Pre-Conference Workshop Report: Nurturing a Culture of Candour – Disclosure and the Role of the CEC

IMG_6869 (first pre-conf).JPGOn January 20, 2016, CENTRES held a pre-conference workshop on disclosures of medical errors, oversights and unprofessionalism to patients and/or other professionals. The workshop consisted of two primers by Dr. Anne Slowther (Warwick) and Dr. Lee See Muah (NUS and Ng Teng Fong General Hospital), followed by two case discussions. Here, I’ll give some highlights of each component of the workshop.

Dr. Slowther’s Presentation

IMG_6884.JPGDr. Slowther gave an introduction to the main ethical considerations in disclosure of errors, whether to patients or others. She noted that while we all have general duties of honesty, clinicians have special duties as professionals to provide relevant information even when it is not asked for – and even when it may reflect poorly on the clinician. These can be grounded in at least three of the four principles of ethics – autonomy, non-maleficence and beneficence. Providing accurate and reliable information is a key part of respect for others as autonomous agents, capable of making informed decisions on their own. Disclosure can help avoid future similar errors, preventing harm, and prevent an erosion of trust between patient and clinician. There may be some reasons weighing against disclosure – legal liability and potential distress – but as a general rule, physicians should embrace a culture of candour.

Dr. Lee’s Presentation

IMG_6892.JPGDr. Lee gave a case-based discussion of three cases he had encountered in his clinical work that question when it is appropriate to disclose information. I will mention two here. The first involved a patient who died of a brain aneurism; the prior day, he had reported to a clinic after falling on his rear end. Should the family be informed of the fall? In a close vote, the CEC recommended against disclosure as there was not a likely connection between the fall and the patient’s demise; here, the duty of candour was not triggered because it was judged not germane to the death, and would only cause confusion in the family.

The second case involved a disclosure of terminal illness to an elderly patient, after which the son strongly objected – the son wanted the diagnosis to be given to the family, who would judge how best to communicate it to the patient. Here, there is a tension between the physician’s duty of candour and a duty of compassion, and the local cultural context may generate special reason to defer to families.

Case discussion 1: Non-indicated prescription

IMG_6897.JPGThe participants broke out into small groups to discuss two cases. The first case involved a migrant worker who reported to one hospital for inguinal hernia, and reported breathlessness. He was given Diclofenac and was discharged. Two days later, he died at a second hospital due to asthma. Diclofenac was contra-indicated for asthma, but it is unclear whether or not it contributed to the worker’s demise. Should the apparent error be disclosed to the family?

Participants reflected on the practical difficulties of disclosure in this case, given that the family was abroad and communication may be difficult. In addition, the uncertainty of the connection to the death may – as in the case mentioned above – simply cause more confusion. At the same time, the prescription of diclofenac was a clear error; it may be appropriate for the second hospital to report the death to the first, in order to improve practice.

Case discussion 2: brain-death tracheostomy

IMG_6908.JPGIn the second case, a patient in the ICU deteriorated and became brain dead. But the family was unwilling to accept that care should be withdrawn. To give the family time to cope, the physician delayed official declaration of brain death, and performed a tracheostomy. A consultant happens upon the procedure, and strongly objects that tracheostomies should not be performed on dead patients. But should the consultant disclose the occurrence to any further individuals (including the CEC), to get the tracheostomy removed?

The question of whether to disclose, in this case, turned on whether the tracheostomy was inappropriate. Participants were divided on this question – while maintaining a corpse is not standard procedure, flexibility in approaches may be appropriate to help the family. If the case was clear, a CEC may not need to be involved – but given these ambiguities, it was thought that bringing the case to a CEC could help resolve whether the action was unprofessional in the first place, and whether further disclosure to a professional board is appropriate.

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