When a serious adverse outcome occurs, expect scrutiny for what you say and do

When a serious adverse outcome occurs, expect scrutiny for what you say and do

Recent brain death case raises awareness: Be prepared

By Joy Daughtery Dickinson

"Ms. McMath is dead. Children’s is under no legal obligation to provide medical or other intervention for a deceased person." "Turning off a ventilator that assists in delivery of oxygen of a dead person causes no irreparable harm — regardless of the parental or religious beliefs of the decedent’s family."

These statements from Children’s Hospital Oakland (CA) and its lawyer, regarding the highly publicized case of a 13-year-old declared brain dead after an adenotonsillectomy, brought negative reactions from the patient’s family and the public.

Jahi McMath was admitted to Children’s Hospital Oakland on Dec. 9, 2013, for an adenotonsillectomy as well as a uvulopalatopharyngoplasty and a submucous resection of bilateral inferior turbinates to improve her breathing and sleep. She suffered bleeding and cardiac arrest while in recovery, and blood flow to her brain was lost for an undisclosed amount of time. On Dec. 12, she was declared brain dead by doctors at the hospital. Her family was informed that she was legally dead and life support systems would be removed.

The family refused to accept that conclusion and petitioned a judge to order an independent second opinion. A doctor was appointed by the court, and he reaffirmed the diagnosis of brain death.

McMath’s mother claimed that declaring her daughter dead under the Uniform Determination of Death Act violated her freedom of religion and privacy. The county superior court granted an extension to keep McMath on a ventilator until Jan. 7, but refused the family attorney’s request for hospital staff to insert a tracheostomy and feeding tubes. On Jan. 5, the hospital released McMath’s body to the coroner, which then released her body to the custody of her mother. The family has since issued statements saying McMath is on life support at an undisclosed facility.

Every statement by the hospital fell under scrutiny as the family kept this story in front of the mainstream media and social media, which forced the hospital to respond reactively.

"You never get a second chance to make a first impression," Gerard Braud, president of Braud Communications, a crisis communications and media training firm based in New Orleans. "If the first statement isn’t sensitive, and the second statement isn’t sensitive, the perception of what you are and who you are as an institution is immediately tainted."

Family members and others loved ones can be hypersensitive in a patient crisis, Braud points out. While the "medical facility traditionally tries to communicate on a clinical or legal level, what the family wants to hear is communication on an emotional level," he says.

Responding to serious adverse events can be particularly difficult for ambulatory facilities because they don’t have dedicated risk management staff, the atmosphere is high on stress and time constraints, and adverse events are rare, according to an article just published by The Joint Commission that targets response to adverse events. (See story, p. 51.)

Consider these suggestions on how to address a patient crisis:

• Have a crisis communication plan.

Medical institutions "don’t plan on a clear sunny day what they’re going to have to say on their darkest day." Braud says. "In a social media and twitter word, the problem with the one-hour goal of getting out information to the world is that it’s 59 minutes too late. It’s likely people in social media already are communicating about the same topic."

Write your crisis communication plan on a day "when you can be free of anxiety, and address the issue on both an emotional and clinical level." Create a library of documents that you can pull from when needed that will allow you to communicate quickly and sensitively, he says. The preamble for each should convey "empathy in appropriate matter before getting to the clinical facts," Braud says.

Even the clinical facts should be stated as sensitively as possible, in a non-adversarial tone, he says. "Start by stating obvious truths that everyone could agree with," Braud says. He gives this example: "Few things in life are as tragic or as difficult to deal with as when a parent loses a child."

"Not a human being on earth would disagree," he says. When you read that statement, the audience figuratively will be nodding their heads. The next line should say, "The case we’re here to discuss today is one of those."

Next, consider what the cynics in the audience will say. For example, Braud says, you can say, "While trained physicians hope for the maximum outcome in every surgery, there are those sad times when conditions beyond our control exist, and this is one of those times."

Confirm the information that you can, he says.

