Death declaration by doctor: complex communication skill. “No negligence in alive baby declared dead: hospital “


The death pronouncement is one of the most sensitive and complex part of communication in and out of hospital, intensive care. It comprises more than the actual declaration of death. It may be a relatively straight forward when the death is expected and the family is mentally prepared and accepting the outcome. However, when the doctor is interacting with a grief-stricken family, dealing with the death of a child, or coming to terms with the death of a personal patient, a death pronouncement becomes complex. Problem is compounded often in presence of violent relatives, non acceptance of death, medico legal cases and   especially in cases of unnatural causes for the death. Relatives often refuse to accept death and within no time mobs swell in number, threatening of physical and verbal assaults and revenge against the doctor in various forms. Although there can be specific protocols and hospital policies, it will still depend upon the timely thoughts and skills of the doctor, how to handle the situation. Doctors should be better trained for handling of death as it can put them in risky situation, because of following reasons.

  1. Death itself is a complex issue. Even today modern science has not reached scientifically at the bottom of life and death.
  2. Communication of death is complex. It varies with each patient, type of relatives, place, country and every situation in same hospital is different.
  3. Declaration of death is a legal matter. How a doctor verifies death, communicates and documents death, it can create legal and other problems for doctor.

Any problem related to declaration of death is immediately picked by media and the initial reaction is to blame the doctors. The doctors in such cases are projected as incompetent and callous, and that makes a media news. Invariably one stray incidence is used as to project whole medical community in negative manner. Later inquiries and further inquiring continue, and even later truth emerges, that is not enough to bring back the lost prestige for medical profession.

Take for example the latest news of “ Alive Baby declared dead.”

http://timesofindia.indiatimes.com/city/delhi/alive-newborn-declared-dead/articleshow/59208765.cms

Later after two days, news was “ hospital enquiry claims No negligence in alive baby declared dead”

link   http://www.dnaindia.com/india/report-no-medical-negligence-in-case-where-newborn-was-declared-dead-2479826

Above news just conveys the complexity of situation, doctors often face. My aim here is to convey  that communication of death is a very complex subject. Ironically no structured training of emotional, communicative and legal issues is imparted to medical students. But they are supposed to face the situation everyday, when they function as doctors.

 

Most legal determinations of death are certified by medical professionals who pronounce death when specific criteria are met. Two categories of legal death are death determined by irreversible cessation of heartbeat and breathing (cardiopulmonary death), and death determined by irreversible cessation of functions of the brain (brain death).

Especially new doctors need to realize that the structure of modern society is to make life and death, medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities.  Because of all  these sensitive issues, emotional aspects and legal dimensions of death being  huge, so need more attention. .

In remote areas doctors are totally alone and helpless, so security issues will remain. There is no solution in sight for these problems. Already I have written about a “real story of female doctor assault”.

Problem is that doctors during training days or residency are not trained in such kind of communication. Although while doing their duties they observe seniors and learn how they are communicating. But still when actual situations arise, which can be diverse, complex and challenging, and everyday getting more demanding. In view of current scenario against doctors, they need better training on these issues. Basic question is, if doctor needs help, where can he turn to for help or information. The resources, other staff and the setup is not of much help in difficult scenarios.  It is not uncommon that doctors are left to themselves, if a difficult situation arises. Medical education and Hospital systems need to be better equipped to provide more support to doctors in present era. For doctors, if they make a mistake, there is no one to support them or save them from verbal, physical assaults, law and medico legal cases.

Harassment is tremendous. Therefore   doctors, be careful – save the patient, but save yourself also.

Artemis doctors, CEO booked for negligence: how to save medical lawsuit in case of post operative complications?


Doctors save the patient, but save yourself also.

News of this kind brings tsunami of fear in minds of doctors all over. Not only doctors, but patients also fear that something like this should not happen to them. In general, it will also create a negative impact on trust of patients, because it reflects that harm is a result of blunder done by doctors.

Artemis Hospital Gurgaon, its CEO, medical director, medical superintendent, and three other doctors of the hospital were booked on  Sunday, based on the complaint of the husband of a patient who died in the hospital in August last year after undergoing treatment in it for two months. (link)

http://timesofindia.indiatimes.com/city/gurgaon/artemis-docs-ceo-booked-for-negligence/articleshow/59008481.cms

Reality and impact of this scenario may be a bit different from what is usually conveyed and is suffocating medical profession as a whole, all over the world, in some form or the other. Loss to the patient is immense and with sympathy wave against the doctor, everybody will cry for harshest punishment for the doctors. For a human error (which is called negligence), an unintentional harm and failure to anticipate a difficult situation has landed doctors in a soup. The   situations, which are detected by retrospective analysis along  with wisdom of hindsight are challenging and are real trouble. Real time diagnosis  may not always be possible to anticipate and often difficult.

As a doctor, I am forced to ponder whether by punishing the doctors in harshest way for unintentional errors, especially for one incident is the solution to the problem.

  • Can treatment and surgeries be made complication free anywhere? Unless everything is done by a Robot and computers.
  • If consequences of one mistake are such horrifying, will doctors be able to do work, especially in difficult situations free of fear? Or really should they opt for being in such situations?
  • If lots of doctors do not want difficult situations, what will happen to patients?

