Complication ??? Breaking the news !!! G N Ramesh PVS Memorial Hospital Kochi

Complications happen …… to every one. The busier you are …… the higher the risk A good endoscopist …. does many..... gets away with it. A professional one …. does many …. May have the odd complication … handles the aftermath with calm, assurance and common sense.

Complications in GI endoscopy The challenge….to keep it to the minimum The science……effective management The ultimate trial….. To deal with complications at a personal, psychological and social level.

“ Don’t read stories of success Read stories of failures. Success stories give messages Stories of failures give new ideas to win ”

One of the golden rules of life!

‘ If you deserve to blossom like a rose in the garden,

you have to learn the art of adjusting with the thorns ’ - Anonymous

What could go wrong ? Desired result not achieved Co morbid illness related event Bleed

What could go wrong ? Desired result not achieved Co morbid illness related event Bleed Perforation Cardiac arrest on table Colleague related event The worst !!!

Situation ….Saturday afternoon 68 year old thin lady screening colonoscopy 5 th on a list of 6 cases. all bags packed….ready to go. prep took a little while longer… finally clear at 3 pm. difficult sigmoid………..hell!!!

Then the recap starts…….. Did I need to do it ? What have I told them ? Was the consent form signed ? Who must have signed ? Do I know any one of them ? Were the risks explained ?

Then the recap starts…….. Did I need to do it ? Maybe not!!! What have I told them ? Nothing!!! Was the consent form signed ??? Who must have signed ? Don’t know !!! Do I know any one of them ? No!!! Were the risks explained ? Not exactly !!!

Then the recap starts…….. Did I need to do it ? What have I told them ? Was the consent form signed ? Who must have signed ? Do I know any one of them ? Were the risks explained ? Whom should I talk to ? What next ? What about the expenses ?

Then finally…….. And……….. What about my bags ???

The first feeling The first feeling ‘ I just wish I were somewhere else ….. I don’t care where it is, I just don’t want to be here now facing this patient and their family, telling them these bad things have happened’ - John L Petrini.MD. President, ASGE

How to break the news to the patient / relatives?

Cocktail of emotions Guilt Frustration Remorse Sympathy Panic Confusion………………

Basic 2 questions How should I maintain/ repair my relationship with the patient/ relatives ? How do I keep from getting sued ?

The realisation….. Complications are an anticipated part of procedures. It is how you face them (as much as how you avoid them) that defines your character as a professional. It is also about planning and preparedness

Don’t think that the world is going to end!!! Don’t try the escapist route !!! Deal with it head – on.

Can complications be avoided completely?

Avoiding Complications Just Stay out of the way !

Avoiding complications ‘not being in the wrong place at the wrong time”

You’ll never be BRAVE if you don’t get hurt You’ll never LEARN if you don’t make mistakes You’ll never be SUCCESSFUL if you don’t encounter failure

The art of breaking news of a complication

Breaking news of a complication What can make it easier? The essentials The do’s The don’ts

What can make it easier?

3 steps Preprocedure Explanation/Informed consent Post procedure communications Being present and in control

Pre-Procedure Explanations No procedure is “ a piece of cake ” Packaging of the ‘ flip side ’ Take relatives into confidence Not demeaning to inform possible complications

The E M B R A C E format A full Explanation of the procedure The Motivation(reasoning) behind the medical recommendations The Benefits from undergoing the procedure The Risks involved What Alternatives are available(including doing nothing) What Complications may occur ( including their frequency) Any possible side Effects

The informed consent will take care of 80% of the problem. The rest of the story unfolds after the complication …and you are the lead character!!!

The 3 golden rules The consent Communication Rapport

The essentials

Breaking the news of a complication…… Is an art, nothing very scientific about it!!!

Breaking news of a complication is EXCRUCIATING

“ Life’s challenges are not supposed to paralyse you, they’re supposed to help you discover who you are ”

The facts Most endoscopists don’t know how to handle complications beyond the procedural nuts and bolts No forum for discussion

“ Doctors are wonderful. Up until the last few years, unfortunately they received virtually no training in medical school on how to communicate bad outcomes to patients ” “ They are taught everything under the sun clinically and academically, but nobody teaches them the softer side of medicine ” David Sousa, Sr. VP, Medical Mutual Insurance Company of North Carolina

“ When complications or adverse events occur, it is critical that physicians are honest with themselves and with their patients ….. that they acknowledge the possibility that an adverse event has occurred ……. And communicate these concerns in a timely fashion and with complete truthfulness to patients and their families ”

“ When complications or adverse events occur, it is critical that physicians are honest with themselves and with their patients ….. that they acknowledge the possibility that an adverse event has occurred ……. And communicate these concerns in a timely fashion and with complete truthfulness to patients and their families ”

Post complication communications Choose a comfortable briefing area 2-3 relatives ( close ones ) Offer undiluted, undivided attention Be calm yet assertive and reassuring

Post complication communication Be transparent: Talk about the procedure, risks, your intended aims, and what happened Express empathy and apologize without implying blame/ malpractice Tell them what you intend to do

Post-Procedure Communications Be there and be in control!!! Get the team together Surgeon/ Intensivist/ Cardiologist/ Physician Make sure the patient is being attended to Arrange to shift patient to intensive care

No one will ask you why it happened!! You will be judged by what you do in the aftermath By the clarity of your thoughts and communication By your sincerity and empathy THE RESPONSIBLE RESPONSE!!!

Manage the patient Manage the relatives Manage yourselves Manage the records Risk of litigation

Manage the patient Manage the relatives Manage yourselves Manage the records Risk of litigation If you wrote it, you did, If you didn’t, you had it !!!

Reactions 1. Some patients will want a lot of contact/empathy. 2. Some will be satisfied with an apology, and a reassurance/ assurance 3. The inquisitive/ probing patient/ relatives 4. Anger/ threats

Anger/ Threats Don’t loose cool Inform your team Inform the management Don’t abandon Keep communicating with the people

Angry relatives – short term crisis Quiet relatives - dangerous

The Do’s Sit down….calm yourselves..get thoughts together Write / Document Involve …..surgeon/intensivist Plan Empathise….Communicate…………..communicate….Listen

The Don’ts Don’t transfer ownership Don’t delegate communication Don’t be defensive Don’t be arrogant Don’t cover up

May there be minimum complications May each complication be the beginning of a new learning

Medicine is not now, and never has been, an exact science. Despite the exercise of the greatest skill, things can go wrong

Thank you

Complications of Endoscopy Summary know limits recognize promptly deal ‘head on’ early, appropriate management communicate keep channel open seek help and opinion

The bottom lines: Establish rapport ( patient and family ) Show warmth and compassion No procedure is too simple ! Express empathy, compassion and confidence Don’t assume litigation … but take precautions Careful and complete records

The biggest problems Inadequate pre-procedure preparation The consent The guilt that follows Tendency to deny / escape Enemies within Lack of communication Crazy documentation