Complication ??? Breaking the news !!! G N Ramesh PVS Memorial Hospital Kochi.

Complication ???Complication ???Breaking the news !!!Breaking the news !!!

G N RameshPVS 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 Complications in GI endoscopyendoscopyThe challenge….to keep it to the

minimum

The science……effective management

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 One of the golden rules of life!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 ?What could go wrong ?Desired result not achievedCo morbid illness related eventBleed

What could go wrong ?What could go wrong ?Desired result not achievedCo morbid illness related eventBleed

Perforation Cardiac arrest on table Colleague related event

The worst !!!The worst !!!

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……..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 ?

Then the recap starts……..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……..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……..Then finally……..

And……….. What about my bags ???

The first feelingThe 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 How to break the news to the patient / relatives?the patient / relatives?

Cocktail of emotionsCocktail of emotionsGuiltFrustration RemorseSympathyPanicConfusion………………

Basic 2 questionsBasic 2 questions

How should I maintain/ repair my relationship with the patient/ relatives ?

How do I keep from getting sued ?

The realisation…..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 Don’t think that the world is going to end!!!going to end!!!Don’t try the escapist Don’t try the escapist route !!!route !!!Deal with it head – on .Deal with it head – on .

Can complications be Can complications be avoided completely?avoided completely?

Avoiding Complications Avoiding Complications

Just Stay out of the way !

Avoiding complicationsAvoiding 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 The art of breaking news of a complicationof a complication

Breaking news of a Breaking news of a complicationcomplicationWhat can make it easier?

The essentials

The do’s

The don’ts

What can make it easier?What can make it easier?

3 steps3 steps

Preprocedure Explanation/Informed consent

Post procedure communicationsBeing present and in control

Pre-Procedure Pre-Procedure ExplanationsExplanations

No procedure is “ a piece of cake ”

Packaging of the ‘ flip side ’Take relatives into confidenceNot demeaning to inform possible

complications

The E M B R A C E format The E M B R A C E format A full Explanation of the procedureThe Motivation(reasoning) behind the

medical recommendationsThe Benefits from undergoing the

procedureThe Risks involvedWhat Alternatives are

available(including doing nothing)What Complications may occur

( including their frequency)Any possible side Effects

The informed consent will The informed consent will take care of 80% of the take care of 80% of the problem.problem.

The rest of the story unfolds The rest of the story unfolds after the complication …and after the complication …and you are the lead character!!!you are the lead character!!!

The 3 golden rulesThe 3 golden rules

The consent

Communication

Rapport

The essentials The essentials

Breaking the news of a Breaking the news of a complication……complication……

Is an art , nothing very scientific about it!!!

Breaking news of a complication

isEXCRUCIATING

“ Life’s challenges are not supposed to paralyse you, they’re supposed to help you discover who you are ”

The factsThe facts

Most endoscopists don’t know how to handle complications beyond the procedural nuts and bolts

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 Post complication communicationscommunications

Choose a comfortable briefing area

2-3 relatives ( close ones )

Offer undiluted , undivided attention

Be calm yet assertive and reassuring

Post complication Post complication communicationcommunication

Be transparent:

Talk about the procedure, risks, your intended aims, and what happened

Express empathy and apologize without implying blame/ malpractice

Tell them what you intend to do

Post-Procedure Post-Procedure CommunicationsCommunications

Be there and be in control!!!

Get the team togetherSurgeon/ Intensivist/ Cardiologist/

PhysicianMake sure the patient is being

attended toArrange to shift patient to intensive

care

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 the relatives

Manage yourselve

s

Manage the

records

Risk of litigation

Manage the

patient

Manage the relatives

Manage yourselve

s

Manage the

records

Risk of litigation

If you wrote it , you did,

If you didn’t , you

had it !!!

ReactionsReactions

1. Some patients will want a lot of contact/empathy.

2. Some will be satisfied with an apology, and a reassurance/ assurance

3. The inquisitive/ probing patient/ relatives

4. Anger/ threats

Anger/ ThreatsAnger/ ThreatsDon’t loose coolInform your teamInform the managementDon’t abandon Keep communicating with the

people

Angry relatives – short term crisis

Quiet relatives - dangerous

The Do’sThe Do’sSit down….calm yourselves..get thoughts together

Write / DocumentInvolve …..surgeon/intensivistPlanEmpathise….Communicate…………..communicate….Listen

The Don’tsThe Don’ts

Don’t transfer ownershipDon’t delegate communication

Don’t be defensiveDon’t be arrogantDon’t cover up

May there be minimum complications

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 Thank you

Complications of Complications of Endoscopy Endoscopy Summary Summary know limitsrecognize promptly deal ‘head on’early, appropriate managementcommunicate keep channel open seek help and opinion

The bottom lines:The bottom lines:Establish rapport ( patient and

family )Show warmth and compassionNo procedure is too simple !Express empathy, compassion

and confidenceDon’t assume litigation … but

take precautionsCareful and complete records

The biggest problemsThe biggest problemsInadequate pre-procedure

preparationThe consentThe guilt that followsTendency to deny / escapeEnemies withinLack of communicationCrazy documentation