Difficult scenario for doctors, as even simple surgeries can lead to big complications in certain situations.  Not frequently, situations are unpredictable. So, what should doctors do to avoid to be in such difficult scenario?

How to survive medical lawsuit in post operative complications: Reality is that complications are part and parcel of treatment and surgeries. There will always an element of unintentional harm, whatsoever treatment is being done.No doctor can guess, which patient is going to have complications and give saviour the lifetime pain and shame. It is like a bad lottery. Only improvement can be made is to decrease the number of complications and timely recognition.  How to avoid such problems?

  1. Just be extra careful, extra conscious. Always have in mind that something can happen. It may lead to defensive practice, but that may be the need of the hour.
  2. Due to irony of present era, the preparation of saving yourself, the doctor has to start from the time the preparation of surgery starts. Most important part is consent. Doctor cannot predict, which patient will have what kind of complications. Detailed consent with detailed list of complications have to be mentioned and told to patient and relatives and duly signed with witness. Complications, although rare must be mentioned.
  3. Separate consent for anaesthesia to be obtained along with complications.
  4. Must check for coagulation profile and presence of infection in body.
  5. Risk to be assessed besides actual surgery, for other factors.
  6. Simple surgeries become high risk because of malnutrition, infections, low albumin levels and presence of other medical illness like diabetes, cancer, cardiac ailments. In presence of other factors, high risk consent to be taken.
  7. Never ever risk is to be understated, for the thought that patient will not agree, in case he is told about all the possible complications and risks.
  8. Careful surgery, with high index of suspicion for possibility of complications is required. Never be overconfident. Complication can happen in hands of most experienced people also.
  9. Post operatively : maintain a good record of vitals and pain. If patient is having problem, go to every detailed investigations to rule out your worst fears. Investigations will cost some money and people may accuse you temporarily of getting extra investigations. But it is better not to be accused later for criminal charges and losing all your peace of mind and reputation.
  10. Never discharge a patient, while problems are unresolved. May get a CT scan done and let people accuse you again for getting extra investigation . Time is such that doctors will be blamed and accused for something or the other by retrospective analysis. Let us take a smaller accusation. Later there no body will be forgiving.
  11. If you are not convinced or patient is unable to understand the risk, opt out of surgery. Doing few less procedures will not harm you.
  12. Upgrade quality assurance program of hospital and your department. With aim to minimize complications and early detection.
  13. Periodic audit of medical records.
  14. Medical Indemnity insurance: importance of indemnity insurance is immense these days. Be careful of not disclosing the medical indemnity insurance coverage, because litigant lawyer or patient may exploit it for litigation purposes.

 

Not infrequently, whole scenario becomes a story of revenge against the doctor, even for routine complications and naturally poor prognosis of disease. Therefore, Doctors – save the patient, but save yourself also.

 

 

How to survive medial lawsuit for central venous line insertion


 “ doctor- save the patient, but save yourself also”.

Consent must before invasive procedures: consumer panel  

National Consumer Disputes Redressal Commission has said that doctors must take consent of a patient or his family members for any invasive procedure during treatment. (11.5.2017 Times of India link below).

I really feel sad for the doctors, who sometimes due to overwork or zeal to do things  find themselves in a soup, because of lack of paperwork.  But they are learning the lessons the hard way. Law and media call them a mistake but I think the errors in documentation are due to lack of proper training and poor understanding of legal requirements of profession in consumer’s era. The ignorance is about necessity to save thou self, when we try to save the patient. These documentation have become all the more necessary in current scenario because of the non-acceptability of even common complications. If a complication occurs during treatment, prolonged retrospective analysis goes on at leisure by lawyers with an intention to find fault. They are driven by money as an incentive, and with the wisdom gained on the hindsight, they may find some fault almost always in some way. Thus, doctors are at great disadvantage on this issue. choosing medical career a disadvantage to doctors.

It is high time for doctors to learn how to save themselves. It is important to have a thorough documentation. I am mentioning certain aspects which should be taken care of, while putting a central line .

  1. As already in news “consent” is very important. Take care to write patient identity, age sex and all other relevant columns. Explain and write all benefits and possible complications of procedure. Get signature of patient, relative and a witness. Put doctor’s signature with date and time.
  1. Always try to use ultrasound to help you to locate lines. Patient can be obese, having short neck and it may be difficult anatomy. Ultrasound will help you in differentiation of artery and vein and avoid arterial puncture as in above case.
  1. Be sure before dilatation that you are in vein. Sometimes it is difficult to differentiate between artery and vein. Do everything to prove that you are in vein before dilatation.
  1. Take suitable precautions for to prevent sepsis, air embolism
  1. If it is not emergency always check coagulation profile.
  1. Make sure doctor who is doing the procedure is well trained for it.
  2. Upgrade quality assurance program by keeping record of adverse events during procedures.

These are simple steps, although documentation is cumbersome. But it is worth because it can help the doctor from future litigation, harassment and so many problems. This is need of the hour. Bottom line is “save the patient, but save yourself also”.

http://timesofindia.indiatimes.com/city/delhi/consent-must-before-invasive-procedures-consumer-panel/articles how/58618137.cms

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