Guilt, fear after medical error can be bridged
Guilt, fear after medical error can be bridged
Careful steps can yield solutions — and forgiveness
A medical error creates guilt, fear, and loneliness for both the caregiver and the patient and patient's family — feelings that can lead each side to withdraw unless efforts are taken by all parties to develop solutions and foster forgiveness.
Much attention is given to prevention of errors and defusing potential for lawsuits, but Tom Delbanco, MD, and Sigall K. Bell, MD, both of Harvard Medical School, suggest that's only part of the solution.
"How can we characterize and address the human dimensions of medical error so that patients, families, and clinicians may reach some degree of closure and move toward forgiveness?" they ask in a recent commentary in the New England Journal of Medicine.1
Though there is a movement among health care providers nationwide to assume transparency when an error occurs — to acknowledge and disclose the error, and apologize for it — too often, fear keeps physicians and patients (or their families) from talking to each other.
According to Delbanco and Bell, while it has been well recognized that clinicians feel guilty after medical mistakes, family members often have similar or even stronger feelings of guilt. Further, patients and their families may also fear further harm, including retribution from health care providers, if they express their feelings.
Fear and guilt on the part of clinicians may further isolate patients, when fear of loss of reputation or license, or distress over the outcome of the mistake, cause them to avoid patients who have suffered harm, the authors say.
According to John Banja, PhD, assistant director for health sciences and ethics at the Emory University Center for Ethics in Atlanta, quickly creating a "transparent, empathetic conversation" after an error is realized is crucial to limiting the damage.
"We don't often think about how the patients may be traumatized into silence," says Banja. "And while patients or their families may be traumatized into silence while they're still in the hospital, once they get out of the hospital, that guilt and distrust and terror they felt while in the hospital might translate into anger, and that's when they go see a lawyer."
Truth, responsiveness key to dialogue
Family members of a patient hurt by a medical error sometimes will blame themselves — for not being present at the time, not monitoring care, not asking the right questions or anticipating the mistake, Delbanco and Bell suggest. Concurrently, physicians who are directly or peripherally involved in a medical mistake may assume the family will automatically be adversarial, and so distance themselves from them.
For both reasons, Banja says, honest and direct communication at the very earliest point following discovery of an error is important.
"There are two stages we're talking about here, and two sets of experiences," says Banja. "The first stage is simply the brute fact that this error occurred. The second stage occurs afterward, when the family or patient becomes more angered, more upset, and if no one is talking to them, they feel disbelief and a sense of injustice.
"If they sense that something went wrong and the health care team doesn't address it with a truthful, honest account of what happened, then you go to stage 2."
Some 30 states have adopted forms of so-called "I'm Sorry" laws, which permit health care providers to apologize for errors without the apology being used as an admission of guilt should litigation arise from the mistake.
But there remains some lack of clarity as to how much a physician can say when issuing an apology; medicolegal experts have said some of the laws allow providers to apologize, but don't protect them if they discuss specifically what they are apologizing for.
"Organizations need a policy that provides that you disclose a medical error in a truthful way," says Banja, who is a board member of the Sorry Works! Coalition, which advocates for disclosure, apology (when appropriate), and upfront compensation after adverse medical events occur.
Banja says keeping the patient or family in the loop as the error is investigated is important.
"That's what doesn't happen — there may be a lapse in time between when they're told an error happened and the conversation picks back up while the hospital investigates, and the family can feel dismissed during that time," he explains. "What doctors and hospitals have to do is really understand more keenly and empathetically what patients and families are experiencing during the time this is going on."
One way of including families is to give them the name, phone number, and pager number of someone within the organization who they can reach anytime, night or day, with questions about their family member's care or about the investigation.
"Also, when a family says, 'We want names,' that's a contentious issue — do you protect the nurse who gave the wrong medication? Most of the time, there's more than one person involved in a medical error, so do you just come out and give the names?" Baja continues. "The family will find out sooner or later, so maybe the response should be, 'We can give you the name, but right now we are investigating what happened, and we don't know exactly what that persons' involvement is yet, but when we find out what happened, we'll tell you.'"
Possible to regain trust?
Delbanco and Bell say that doctors who frankly admit their mistakes and tell patients how they would safeguard against repeating the errors not only can avoid litigation, but also may be able to rebuild strong, long-lasting bonds with the patients and their families.
Saying "I'm sorry" and taking steps to prevent a recurrence of the error can reduce ill will. But is re-establishing trust after a medical error too much to ask? Banja says it strongly depends on the parties involved.
"Re-establishing trust [in the health care provider or hospital] depends on how narcissistic the family is," says Banja, who has written on physician narcissism, the need for physicians to protect their reputations as competent, authoritative, and even perfect — a need that conflicts with admission of error.2 A "narcissistic" family might be one whose outrage at the personal harm that has come to them makes forgiveness and trust difficult, or impossible.
"I think that if I were the doctor and I was in error, in disclosing the error I might say, 'You might not want me to continue taking care of your mother, and please know that's a totally understandable decision.'"
References
- Delbanco T, Bell SK. Guilt, fear, and loneliness often plague patients, families, and caregivers in wake of medical error. N Engl J Med 2007;357:1,682-1,683.
- Banja J. Medical Errors and Medical Narcissism. Sudbury, MA: Jones and Bartlett Publishers Inc.; 2005.
Sources
For more information, contact:
- John Banja, PhD, assistant director for health sciences & clinical ethics, associate professor of clinical ethics, Center for Ethics, Emory University, 1462 Clifton Road NE, Atlanta, GA 30322. E-mail: [email protected].
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