Month: February 2015

Overheard

The medical ward. A concentration of illness, anxiety, uncertainty, need and exemplary patience. Each patient, although concerned primarily for their own welfare, cannot avoid noticing and following momentous events in the lives of others. The architects of the ward designed a semblance of privacy, and the medical staff try to maintain it by pulling (literally) paper-thin curtains around the defined space that belongs to each patient. Sometimes the edges of the curtains do not meet, allowing glimpses of flesh, a trembling hand, a bent back or shuffling feet. These things are only seen if the patient opposite chooses to watch. The skill that one acquires in pressed tube trains or crammed lifts comes into its own – the ability to ignore, to pretend that it is not happening, to avoid eye contact until decency or distance has been regained. Even if the curtains do meet, the air above, below and around them is unrestricted. Sound travels. Only whispered words remain in the immediate vicinity of the patient. Doctors tend to shout rather than whisper. Perhaps it is the fact that a good proportion of their patients are deaf, and many are barely responsive. The habit of communicating declaratively and with painful deliberation, like an ignorant tourist in a tumultuous bus station somewhere in rural China, is sometimes hard to modulate.

 

I sit on the edge of a patient’s bed, while his wife leans forward in the chair alongside. He looks over, eyes tinged with yellow. His liver has failed, and there has been no response to medication. I am here to tell him that this failure to respond means that his chance of survival beyond six months is less than 25%. There is no point using numbers. Instead I say that the time has come to think about going home, but that other parts of his body – like the kidneys, and later the heart – may soon begin to fail in sympathy with the liver. If that happens he may become too weak to move, and will begin to die. Alternatively, a sudden emergency such as bleeding from the gut or overwhelming infection, may hasten his deterioration. We will make sure that there are nurses and carers at hand to help him remain comfortable. He is 42.

 

The younger doctor, who remained standing (there was no room for another chair, and the patient was too ill to come into the relatives room) reads the situation correctly. We have finished. She parts the curtains slowly, respectfully. Not briskly, as we do when the news has been good, when the discharge plan has come as a symbol of recovery or cure. She and I walk back to the notes trolley. We pick up the folder of the next patient. Another man in middle age, another partially destroyed liver. We approach, and I pull the curtain round. His illness is less advanced, but the trend in his blood tests is not encouraging. There are tears in his eyes. He looks up and says,

‘I don’t want to die.’

‘Why do you…?’ But I know why. He has heard everything.

 

 [As usual, the scenario described is based on historical experiences and not a single case]

oOo

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Unreconstructed: the challenge of delivering candour

The duty of candour is now a law of candour. Regulation 20 of the Health and Social Care Act came into force on November 27th 2014, and requires a Trust to inform patients swiftly after the recognition of significant harm events. 10 working days appears to be the expected timeframe (this document from the CQC explains it well.)

Trusts around the country are now frantically working out how to incorporate this regulation into their systems and patient safety processes. Making it happen will require the engagement of all medical staff, and a change of culture (that well-worn phrase!). Changes in culture occur over years rather than over specific dates in November, and this article will explore the challenge that lies before us; specifically, the nature of traditional medical mind sets – the ‘unreconstructed’.

 

Easy truth, hard truth

Being open about error does not come naturally. The unreconstructed might say – ‘Error is inevitable, it is part of medical life…’ and ‘Our systems are already self-improving, we notice error and make changes… we don’t need to tell patients about every little incident…’ Truth spills easily when mistakes are obvious  – it is revealed to patients when procedures prove injurious or disastrous, when unexpected things happen, or when confidently stated predictions do not come to pass. Sometimes it is revealed in the faces of those involved, be they junior doctors or senior consultants. In these situations it takes a positive effort of concealment not to be open – a conspiracy of silence, the complicity of nurses – ‘They don’t really need to hear it…’; something along those lines.

Candour over less obvious or historical incidents relies on a sustained effort to break through the patient’s shell of medical ignorance. Details of what has gone wrong need to be explained. A mini-education in ‘normal’ or expected process or behaviour is followed by a description of what actually happened – the variance – why it happened, what will be done to make sure it doesn’t happen again, and, importantly… an apology.

