We have all heard the colloquialism, “Don’t count your chickens until they’ve hatched,” yet in healthcare we tend to frequently do so, especially in the immediate post-op period.
Take, for example, the post-surgical discussion with the patient and family that surgery went as planned. Sometimes we even dare say there were “no complications.” Then, seemingly out of the darkness, comes a “complication” that sets the patient back a month or more and hits like an ambush out of a bad Western. And therein lies the root of this article – a complication should never take a patient by surprise. While it may be disappointing, patients must not feel like their health has been ambushed. The cause rests with us in our lack of adequate assessment and management of patient expectations that can end up being our litigation storyline.
Many complications take time to evolve, and we can do a better job at educating patients about those. By assuring our patients understand and know what to recognize, we draw them closer into a healthcare partnership with us, so if or when a problem arises, it is not “what is wrong” but instead “I am having that complication we discussed.”
Picking a body part to demonstrate this effect, let us talk about ureters and female abdominal surgeries. The effects of radiant energy from cautery may not be evident at the time you’re looking for a problem, but arrives as a urinary issue days or weeks later. This is after the patient was told she had no surgical complications (you do put in the Op report that you inspected those little tubes along with bladder, bowel, and other parts all looking okay, right?)
The wiser alternative is to teach your patient that some complications are immediately obvious while others could arrive days or weeks later. That stages you to reiterate those at discharge, and primes the patient to know and look for symptoms to alert you. In turn, that can reduce the time between onset, diagnosis, and treatment. While the patient’s experience may be disappointing, it is not shock and horror with your name attached – especially if you told them everything was "okay" when it really was not. The key is to manage the patient’s expectations in advance and let adequate time pass so you in fact know you are truly beyond the reach of those insidious and not immediately apparent problems.
That brings us full circle to the concept that “good consent” is expectation management. It is a harmonious compilation of your expectation assessment and your oral discussion on the risks and benefits of your proposed procedure. As to the consent form, it is just that – a “form.” It does not itself prove you discussed anything with your patient. It only proves the patient signed a form. Without documenting your discussion in the record to marry the form into the consent process, the marriage is incomplete. Always take a few extra minutes to go over what the patient expects and jot down a comment that you discussed the risks and benefits...and don’t forget those insidiously sneaky complications in the process.
Lee McMullin is a senior risk management and patient safety specialist in the CAP Cares service area. Questions or comments related to this article should be directed to lmcmullin@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.