donabedian's model of structure, process, and outcome provides a useful framework for assessing the nonclinical aspects of proposed institutional changes to promote and support culturally competent practice.
Measures of structure and process for cultural competence include representation of cultural diversity among physicians, management and nursing staff, management support and accountability for cultural competence training of staff, staff motivation to participate in training, and multidisciplinary participation in training.
Patient satisfaction measures should reflect changes in health behaviors and health care utilization patterns, as well as improvements in health outcomes for culturally diverse groups.
Culture is fundamental to the development and management of disease in every population, and physicians would benefit by learning how to be cross-culturally effective.
The tapestry metaphor concretizes how cultures express their identities using the universal technique of weaving their multiple elements into unique wholes. Individuals are unique and develop their own interpretations
of cultural ''guidelines.''
To implement a culturally-based systems approach, first be aware of your own beliefs, values, and biases, then conduct a RISK reduction assessment, and finally institutionalize structural and systemic changes to provide optimal care.
The logic of cultural construction makes it impossible to view cross-cultural differences as epiphenomenal. Physicians must build skills necessary for cross-cultural expertise to improve health outcomes and increase quality of life.
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Foster GM, Anderson BG, Fadiman A, Bronfenbrenner U, Ceci S, Jones MR, Bond ML, Kagawa-Singer M, Airhihenbuwa CO, and others have written about the impact of culture on the cognitive structure of illness, and the role of culture in outcomes management. Racial disparities in physical and mental health: socioeconomic status, stress, and discrimination. Kagawa-Singer M, Ying YW, Lee PA, Tsai JL, Yeh YY, Huang JS, Singh GK, Yu SM, Porter CP, Villaruel AM, Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications.
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Gudykunst, Ting-Toomey, Wellesz, Sternfeld, Lukes, Individualism, The Age of Enlightenment, The Age of Individualism, and Ersek, Multicultural considerations in the use of advance directives. A number of articles have
been written about cultural issues in end-of-life decision making, including Johnson FA, Marsella AJ, Johnson CL, Kleinman A, Jackson LE, Kagawa-Singer M, Heelas P, Lock A, Charmaz K, Kleinman A, Pietsch JH, Blanchette P. Eisenberg L, Fabrega H, Lemelson RB, Schulman KA, Tervalon M, Murray-Garcia J. The effect of race and sex on physicians' recommendations for cardiac catheterization, and Levy D. White doctors and black patients: influence of race on the doctor-patient relationship.
Ethnicity is a risk factor for inadequate emergency department analgesia. A checklist for the examination of cultural competence in social service agencies was developed by Isaacs MR, Benjamin MP, Dana RH, Behn JD,
Gonwa T, Klessig J. The relationship between patient race and the intensity of hospital services is discussed, as
well as the responsiveness of health services to ethnic minorities of color, and the importance of enhancing the racial and ethnic diversity of the pediatric workforce.
Page 20
A survey of 1,891 physicians nationwide found that although two-thirds agree they should share serious medical
errors with their patients, one-third do not completely agree. Nearly two-fifths do not disclose their financial relationships with drug and device companies.
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Many doctor errors are simply a matter of bad luck, and some bad outcomes are not really the physician's fault. Doctors may be reluctant to admit their lack of control over a situation, but patient families are usually forgiving and rarely sue.
Why would a doctor not be honest about a patient's disease or prognosis? Because doctors are not always the best communicators.
Our medical system pays doctors handsomely to do medical procedures, but does not reimburse well for talking
to, counseling and spending time with patients.
Telling a patient bad news is horribly difficult. It is harder for me to tell a patient they are dying than to tell a family member they have died.
We need to transform health care by empowering patients and by more members of the medical profession realizing the meaning of the term "profession".
Page 22
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More than 55% of physicians described a patient's prognosis in a more positive manner than the facts might support. These survey results are unsettling.
Page 23
The CNN survey about dishonest doctors is sad, but take it from the perspective that these surveys are blind and the answers were quite likely honest. To those who don't feel doctors should be portrayed in a negative light, I say don't do wrong or admit when you do.
