2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

DISCLOSING MEDICAL ERRORS
Disclosure in oncology, as in other fields of medicine,
follows directly from the fiduciary nature of the relationship.
5,11,17,18 The relationship between patients with cancer
and their oncologists occurs in a particular context of uncertainty
about the evolution of the illness and prospects for
treatment effectiveness that affects both parties and their
reciprocal communication. 18,19 This uncertainty also contributes
to burnout among oncologists. 20 In addition, the
close relationships they may develop with their patients can
make committing and disclosing error more difficult for
them to bear. At the same time, severe illness and imminent
mortality among their patients may tempt them to withhold
information about error or adverse events. 5
Even if barriers to disclosure could be reduced, the use of
experimental anticancer protocols and multiple medications—often
carrying a high toxicity—along with the multidisciplinary
nature of most cancer treatments, can render
more difficult the oncologist’s assessment of whether an
adverse event is a side effect of treatment or the result of
medical error. Given all these factors, oncologists may be
tempted to rationalize away some errors and question the
need to disclose them to patients. 5
Questions of error, disclosure, and living with error in
oncology should be viewed in the context of truth telling to
patients with cancer. On one hand, because of the seriousness
of their illnesses, patients with cancer may be particularly
vulnerable to the inherent power asymmetry between
them and their oncologists. On the other hand, oncologists
often must deliver devastating news to their patients, and
the manner and content of their delivery can mean the
difference between mere fact giving and truth telling. 18
They may hide behind a torrent of medical information,
which, although factually correct, overwhelms and confuses
their patients. On the other hand, however, oncologists can
provide accurate and complete information to their patients,
while still supporting their sense of hope through assurance
that they will “be there” for them through the difficult paths
toward cure or palliative care.
KEY POINTS
● The two most effective ways to reduce the effect of
medical errors are system management and improved
communication.
● Oncologists may experience psychologic and emotional
difficulties, such us anguish, guilt, and shame,
associated with acknowledging and disclosing a
harmful medical error.
● Errors should be communicated openly and clearly,
and a sincere apology should be offered to patients
and their loved ones.
● An apology is essential to restoring trust in the
patient-doctor relationship and initiating a healing
process for all parties in the aftermath of a medical
error.
● Making a shift toward increased disclosure requires
humility, accountability and openness among oncologists,
as well as communication skills that can be
learned.
The reality of each patient’s illness evolves in unique ways
under the influence of many interrelated, contextual variables,
including the patient-doctor relationship. 18 In disclosing
to patients the seriousness of their cancer diagnosis and
formulating a prognosis, oncologists can draw on the creative
power of the reciprocal trust involved in their relationship,
as much as focusing on the facts of the case. Patients
with cancer and their families can thus know that honest
dialogue and true cooperation will take place throughout the
course of the illness and feel reassured that they will not be
left alone to cope with the hardest truths, including those
about medical errors. 21
Disclosure of Medical Errors in Oncology
The two most effective ways to reduce the effect of medical
errors are system management and improved communication.
22 Telling the truth to patients about medical errors
involves psychologic-emotional elements, in addition to professional
and legal ones. For patients, the physical effect
of error and the shock of learning about it may be compounded
by grief, loss, and a sense of isolation. Furthermore,
patients may be forced to live with the possible long-term
physical effects of error and the stigma of reduced family,
social, and occupational roles sometimes associated with
illness. 5 Finally, the effect on grieving families of knowing or
suspecting that a loved one with an incurable illness has
suffered or died from a medical error is potentially devastating,
and thus requires special consideration in regard to
disclosure. 21
As in all clinical communication, content, setting, and
emotional support are important. 23 The late Dr. Robert
Buchman, a major expert in communication with patients
with cancer summarized in the acronym CONES the essential
elements of a discussion involving a medical error: C for
choosing the appropriate “context” for carrying a difficult
conversation; O for the “opening” statement that alerts the
patient to a difficult conversation; N for a proper “narrative”
to describe the error, starting with plain words such as “I
found out that”; E for acknowledging and addressing “emotions”
in a direct empathic way by stating upfront, “ it is very
upsetting for you and it is awful for me too”; and S for
“strategy and summary.” 24
In disclosing medical errors it is essential for oncologists
to attend to both medical and emotional aspects of the
information provided and the reactions they may elicit from
patients and families. The physician’s response must be
clear at the clinical level and also address the emotional
needs of patients and family members. In addition, in
disclosing medical errors and discussing their causes and
actual or potential consequences, oncologists should also
share their own emotions. Four different levels of response—
direct, escalationary, exploratory and empathic—have been
identified. Although the first three predominantly address
the factual aspects of the situation, only an empathic response
has the potential to result in effective communication
about something so painful and upsetting as a medical
error. 24
Culled from practical guidelines developed by institutional
bodies, published research, and clinical experience,
Table 1 lists suggestions for oncologists facing the difficult
task of revealing to patients or family members that a
medical error has occurred. 25-27
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