• Ensure any publicly released comments are sensitive to the family.

Brad Phillips, founder and managing editor of the Mr. Media Training Blog and president of Phillips Media Relations in New York City and Washington, DC, says that some of the statements from Children’s Hospital Oakland "struck the right tone: sympathetic, acknowledging the seriousness of this case, and expressing a commitment to look into and learn from this case."

Other statements were "unusually sharp," he says. Phillips gives the following statement as an example: "Unfortunately, we are unable to correct many of these inaccuracies because of the family’s refusal to let Children’s Hospital & Research Center Oakland speak about this case."

"That blame-the-victim’ strategy rarely plays well with the public, and nor should it," Phillips says.

The statements appear to be written by an attorney, which gives the impression that the legal case is more important than public perception, he says. "The hospital may be right on the facts, but they need to remember that facts alone don’t win crises; they need to be presented in the right way, by the right person, using the right tone," Phillips says. "They should be mindful that other patients and potential future patients are watching how they’re handling this case, and any whiff of condescension or lack of compassion toward the family will play badly with them."

Phillips also took issue with the hospital lawyer’s statement in legal papers that said, "Turning off a ventilator that assists in delivery of oxygen of a dead person causes no irreparable harm — regardless of the parental or religious beliefs of the decedent’s family."

"The second portion of that quote feels like an unnecessary dig," he says. "A more compassionate phrasing might be: `We understand and respect that different people hold different parental or religious beliefs. In this case, however, the science is clear: Turning off a ventilator that assists in delivery of oxygen of a dead person causes no irreparable harm.’"

The family apparently was upset that the hospital referred to Jahi as "the body." Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp. in Haslett, MI, says such wording "is insulting" and "add fuel to anger and makes the hospital appear not caring." If the hospital is not responsive to the needs of family, it "can be a PR problem and can inflame the family in terms of possible litigation," he says.

Not every response of the hospital is being criticized. A statement was released on Dec. 21 that referred to Jahi’s mother and said, "Our hearts go out to Nailah, her family and the community. We understand the intense grief of a mother who has lost a child. We are committed to fully investigating what caused this catastrophic outcome from this complicated surgery. As medical professionals, it is our responsibility to ensure that we don’t create hope where there is none. When one’s brain ceases to function, it never restarts. We have the deepest sympathy for Jahi’s mother who wishes her daughter was alive; but the only thing maintaining this child is a ventilator machine and it would be unfair to give false hope that Jahi will come back to life."

"I think that hospital statement was a good one," Trosty says. "It did not admit guilt, it showed they were concerned and recognized it was a catastrophic outcome, which it was, and committed to full investigation."

Consider similar wording if your facility has a poor patient outcome, sources say. "You do not want it to appear as if you are hiding things or sweeping things under the rug, nor do you want to appear as not caring," Trosty says.

RESOURCES

• The Media Training Bible, a step-by-step guide to media interviewing, by Brad Phillips. Web: http://www.mrmediatraining.com/Book.
• Braud Communications offers a two-day crisis communications plan and writing retreat. Web: http://braudcommunications.com/crisis-communications. n

TJC article suggests response to adverse event

Disclosure and apology encouraged

"The Joint Commission Journal on Quality and Patient Safety" has published guidelines for responding and communicating adverse events.¹

The article focuses on the PROMISES project (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction), which promotes disclosure and apology practices for ambulatory practices in responding to adverse events. Key components are:

• Immediately disclose the situation.

• Ensure patient receives appropriate care or treatment.

• Empathize with your patient and his/her family.

• Follow up and follow through.

• Support your colleagues.

The article also discusses patient communication techniques, such as being attentive, listening actively, and apologizing. It includes a four-page document that busy practitioners can refer to when needed. (To reach the four-page summary, go to http://bit.ly/1iutZsR.)

Reference

1. Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory setting. Joint Comm J Qual Patient Safety 2014; 40(2):91-96, AP1-AP4. n