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The Health Industry needs an investigation to protect patients with Chronic Health Conditions, because the importance of the "Free Enterprise" by local, national Political Agendas clearly establishes the fact that not even citizens, consumers or patients are taken seriously.
Medical professionals are just men and women, basic human beings, not the gods some of them think they are. Most of them barely made it through medical school with very good grades, so we get lies, cover-ups, mistakes and bad attitudes.
The relationship between a patient and their doctor is complex. I have learned that doctors are caring and honest, and have given my mother years to enjoy life.
Page 24
Four years ago, a well known, educated and trained surgeon cut my L-5 nerve leaving permanent damage and burning pain. He lied to my husband and four children post-op about what had happened.
I am a surgeon and physician, and while I am you...I would like to respond to the article. I have made and seen mistakes in the OR, both minor and major, and each time I told the patient and their family that a mistake occurred.
My back surgeon covered it up, and now I see him as a potential liar.
I think it is inexcusable for the medical culture to accept lying. Patients need honesty to heal themselves.
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I resent this article generalizing physicians into a group of "liers", because making a judgement about how to best communicate information regarding serious health concerns does not make one a "lier". It creates a sensationalist headline that increases mistrust among patients.
CNN did not vet this article nor the survey, and does not seem to vet any article from anyone. Tabloid journalism
seems to be the ONLY news fit to present.
The article was not generalizing doctors into a group of 'liers', and the author listed statistics from surveys that make it pretty clear what the breakdowns are.
Page 26
Doctors are fierce, merciless and often successful competitors. They spout silky sweet platitudes about the "poor" patient, but work day and night to correct the situation by threats, coercion, sabotage, bribery, collusion, chicanery and sycophancy.
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When Internal Medicine Residents Use Deception With Their Colleagues
Two versions of a confidential survey were distributed to all internal medicine residents at 4 teaching hospitals in
1998.
Three hundred thirty surveys were distributed, and 36% of respondents indicated they were likely to use deception to avoid exchanging calls, 15% to protect patient privacy, and 6% to protect a colleague.
Internal medicine residents are likely to deceive a colleague, and medical educators should be aware of circumstances in which residents are likely to deceive, and discuss ways to eliminate incentives to lie.
Physicians commonly use deception in other contexts, such as lying to patients and insurance companies, and they have strongly negative attitudes toward moral lapses. In this article, we report findings from a survey of internal medicine residents about their likelihood of deceiving colleagues.
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SUBJECTS AND METHODS
We developed a survey to assess physicians' attitudes toward using deception in their interactions with colleagues. The survey included 7 vignettes that addressed 5 reasons a resident may be motivated to use deception: to avoid extra work, to protect a colleague, to avoid embarrassment, and to cover up a mistake.
We developed 5 vignettes in which residents were asked to exchange calls with colleagues, substitute their own
urine for a colleague's urine drug screen, report a laboratory result, protect a patient's privacy by falsifying a diagnosis, and fail to perform a rectal examination.
Subjects were asked to indicate how likely they would be to use deception in a particular case. Demographic information was obtained from each subject, and several questions were asked about attitudes toward, and experience with, deception.
We hypothesized that factors such as the consequences of being truthful, the chance of being caught, and the effect on patient confidentiality would influence physicians' stated likelihood of deceiving a colleague. We tested these hypotheses by comparing responses between survey versions.
We hypothesized that residents would indicate that their peers were more likely to use deception than they were. The McNemar test and Pearson x2 test indicated that significant associations existed between demographic variables and deception.
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We sought to answer 3 questions about the likelihood that residents would deceive other physicians.
Of the 330 surveys distributed, 222 were returned, and the mean age was 30 years. There were no significant differences in respondent characteristics between survey versions.
Thirty-six percent of residents were very or somewhat likely to use deception to avoid exchanging call, 6% were likely to substitute their own urine in a drug test to protect a colleague, 14% were likely to fabricate a laboratory value to an attending physician.
