Transcript Managing treatment complications…

Complication ???
Breaking the news !!!
G N Ramesh
PVS Memorial Hospital
Kochi
Complications happen …… to every one.
The busier you are …… the higher the risk
A good endoscopist …. does many ..... gets away
with it.
A professional one …. does many …. May have the odd
complication … handles the aftermath with calm,
assurance and common sense.
Complications in GI endoscopy
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The challenge….to keep it to the
minimum
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The science……effective management
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The ultimate trial….. To deal with
complications at a personal, psychological
and social level .
“ Don’t read stories of success
Read stories of failures.
Success stories give messages
Stories of failures give new ideas to win ”
One of the golden rules of life!
‘ If you deserve to blossom like a rose in
the garden,
‘ If you deserve to blossom like a rose in
the garden,
you have to learn the art of adjusting with
the thorns ’
- Anonymous
What could go wrong ?
Desired result not achieved
 Co morbid illness related event
 Bleed
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What could go wrong ?
Desired result not achieved
 Co morbid illness related event
 Bleed
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The worst !!!
Perforation
 Cardiac arrest on table
 Colleague related event
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Situation ….Saturday afternoon
68 year old thin lady
screening colonoscopy
5th on a list of 6 cases.
all bags packed….ready to go.
prep took a little while longer…
finally clear at 3 pm.
difficult sigmoid………..hell!!!
Then the recap starts……..
Did I need to do it ?
 What have I told them ?
 Was the consent form signed ?
 Who must have signed ?
 Do I know any one of them ?
 Were the risks explained ?
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Then the recap starts……..
Did I need to do it ? Maybe not!!!
 What have I told them ? Nothing!!!
 Was the consent form signed ???
 Who must have signed ? Don’t know
!!!
 Do I know any one of them ? No!!!
 Were the risks explained ? Not
exactly !!!

Then the recap starts……..
Did I need to do it ?
 What have I told them ?
 Was the consent form signed ?
 Who must have signed ?
 Do I know any one of them ?
 Were the risks explained ?
 Whom should I talk to ?
 What next ?
 What about the expenses ?

Then finally……..
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And……….. What about my bags ???
The first feeling
‘ I just wish I were somewhere else ….. I
don’t care where it is, I just don’t want to
be here now facing this patient and their
family, telling them these bad things have
happened’
- John L Petrini .MD.
President , ASGE
How to break the news to the
patient / relatives?
Cocktail of emotions
Guilt
 Frustration
 Remorse
 Sympathy
 Panic
 Confusion………………
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Basic 2 questions
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How should I maintain/ repair my
relationship with the patient/ relatives ?
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How do I keep from getting sued ?
The realisation…..
Complications are an anticipated part of
procedures.
 It is how you face them (as much as how
you avoid them) that defines your
character as a professional.
 It is also about planning and preparedness