 

‘What difference will this make?’ – an analogy

Doctors are impelled by their training to ask a question before making any intervention – ‘How will this change my management?’ By this I mean that any decision or action has to be justified by its consequence. Every intervention carries risk, be it a drug, an operation… or the delivery of information. Only if the likely good that to come of an intervention outweighs the potential harm will it be undertaken.

Consider the decision to perform a colonoscopy on an asymptomatic 92 year old man with anaemia. The investigation will cause discomfort and could cause injury. Even if a bowel tumour is found he will not be considered for major abdominal surgery. An ‘intervention’ that seems justifiable at first is likely to bring nothing but harm. The weighing  of harm and benefit needs to be examined in relation to candour.

 

Harm – rekindling grief, complicating the past

Doctors worry about the distress that ‘open and transparent’ conversations might cause. This applies particularly to cases of death (conversations with relatives) or irreversible harm. Will a letter or phone-call coming out of the blue in the midst of grief or convalescence add to the pain? Such concern is undoubtedly over-paternalistic. The issue of ‘protecting’ patients from such harm has been rehearsed in another arena – resuscitation, the Janet Tracey judgment – where it was found that over-sensitivity to a patient’s distress is not a good enough to reason to shy away from difficult discussions. Nevertheless, it is a factor, and a hurdle. A doctor considering whether to ‘come clean’ over a mis-interpreted blood result or a mislaid CT report might find, after deep and sincere reflection, that there really is nothing to gained for the patient, or for future patients, from an unasked for communication weeks after the event. The damage has been done, the lesson learned. Why kick the hornet’s nest?

 

Gatekeepers to knowledge

Returning to the analogy, a lay person unused to the ways of medical staff might ask, ‘Isn’t it up to the patient to decide if he wants the colonoscopy? After all, he might well want to know what’s going on inside his own body. And it is his body.’ The unreconstructed doctor might reply, ‘Wanting to know is not enough. It’s how the knowledge will change what we do that matters.’ Knowledge in and of itself has no intrinsic value, only its consequence; such as knowing about a bowel tumour when no surgeon will remove it. This is the unreconstructed, utilitarian view. The reconstructed doctor would say – ‘The right to withhold knowledge does not flow automatically from ones role as gatekeeper to that knowledge.’ Knowledge, in the patient’s hands, might lead down an entirely different path. It may augment self-awareness, it may cast a different contextual light on their days, months, years or decades to come. Without such knowledge, patients will progress through life knowing only half the story – half their story. Ownership of knowledge lies at the heart of candour, and wresting it away from doctors is a major part of the culture change.

 

Pressing the right buttons

I have tried to show how, if candour is to become second nature, doctors need to understand what good will come of it. The bare instruction to be ‘open and transparent’ is not enough. It does not press the right buttons. So what buttons can be pressed?

How about ensuring that the same thing does not happen again? This is getting closer. This is the leverage, in my view.

Nothing makes more of an impression on a doctor than sitting before a wronged or wounded patient and explaining. The emotional work involved in laying out the details, treading the fine line between self-flagellation and blaming the ‘system’ is immense. The result is a memory scar. Whatever happens, the doctor won’t let that happen again. There is now a motive to go out and change practise (be it heightened vigilance, focussed training or improved supervision of trainees – just a few examples) or work to strengthen the weak links within the system.

So, candour may have a motivating role – as a sort of punishment. This still feels unsatisfactory. There has to be a more methodical justification.

 

A pre-candour routine

The work that precedes a duty of candour approach should not only include an analysis of what went wrong, but how it can be avoided in the future. This analysis is undertaken coolly, away from the demanding emotional work of the discussion itself. It is here, around tables with colleagues, over timelines and written accounts, that weaknesses in the system can be identified and suggestions as to how they might be reinforced offered. Then, when conclusions have been drawn and commitments to change made, the doctor can enter the room armed…  with the promise of genuine improvement. The experience provides motivation, but the process that has come before provides progress.

 

Conclusion

The move to ensure candour is borne of respect for patients as people rather than receivers of care. The actions required by the new regulation seems uncontroversial in principle. Most reasonable people would argue that no further persuasion should be required to bring doctors into the process. But this is not enough. Doctors working within a hugely pressurised system are pulled from patient to patient without pause, and there is little space for reflection, regret or reaching out to families after the event. There is always another cohort of patients coming through the front door. To achieve candour routinely, such that good intentions are not trampled in the incessant flow of illness (and inevitable error), the NHS needs to make it easy. For like it or not, most of us are, at heart, unreconstructed.

oOo

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Ownership

6.30PM, and Dr D was leaving his office. The next train was at 6.45, and if he ran he could catch it. In the corridor a medical registrar looked up, her face brightening as she recognised him.