FACTORS THAT INCREASE THE LIKELIHOOD OF USING DECEPTION
Residents were malleable about using deception with their colleagues, and the reason for the request affected the likelihood of deception. When a colleague wanted to attend a bridal shower, 44% said they were likely to lie.
Residents were marginally more likely to intentionally misrepresent a diagnosis in the medical record to protect a patient's privacy if the diagnosis was the more stigmatizing condition of genital herpes.
The manner in which attending physicians responded to residents who were unable to recall a precise laboratory value affected the likelihood that residents would fabricate a laboratory value. Women were 8 times more likely to indicate they would fabricate a laboratory value than men.
Page 30
The likelihood that residents would lie about checking for blood in a patient's stool was marginally correlated with the patient's medical outcome.
Most respondents indicated that deceiving colleagues was not acceptable behavior, and only a few agreed that it was acceptable if no one got hurt.
DECEPTION BY PEERS
Although residents indicated it was wrong to deceive their colleagues, a substantial percentage reported they had witnessed other residents intentionally doing so. Nevertheless, only 1 out of 5 vignettes showed that residents believed their peers were more likely to use deception than they were.
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Physicians indicated that under some circumstances, they would be likely to use deception with their colleagues. While there is widespread agreement that explicit lying is morally suspect behavior, there is debate about whether physicians have a similar duty to avoid all other forms of intentional deception.
Medical residents are likely to lie about essentially private matters, and many believe they can separate their private and public behaviors without causing lasting harm. Although we would not condone such actions, it is a reasonable subject for debate whether the medical profession ought to be concerned about deceptions of this nature.
Residents are more likely to lie about clinical than nonclinical issues, and are more likely to fabricate laboratory values when concerned about being ridiculed. This undermines effective clinical communication and may even have a direct bearing on a patient's medical outcome.
Nineteen percent of responding residents said they would misrepresent information in the medical record to protect a patient's privacy about genital herpes. This practice is ethically troubling because it could harm the patient if the deception is discovered or if the patient believes he or she has a disease that is not present.
Figure 3 shows that the general attitudes towards deceiving colleagues are negative. The few residents who said they were likely to substitute urine emphasized the duty one has to friends and colleagues and the unreasonableness of mandatory drug screening policies.
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Residents said they were motivated to deceive to avoid being ridiculed and feeling embarrassed. Female residents were particularly susceptible to such pressure, and those involved in medical education should be aware of the adverse effects of certain teaching styles on resident behavior.
Residents' willingness to use deception to avoid exchanging call compared with issues of clinical importance raises a question about physicians' perceptions of their moral duties. Do residents believe they have different ethical obligations in their professional and private lives?
This study has several limitations, including the fact that we can't know whether respondents actually use deception in these situations, that they could interpret the scenarios in multiple ways, and that responses may be affected by a social desirability bias.
Most internal medicine residents report they are unlikely to deceive colleagues, but a small percentage say they would lie to a colleague to avoid doing that person a favor. In light of these findings, medical educators should include issues of professionalism and collegiality in the ethics curriculum, be aware that residents exhibit a wide range of moral behaviors, and educate attending physicians about the potential impact of their own teaching styles on residents' behavior.
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Instead of explaining how high blood pressure affects the heart in detail, try giving more specific advice, such as
"take your medication and get some exercise" or "walk around the block once in the morning and again in the afternoon."
While some patients will have researched their condition on the Internet, others may not even recognize the name of their disease. It's useful to start out by asking what they already know about their health.
If you think you're doing a great job of communicating with your patients, ask them if they have any questions and ask them to repeat information back to you if they don't understand.
Dr. Levinson said you may need to alter the treatment plan or spend more time educating the patient. Dr. Smith suggested concluding patient encounters by asking the patient to explain what they have learned during the visit.
Experts say you shouldn't worry about overloading patients with information, but rather about providing them with the information they need.
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Therapeutic privilege is the practice of withholding pertinent medical information from patients in the belief that disclosure is medically contraindicated.