Don’t think that the world is going
to end!!!
Don’t try the escapist route !!!
Deal with it head – on .
Can complications be avoided
completely?
Avoiding Complications
Just Stay out of the way !
Avoiding complications
‘not being in the wrong place at
the wrong time”
You’ll never be BRAVE if you don’t get hurt
You’ll never LEARN if you don’t make
mistakes
You’ll never be SUCCESSFUL if you don’t
encounter failure
The art of breaking news of a
complication
Breaking news of a complication
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What can make it easier?
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The essentials
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The do’s
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The don’ts
What can make it easier?
3 steps
Preprocedure Explanation/Informed
consent
 Post procedure communications
 Being present and in control
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Pre-Procedure Explanations
No procedure is “ a piece of cake ”
 Packaging of the ‘ flip side ’
 Take relatives into confidence
 Not demeaning to inform possible
complications
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The E M B R A C E format
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A full Explanation of the procedure
The Motivation(reasoning) behind the medical
recommendations
The Benefits from undergoing the procedure
The Risks involved
What Alternatives are available(including doing
nothing)
What Complications may occur ( including
their frequency)
Any possible side Effects
The informed consent will take
care of 80% of the problem.
The rest of the story unfolds after
the complication …and you are the
lead character!!!
The 3 golden rules
The consent
Communication
Rapport
The essentials
Breaking the news of a
complication……
Is an art , nothing very scientific about it!!!
Breaking news of a complication
is
EXCRUCIATING
“ Life’s challenges are not supposed to
paralyse you, they’re supposed to help
you discover who you are ”
The facts
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Most endoscopists don’t know how to
handle complications beyond the
procedural nuts and bolts
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No forum for discussion
“ Doctors are wonderful. Up until the last few
years, unfortunately they received virtually no
training in medical school on how to
communicate bad outcomes to patients ”
“ They are taught everything under the sun
clinically and academically, but nobody teaches
them the softer side of medicine ”
David Sousa, Sr. VP,
Medical Mutual Insurance Company of
North Carolina
“ When complications or adverse events occur,
it is critical that physicians are honest with
themselves and with their patients ….. that
they acknowledge the possibility that an
adverse event has occurred ……. And
communicate these concerns in a timely
fashion and with complete truthfulness to
patients and their families ”
“ When complications or adverse events occur, it
is critical that physicians are honest with
themselves and with their patients …..
that they
acknowledge the possibility that an adverse
event has occurred …….
And
communicate these concerns in a timely fashion
and with complete truthfulness to patients and
their families ”
Post complication communications
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Choose a comfortable briefing area
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2-3 relatives ( close ones )
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Offer undiluted , undivided attention
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Be calm yet assertive and reassuring
Post complication communication
Be transparent:
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Talk about the procedure, risks, your
intended aims, and what happened
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Express empathy and apologize without
implying blame/ malpractice
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Tell them what you intend to do
Post-Procedure Communications
Be there and be in control!!!
Get the team together
 Surgeon/ Intensivist/ Cardiologist/ Physician
 Make sure the patient is being attended to
 Arrange to shift patient to intensive care
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No one will ask you why it happened!!
You will be judged by what you do in the
aftermath
By the clarity of your thoughts and
communication
By your sincerity and empathy
THE RESPONSIBLE RESPONSE!!!
Manage
the
patient
Manage
yourselves
Manage the
relatives
Manage the
records
Risk of litigation
If you wrote it ,
you did,
If you didn’t ,
you had it !!!
Manage
the
patient
Manage
yourselves
Manage the
relatives
Manage the
records
Risk of litigation
Reactions
1.
2.
3.
4.
Some patients will want a lot of
contact/empathy.
Some will be satisfied with an apology,
and a reassurance/ assurance
The inquisitive/ probing patient/ relatives
Anger/ threats
Anger/ Threats
Don’t loose cool
 Inform your team
 Inform the management
 Don’t abandon
 Keep communicating with the people
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Angry relatives – short term crisis
Quiet relatives - dangerous
The Do’s
 Sit
down….calm yourselves..get
thoughts together
 Write / Document
 Involve …..surgeon/intensivist
 Plan
 Empathise….Communicate…………
..communicate….Listen
The Don’ts
 Don’t
transfer ownership
 Don’t delegate communication
 Don’t be defensive
 Don’t be arrogant
 Don’t cover up
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May there be minimum complications
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May each complication be the beginning
of a new learning
Medicine is not now, and never
has been, an exact science.
Despite the exercise of the
greatest skill, things can go
wrong
Thank you
Complications of Endoscopy
Summary
know limits
 recognize promptly
 deal ‘head on’
 early, appropriate management
 communicate
 keep channel open
 seek help and opinion
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The bottom lines:
Establish rapport ( patient and family )
 Show warmth and compassion
 No procedure is too simple !
 Express empathy, compassion and
confidence
 Don’t assume litigation … but take
precautions
 Careful and complete records
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The biggest problems
Inadequate pre-procedure preparation
 The consent
 The guilt that follows
 Tendency to deny / escape
 Enemies within
 Lack of communication
 Crazy documentation
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