Bacon, A.K., Death on the Table. Anesthesia 1989:44;245-248.
Dr. Bacon provides a prescription for responding to a death in the operating room and discusses the human relationships that are touched by this rare and tragic event.
He begins with a few “golden rules” for both the family and the care-givers: how to (1) break the news, (2) give the facts, (3) allow ventilation of emotions and grief, (4) answer questions, (5) restate the facts, (6) outline the steps that have to be taken by law, (7) express continuing support for the family and sympathy with them in their time of tragedy.
Following this initial and brief meeting, he suggests the medical team (surgeon, anesthesiologist, nurse, and another professional such as a chaplain or social worker) break for a final briefing for twenty minutes, and then return to the family to discuss the formalities of what happens next.
Dr. Bacon implies familiarity of the team with hospital procedures such as completion of the medical record, notification of the family doctor and the filing of incident reports and other forms. He specifically notes checking and recording the anesthesia machine and medication ampules utilized.
Further attention is directed to the possibility of civil proceeding, including the preparation of a narrative of the events as soon as possible “written to assist in defense of possible legal proceedings,” and a review with a senior anesthesiologist on staff. Finally, he expresses concern about debriefing the operating team, particularly in extremely stressful circumstances such as unusual media coverage, patients who were members of the surgical team and children.
Three questions come to mind. Is this really necessary? The answer on both moral and pragmatic grounds is yes. Our final service to our patients is the duty owed to the family. Moreover, there are suggestions that malpractice actions are driven by bad feelings as well as bad outcomes; such bad feelings have consisted of guilt, rage, grief, surprise, betrayal and abandonment. In the majority of our national and international efforts at quality assurance and risk management, we have begun to address adverse outcomes, but have barely scratched the surface of the bad feelings that may be associated with these bad outcomes.
Is it dangerous to our personal liability exposure to involve ourselves with families in such a manner following a catastrophic event? There are suggestions that just the opposite may be true. “Physicians, like anyone else, will make mistakes”.(1) Many legal actions against physicians are driven not by the quality of the care but by the anger, frustration and outrage of family members who perceive they have not been communicated with fully and in a timely manner. Communication after a catastrophe is no antidote to lack of preoperative evaluation, preparation and communication prior to the catastrophe, as well as selection and administration of an appropriate anesthetic and documentation of care.
Nevertheless, there are suggestions that the “sharing of uncertainty” reinforces the principles and practices of informed consent.’ It is important to remember that in communicating with the family following a catastrophe, an expression of sorrow or regret for the situation without admitting guilt or negligence is inadmissible as evidence of liability in several states, Massachusetts being one of them. This includes any statements, writings or benevolent gestures relating to the suffering of the victim of an accident. Such expressions (with the security of protection under the law) underscore the clinician’s empathic and mature response to a tragic situation.
Is there comparability between the Australian legal system and the American ? It is not completely dear. Yet, although the laws may be different, it is hard to believe that the feelings of those who are touched by medical tragedy are.
Very few practitioners of anesthesia have dared to approach this sensitive subject. Dr. Bacon presents a cogent overview of concerns material to the family, the anesthesiologist, the operating room team and -the practice of medicine.
Abstracted by Robert S. Holzman, M.D., Harvard Medical School and Children’s Hospital, Boston.
1. Hilfiker D. Facing our mistakes. N Eng J Med 1984: to; I IS122.
2. Gutheil TG, Bursztajn H, Brodsky A. Malpractice prevention through the sharing of uncertainty: Informed Consent and the Therapeutic Alliance N Engl J Med 1984:3 1 1’49-5 1.
3. Mass. Gen. Laws c. 233, sec. 23D (1986).