Withholding medical information from patients without their knowledge or consent is ethically unacceptable. Physicians should honor patient requests not to be informed of certain medical information.
Physicians should consider delaying disclosure only if early communication is clearly contraindicated. They should communicate with patients sensitively and respectfully.
Page 40
During the 1990s, apology laws were introduced to reduce the rate of medical error. The laws prevent a health care worker from expressing sympathy or regret.
Apologe laws decrease clinicians' and administrators' reluctance to disclose errors, which encourages more openness about medical errors and the systemic changes needed to improve patient safety. Apologe laws could
also advance other ethical objectives, such as promoting patients' best interests.
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The Joint Commission on Accreditation of Health Care Organizations requires hospitals to inform patients about unanticipated outcomes. The National Quality Forum has issued guidelines endorsing disclosure.
Although apology laws are popular among state legislatures, their impact on medical practice remains uncertain.
One question is whether apology laws confer sufficient protection.
Apologies reduce the chance that patients and families injured by medical mistakes will sue. Apologies also promote trust in physicians and health care institutions, which may help clinicians and institutions in malpractice cases.
Although some observers think that increased communication about medical errors will make error victims less likely to seek legal redress, they also think that more openness about medical errors will enlighten ignorant patients and encourage them to pursue legal remedies.
The debate over the effect of apology laws on malpractice sidesteps a more fundamental ethical question: what is owed to people harmed by medical errors? If apology laws reduce the risk of malpractice claims, they may unfairly burden patients and families.
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When institutions combine disclosure and financial assistance, patients and families can avoid the high costs of litigation.
Whether apology laws and mandatory disclosure programs will have a significant impact on medical practice remains to be seen.
The most significant barrier to disclosure and apology may not be the outside world, but the inside culture of hospitals and the medical community. Physicians' considerable knowledge and power enables them to achieve success in concealing errors.
Wei and others contend that without changes in medical culture, significant movement toward transparency about errors is unlikely. They say that apologies should be considered an essential part of the practice of medicine and should be included in clinical training.
Experts suggest that apology laws will be less influential than disclosure programs that are driven by institutional
leadership and a work force committed to transparency.
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An 80 year old male is being questioned by the staff about dancing in the emergency room. The male is told that
if his mom were here she would not let him get away with this.
Nurse N comes in and puts an IV in the girl, takes some blood, does an EKG, and inserts a catheter to make sure there's nothing wrong with her heart. A doctor will be in a few minutes to give instructions, but the patient needs a catheter. The doctor is late, but the patient's life is crazy too. Julie's father refused to leave her son alone in a place like this, so he put some oxygen on him in case he was having a heart attack.
Page 43
Joe Foreman was having chest pains while rehearsing for a show, and the doctor wasn't quite sure what was going on, so he brought him here. Joe, 80 years old, is getting pain in his back. It's not really a pain, more like an ache, and it comes and goes. Joe's chest pain is not sharp, stabbing, burning, or going anywhere. It is not associated with heartburn, an ulcer, or diabetes, and he doesn't take any pills for anything. F: I don't know what he's talking about, I didn't even know he had Gout. D: Well it doesn't really matter that much.
Page 44
D: I'm not really sure what's going on here yet. We'll do some tests, and then I'll write for some medication to help with the pain. A friend of mine had an aneurism and dropped dead right in front of his doctor, and bled to death. The doctor said he doubted it was an aneurism, but they can't rule anything out yet. Eight hours after Joe's chest pain began, Julie filled out paperwork in the doctor's office. The doctor said Joe was good to go and Julie could get him dressed. The doctor enters and says that the patient is okay, that there was no sign of a heart attack or pulmonary embolism, and that it was probably a muscle strain. The doctor prescribes an H2 blocker for acidreflux disease until the patient can see someone.
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F: Okay, but can you recommend someone in the neighborhood? D: Sure, but the nurse can get you the number or she can make the appointment for you.
Joe, it was good meeting you, be careful out there, and let's blow this pop stand.