98. Case: Talking About an Adverse Event

You are a respiratory therapist working in a large hospital seeing a range of patients, but primarily working with the teams in the Emergency Department and ICU.  With one complex patient in ICU there was a miscommunication that resulted in improper settings being used for ventilation and this resulted in the patient having a longer-than-expected ICU stay.  You feel responsible for this and as part of the adverse event disclosure process you are going to talk to the family about it.  How will you prepare for the conversation?

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Your loved one, who has dementia and COPD, is in ICU and you know that there was a mistake with their ventilator because you overheard some of the nurses talking about it.  You feel that the ICU environment is making your loved one’s dementia worse, and you’re angry that someone’s carelessness has resulted in harm to your loved one.  The nurses let you know that the respiratory therapist wants to talk to you about the incident.  You’re willing to have the conversation, but you’re tired from looking after your loved one and frustrated by your whole experience in the hospital.  What is most on your mind when you go into this conversation?

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Discussion Questions:

• How did your response to the case shift when you read about it from a different perspective?
• What do you see as the most important values for each person involved in the conversation?
• Why is it important to have this conversation from each person’s perspective?
• Which values and principles are reflected in the commitment to ensuring that the conversation happens?
• What can be done to help ensure that this is a “good” difficult conversation?

References:

Alberta Health Services. Disclosure Done Well – Early Disclosure: Unsure If Care Is Reasonable. Published March 16, 2018. https://www.youtube.com/watch?v=i2uEHmElX5M

Bonney, W. (2014). Medical errors: moral and ethical considerations. Journal of Hospital Administration. 3(2): 80-88. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwjjwa2Z7PzgAhUV854KHa5sCPkQFjABegQIBBAC&url=http%3A%2F%2Fwww.sciedu.ca%2Fjournal%2Findex.php%2Fjha%2Farticle%2Fdownload%2F3475%2F2226&usg=AOvVaw2VCJ0K19IQYyW329XHm_C_

Brené Brown on Blame: https://www.youtube.com/watch?v=RZWf2_2L2v8

Canadian Patient Safety Institute. (2011). Canadian Disclosure Guidelines: being open with patients and families. CPSI. https://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf

Canadian Medical Protective Association. Disclosure – Maintaining Trust. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/adverse_events/Disclosure/disclosure-e.html

Canadian Medical Protective Association. Disclosing Harm from Health Care Delivery. Version 3, 2017. https://www.cmpa-acpm.ca/static-assets/pdf/advice-and-publications/handbooks/com_15_disclosure_handbook-e.pdf

Nova Scotia Health Authorities. 2017. Disclosure of Patient Safety Incidents. Patients First. http://www.nshealth.ca/sites/nshealth.ca/files/patientinformation/1448.pdf

60. CASE: Health Care Providers Under Quarantine

My story starts in early April, during a routine day shift in our minor care area. A previously well middle-aged man, recently returned from Hong Kong, presented with fever. Because SARS was already recognized and we’d gone through the recent experience of a crash intubation with our first case at Vancouver General, this patient was isolated at the triage area and we gowned and masked to examine him. Apart from a temperature of 37.8°C, his vital signs were normal and he looked well. He had no other symptoms, and his physical examination, CBC, urinalysis, and chest x-ray were all normal. Although the patient did not fulfill the case definition of SARS then in existence, I kept him in isolation just in case. When I went in to give him discharge instructions, I did not wear a mask and stood just inside the doorway, about two meters from him. Almost predictably, he returned with the full SARS syndrome just over 24 hours later. And wouldn’t you know it, by then, the case definition of SARS had changed!

I briefly wondered if I could pretend I was not in his room unmasked, but the thought of potentially disseminating a lethal virus persuaded me to do my civic duty and tell my boss. Two hours later Public Health phoned to inform me I was officially quarantined. Needless to say, my husband, also a physician, was incredulous and my kids were terrified. I thought it was kind of funny for the first day, like someone was playing a bad joke. Then the reality began to hit home, and I can tell you the reality was difficult to live with. This is what Public Health told me.

• I must stay inside my house (preferably within my bedroom) 24 hours a day
• I must not touch anyone in my family
• I must wear an N95 mask if anyone is in the same room as me
• I must not prepare uncooked food for my family
• I must not sleep with my husband
• I must use a separate bathroom
• I must not touch anything in the house that the kids might later touch
• I must not use the family computer or the main phone
• I cannot have outside visitors
• I cannot shop for groceries
• I cannot go for a walk

