Disclosure of information is the process through which physicians explain clinical information to their patient (or surrogate decision-maker) in a way that the patient/surrogate can understand.
- It is critical for patients to understand their own clinical situation and make informed decisions about their care.
- All aspects of a patient’s clinical status should be disclosed and discussed with the decision-maker.
- Underlying principles: autonomy, honesty, transparency
Disclosure of information and informed consent
Disclosure of information is a prerequisite for informed consent.
- In order to make an informed decision, patients require all the relevant information necessary to make that choice.
- This information typically includes (but is not limited to):
- The patient’s diagnosis and prognosis
- Recommended treatment, including side effects and risks of the treatment
- Alternatives to the recommended treatment, including the risk of nontreatment
Factors in favor of disclosure of information
- Preservation of patient confidence/decreased patient anxiety
- Eliminates uncertainty created by doubt (e.g., bad news is better than “always wondering”)
- Increased patient compliance and adherence
- Involvement of relatives and caregivers
- Reduced probability Probability Probability is a mathematical tool used to study randomness and provide predictions about the likelihood of something happening. There are several basic rules of probability that can be used to help determine the probability of multiple events happening together, separately, or sequentially. Basics of Probability of lawsuits
How to Adequately Disclose Information
Setting and timing
- Quiet and private setting; never with other patients or in a place where one can be overheard
- An adequate amount of time must be allocated for discussion, especially for delicate information; do not rush RUSH Abdominal and cardiac evaluation with sonography in shock (ACES) and rapid ultrasound for shock and hypotension (RUSH) are point-of-care ultrasound (POCUS) examinations indicated in cases of nontraumatic, undifferentiated hypotension, or shock. ACES and RUSH: Resuscitation Ultrasound Protocols the encounter.
- A relative, clergy person, psychologist, and/or social worker may be present to support the patient when discussing serious information.
Who is disclosing the information
- Important information should always be disclosed by the attending physician; e.g.:
- A new diagnosis (even if this diagnosis is not life threatening or “severe”)
- Outcomes of a procedure
- Lab results
- When it is okay to delegate informing patients of lab results:
- Always after the attending physician has reviewed the results
- Information should only be delegated to a trained staff member, typically a nurse.
- The disclosed information should not alter the plan of care already in place (e.g., informing a patient that their urine culture came back consistent with Escherichia coli Escherichia coli The gram-negative bacterium Escherichia coli is a key component of the human gut microbiota. Most strains of E. coli are avirulent, but occasionally they escape the GI tract, infecting the urinary tract and other sites. Less common strains of E. coli are able to cause disease within the GI tract, most commonly presenting as abdominal pain and diarrhea. Escherichia coli and the current antibiotic they are on is appropriate therapy).
- There should always be a way for patients/surrogates to discuss the information being disclosed with their physician should they have questions.
- Relevant information regarding:
- Recommended treatment
- Alternative treatments and nontreatment
- Complications that arise from both treatments and nontreatment
- Information must be disclosed in a way that the patient/surrogate can fully understand. Consider:
- Language barriers
- Always have a professional medical translator present for patients who speak a different language than the physician.
- Family members should not be the primary translators (except in emergency situations), as is not possible to guarantee that the information is being properly conveyed to the patient/surrogate
- Education/mental status/comprehension level of the patient/surrogate
- Patient’s/surrogate’s hearing or visual impairments
- Cultural norms
- Language barriers
Manner of delivery
- Sensitive, considerate, patient, empathetic, and professional
- The clinician must be aware of proper wording and their own body language.
- Pauses should be provided so that the patient can process the information at their own pace.
- The clinician must be attentive to the patient’s verbal and nonverbal responses so that the clinician knows when it’s appropriate to pause.
- Clinicians should never lie to patients.
- The amount of information should be reasonable; it is appropriate to gently check for understanding.
Disclosure of Medical Errors
Medical errors are defined as either:
- The failure of a planned action to be completed as intended (error of execution)
- Use of the wrong plan to achieve an aim (error of planning)
A medical error is often defined as a commission or an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were negative consequences.