“Ah, Dr D, one of your patients was just admitted. He’s having a flare up I think, not well. He said you knew him. Thought you’d want to know.”

“What’s his name?”

“Ah! I’m really sorry, I can’t remember it now. I saw your letter in his notes though. He said to make sure you were informed.”

 

The request has been made, implicitly. Dr D turned mournfully about and headed towards the medical assessment unit. Should he? It might make a difference, especially if it was a complex case. One glance and he might be able to sort it out in five minutes, save the on-call team a lot of guessing and faffing about. He entered the ward and scanned the names on the white board. None of them rang any bells. He asked the charge nurse, who instantly directed him to bed 6. Dr D pulled out Bed 6’s case notes. He flicked through the correspondence. Two letters, from clinic visits three years ago! Then the patient DNA’d (Did Not Attend) twice before dropping out of the system. ‘One of your patients…’ the registrar had said. Dr D eyed bed 6. He scrutinised the patient from across the ward. Yes, he recognised the face. Eye contact was made. Dr D was committed. He would get the next train; or perhaps the next train but one.

 

Two weeks later.

It was 6.20PM. The next train was still gettable. Dr D hurried towards the main entrance, buttoning up his coat. The same registrar approached him, this time from over his shoulder. She had seen him ahead and hurried, stealthily, to catch up with him.

“Dr D! Sorry. I’m on call again. One of your patients again. You do seem to have a lot! Deteriorated. He came in this afternoon. I thought you should know.”

“Name?”

“Oh! Sorry. I’m awful with names. Derek. David…  something.”

“How well do I know him?”

“I’m not sure, I just saw your initials on the front sheet. He comes to your Thursday clinic.”

“Did he ask for me?”

“No. He’s not up to asking for much to be honest.”

“OK. Look. I’m not bring unhelpful but I’ve got something I need to go to. I’m sure the on-call team can handle it overnight. I’ll come and see him tomorrow first thing, before the main ward round. OK?”

“Yes, of course, whatever you think Dr D.”

“OK. Bye.”

 

He caught the train. As he sat back he wondered who it could be. But not for long. After ten years in the job Dr D had seen many thousands of patients. Each one of them were, in a way, and to some degree, ‘his’. He had a responsibility, albeit shared, for them… but only to a degree. He could not be expected to rush to their bedside as soon as they entered the hospital. To be fair, very few patients had that expectation. It was colleagues, more often. They threw around the term ‘your patient’ with freedom, forgetting that the possessive implied something rather significant… duty. And if the requirements of that duty took shape at inconvenient times, what was he to do? Drop everything? Go back in? No way. The system was safe. There were many good doctors around to assess and treat and explain.

Next morning.

Dr D went to the assessment unit. He scanned the white board. There it was – Daniel. Daniel Spencer. No! Not him! Dr D rushed to the corresponding bed – bed 8. It was empty. The sheets were clean and straight. He found a nurse,

“Where’s Mr Spencer, bed 8?”

“Oh, he died Dr D. At three o’clock in the morning.”

Dr D lost focus. The assessment unit consultant came round the corner.

“Oh, morning Dr D. Sorry about your patient. I didn’t call you, the treatment plan was very clear from your letters. Really sad case. Only 36. He went quite quickly, and peacefully…”

“Did the family…?”

“They asked if you were around, they were very grateful for all you’d done, getting pall care involved, being honest with them. You were seeing him every week or two by the looks of it.”

“I wish I could have seen them.”

“I think the registrar let you know, she said she had anyway.”

“Yes… No… She couldn’t tell me who it was. If I’d had the name…”

“The family were fine. Really. Slight shame it couldn’t have happened at home but they weren’t set up for it.”

“Are they still around? I’d like to speak to them.”

“No, they went home earlier.”

 

Dr D avoided the lift and trudged up the stairs to the ward. He thought about ownership, continuity and duty. But he still wasn’t sure how he would react next time the registrar grabbed him in the corridor.