The quarantine requirements were not voluntary, but were enforced by Public Health, who contacted me daily to gauge my cooperation. If I did not comply, it was clear that I would be legally compelled to do so. All this took place under the shadow of potentially transmitting SARS to my family, the people I love more than anything in the world. My nine days of quarantine were a blur of extreme boredom, some highly emotional episodes, and a re-evaluation of what I do for a living. One of our daughters moved out for the duration. Another celebrated her 16th birthday without a hug, cake or present from her housebound mother. And my son told me daily how much he wanted a snuggle. I felt guilty that my colleagues, all of whom are already overworked, had to pick up extra shifts to cover me during my enforced absence. As if all this were not enough, it slowly dawned on me that I wasn’t earning any income, and would have to put in extra shifts after my quarantine was over. I decided I never wanted to see another N95 mask again…

What did I learn from my experience? First, it is very isolating and lonely to be isolated. I hugely appreciated the calls and emails I received from my colleagues while I was off. It helped enormously to know they were thinking of me, and didn’t think this was my fault. Second, I think all emergency physicians should consider the financial implications of a sudden enforced quarantine. None of us have disability insurance that would commence quickly enough. To be under quarantine is difficult enough without the added burden of a financial penalty. Although I suffered an occupational exposure, I was not covered by Workers’ Compensation. I believe we need to negotiate with our hospitals and governments to put financial packages in place. Many hospitals are starting to compensate self-employed health care workers for income missed during quarantine. I would go further and suggest a per diem rate for days confined due to occupational exposures. Although no one can compensate me enough for nine lost days of my life, a token payment certainly wouldn’t hurt. Finally, as emergency physicians we do a far more difficult and noble job than I had ever realized. The consequences of what we do to care for our patients and protect the public are risks that put ourselves and our families in potential danger. This is something we never think about or acknowledge, but maybe we should. And maybe we should celebrate ourselves more than we do. I have huge admiration for my emergency medicine colleagues who had far worse exposures than I did in the early phase of the SARS crisis.

• What values are involved here and for whom?
• What ethical considerations have to be balanced in such quarantine situations? How is the most appropriate balance achieved?
• How would you respond to this physician’s concerns? Do you feel there is any legitimacy to her complaints?

Some Values and Ethics Issues to Consider

• Duty to provide a safe work environment
• Duty to provide care
• Respect for individual liberty
• Community/ public health ethics
• Consent
• Disclosure of adverse events
• Health care provider relationships
• Risk
• Patient safety
• Compliance with policy
• Disclosure of adverse events
• Non-maleficence
• Privacy and confidentiality

34. CASE: To Tell or Not to Tell

The head pathologist of the regional hospital informs the head pathologist of the tertiary care centre that the post-mortem examination of a former patient, Mrs. Dempsey, has revealed that she suffered from a neurological infection called CJD (Creutzfeldt-Jakob Disease). The tertiary centre pathologist reports this to the VP of Acute Care who determines through investigation that Mrs. Dempsey had brain surgery at the tertiary care centre a year and a half ago. At that time, Mrs. Dempsey had a few symptoms consistent with CJD but this diagnostic possibility was not considered by the attending health care team. The surgical instruments used in the Mrs. Dempsey’s surgery were sterilized as per standard protocol and subsequently used in other neurological surgeries at the centre.

Some relevant CJD facts:

• The involved infectious agent is a prion
• Prions are transmitted only by neural tissue (brain/nerves) to neural tissue exposure
• Unlike most infectious agents, prions can survive standard sterilization procedures
• CJD is a progressive, devastating neurological infection that leads to disabling illness and premature death
• The usual incubation period from a person’s exposure to CJD to symptomatic infection is 12 to 28 months
• There is no way to conclusively determine that a person has CJD prior to post-mortem autopsy
• There is no known treatment for CJD

An ad hoc disclosure working group is struck. In the course of using their hospital’s disclosure policy’s decision-making framework, a participating infectious disease specialist, Dr. Bugg, reports on the clinical literature (evidence) related to CJD disease and its transmission. He expresses his informed opinion that, in the particular circumstances under consideration, there is a theoretical, extremely low risk of past transmission of CJD to patients who had surgery utilizing the potentially contaminated instruments for the month after Mrs. Dempsey’s surgery. Dr. Bugg also comments that, in the last twenty-five years, there have been no reported cases of CJD (world-wide) resulting from patients’ exposure to contaminated surgical instruments.

• Using your institution’s disclosure policy decision-making framework (or that provided on NSHEN’S website under the “Ethics Resources” tab at http://www.nshen.ca/docs/nshen_adverseevents.pdf), what do you think are the key issues to be considered?

As per Step 7 in NSHEN’s framework, the working group members collaboratively develop a list of benefits and burdens for each of three identified potential disclosure options, i.e., non-disclosure, disclosure to those who have been exposed, and external-public disclosure.

• Given the facts as presented and using the framework indicated, what decision would you support and why?

 

Some Values and Ethics Issues to Consider

• Accountability
• Honesty, trust and truth-telling
• Compliance with policy
• Medical error
• Disclosure of adverse events
• Patient safety
• Transparency