The report ‘Building a culture of candour – A review of the threshold for the duty of candour and of the incentives for care organisations to be candid’ makes very interesting reading. It seeks to define levels of harm that should trigger an approach to patients and relatives, and explores how organisations can be encouraged or compelled to develop a culture that facilitates this. It also touches on the realities of the ‘post-paternalistic’ era and the demonstration of candour in day to day practise.
‘Modern medicine offers an abundance of hope, but very few absolute certainties. One of the comforts (some would say benefits) of paternalism was to obscure this lack of certainty for patients. This is no longer sustainable, and it means that being candid when things go wrong needs to be grounded in being honest about what could go wrong from the start. Better conversations about risk and the potential for harm are essential for fostering a culture of candour…’
‘Clinical care is inherently risky, and while organisations and individual clinicians must do all they can to minimise those risks, it will never be possible to eliminate them fully.’
These appear to encourage a greater degree of upfront honesty about the risks of healthcare, rather than waiting for mistakes or unavoidable adverse events to happen before ‘owning up’. We could, fancifully, call this ‘pre-candour’.
I find the balance between upfront honesty and the provision of ‘too much information’ a hard one. Not all patients need or want the same depth of information about risk, even if, objectively, they face similar chances of accidental injury or death.
Opportunities to be open about risks begin in the Emergency Department or Admission Unit. Here I sometimes find myself explaining that coming into hospital is never routine, and that being on a ward brings with it physical and psychological risks. Sometimes this is part of the explanation as to why a patient should not be admitted. An example would be a young patient with a headache that does not sound suggestive of meningitis or haemorrhage; coming into hospital will not achieve anything, but they may have been led to expect admission to a ward, and may require convincing that it is right not to come in. The same might be true of a more elderly patient with a mild chest infection; they are weak and tired, they might benefit from three days in hospital, but if it is not entirely necessary, medically. A case may need to be made about why the risks outweigh the advantages. One begins to speak of ‘infections’ or ‘picking up bugs’. Is it appropriate to be negative about hospitals, and their inherent risks?
The ‘hospitals are dangerous’ mantra is unhelpful, but it is dishonest to portray hospitalisation in a neutral way. Henry Marsh, a (clearly disillusioned) neurosurgeon, wrote in the Independent newspaper recently that hospitals are
‘… like prisons and there’s a huge lack of insight into what a ghastly environment they are.’
This is depressing, but he has a point. An alert patient admitted to a general ward for more than a few days is likely to witness distress, disability, physical dependency, acute confusion, wandering, incontinence, the ravages of addiction and sadly, death at close quarters. Even with the most attentive and compassionate nursing, these aspects of frailty and illness cannot be hidden from the watchful. Patients of all ages have mentioned to me how eye-opening and challenging the experience of being an in-patient was. It does not seem unreasonable to explain some of these things in advance.
As to the physical dangers of hospitalisation, the degree of detail we should go into varies. Hospital acquired infections overall are less frequent nowadays (the incidence of MRSA and C Diff has fallen dramatically in recent years), but hospital acquired pneumonia does remain a common development in the frail population. Should we explain this, or quote the incidence? Do elderly patients and their families, who are coping with the news that they are ill and need to be admitted, need to be told that ‘…by the way, there’s a chance you could catch something else as well…’?
A discussion about upfront candour is essentially a discussion about informed consent. In the context of planned procedures, this is clear and simple; we know which risks require explanation, the patient is enabled to understand these risks in relation to the benefits, and they agree or decline. But when we are discussing admission in the context of acute illness, the use of powerful antibiotics or drips that might facilitate the entrance of organisms into the blood stream, consent seems less relevant. The patient has no real choice about whether to come in or not. They are ill. To compound the stress of the situation by enumerating the additional risks may well be ‘too much information’.
The post-paternalistic culture in which we work emphasises that patients are our equals, partners in care, and nothing should be hidden. However, we must surely remain sensitive to the fact that patients are also vulnerable, and may, in certain circumstances, be happy to ‘have things done to them’ without full and frank discussion. All doctors will recognise the scenario of the patient who has halted them mid-explanation with the phrase, ‘Doc, just do what you need to do, OK.’
The key, it seems to me, is in modulating the degree of openness according to the patient’s condition, its severity, its acuity, and the signals given off by the patient regarding their need for information. This modulation depends on the doctor’s ability to understand the context and judge the person in front of them. Perhaps this requirement on the part of the doctor is itself paternalistic, as we are once again putting the doctor’s interpretation centre stage.
Paternalism is always tempting. It makes life simple. As the authors of the report write, ‘One of the comforts [ ] of paternalism was to obscure this lack of certainty…’ If things go to plan, and nothing goes wrong, the patient who was not been subjected to a conversation about risk will leave the hospital oblivious to the dangers that they faced, and their experience will in retrospect seem serene. If we are to encourage more ‘pre-candour’, we must be prepared to help our patients understand and accommodate the anxiety that may be engendered. This will require time to talk, time to listen, and time to answer. This is the price of candour, and of true partnership in healthcare.