Medical errors may or may not cause harm to patients directly.
Types of hazards
- Near miss:
- A patient is exposed to a hazardous situation but does not experience harm, either through luck or early detection of the situation.
- Indistinguishable from a preventable adverse event, except for the outcome
- Error: refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations
- Nonharmful error: An error occurred but did not cause harm.
- Harmful event:
- An error occurred, resulting in harm to the patient.
- Harm may be mild (temporary mild pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain) or severe (permanent disability or death).
Common categories of medical errors
- Medication events:
- Administering the wrong medication or the wrong dosage
- Adverse drug events/reactions
- Healthcare-associated infections:
- Catheter-associated urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections
- Ventilator-associated pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
- Clostridioides difficile infections
- Surgical errors:
- Wrong site
- Wrong procedure
- Wrong patient
- Laboratory errors:
- Wrong test is ordered.
- Appropriate test is not ordered or results are misapplied.
- Testing delays
- Inaccurate results
- Patient falls
- Pressure sores
- Documentation errors (e.g., “copy forward” functions with risks for errors; computerized order entries)
How to disclose medical errors
The hospital’s internal legal team or risk management team should be notified immediately and can assist in the process of disclosure. With the patient, they should:
- Begin by stating that an error occurred.
- Physicians should disclose both harmful and non-harmful events
- Harmful events must be disclosed to patients and families.
- Never lie or try to hide a medical error.
- Disclosing medical errors in a timely, professional, empathetic, and transparent manner helps maintain patient/family trust in the system.
- According to the Code of Medical Ethics Medical Ethics Medical ethics are a set of moral values that guide the decision-making of health care professionals in their daily practice. A sense of ethical responsibility has accompanied the profession of medicine since antiquity, and the Hippocratic oath was the 1st document to codify its core ethical principles. Basics of Medical Ethics of the American Medical Association, “physicians should at all times deal honestly and openly with patients.”
- If medical errors are not disclosed to patients, but later discovered by the patient or family, the patient/family will lose trust in the treating team and is much more likely to take legal action.
- Describe the course of events using plain, nontechnical language.
- Use clear and concise terms to explain the error to the patient.
- State the nature of the mistake, consequences, and corrective action.
- Express personal regret and apologize.
- Sincere apologies help patients understand that their team truly wants the best for them and that the mistake was an honest mistake.
- Patients prefer apologies over statements of regret; e.g., “I’m sorry I caused you harm,” instead of “I’m sorry this happened to you.”
- Maintains the physician–patient relationship
- Decreases the risk of litigation
- Answer all questions and address concerns.
- Plan next steps with the patient.
- Have, H., Gordijn, B. (2013). Handbook of global bioethics. Dordrecht: SpringerReference.
- Steinberg A. (2009). Disclosure of information and informed consent: ethical and practical considerations. Journal of Child Neurology, 24(12), 1568–1571. https://doi.org/10.1177/0883073809337033
- Murray, B. (2012). Informed consent: what must a physician disclose to a patient?. The Virtual Mentor: VM, 14(7), 563–566. https://doi.org/10.1001/virtualmentor.2012.14.7.hlaw1-1207
- Chamberlain, C.J., Koniaris, L.G., Wu, A.W., Pawlik, T.M. (2012). Disclosure of “nonharmful” medical errors and other events: duty to disclose. Archives of Surgery (Chicago, IL: 1960), 147(3), 282–286. https://doi.org/10.1001/archsurg.2011.1005
- Berthold, J. (2014). Disclosing medical errors the right way. Retrieved July 6, 2021, from https://acpinternist.org/archives/2014/06/errors.htm
- Chamberlain, C., Koniaris, L, Wu, A.W. (2012). Disclosure of “nonharmful” medical errors and other events. Arch Surg; 147(3):282-286. Retrieved July 6, 2021, from https://jamanetwork.com/journals/jamasurgery/fullarticle/1107400