Improve communication, use hospice to reduce risk
Though the chance of prosecution for administering high-dose opiates to the terminally ill is remote, the investigation and prosecution could be a disaster for the facility where the incident occurred. Even if the physician ultimately is not indicted or convicted, the media reports could be devastating to the facility’s image.
To reduce the chance that a prosecutor will even hear about an incident, risk managers should heed the lessons learned from the cases already investigated and prosecuted, says Ann Alpers, JD, a professor of medicine at the University of California- San Francisco Medical School. Legitimate cases in which the physician may have committed a crime should not be hidden, but she says risk managers should strive to ensure perfectly innocent cases of pain relief are not reported to authorities by staff who misunderstand the circumstances. She offers this advice:
• Improve the overall effort to control pain.
"In all the cases of prosecution, the patient came into the hospital with uncontrolled pain. That’s a point that often gets lost," she says. "The patient is admitted while actively dying, seeking pain management because the pain has been so poorly controlled. Then you’re operating in an environment in which the family is under tremendous strain, the nursing staff is very concerned, and physicians are trying to play catch-up with stopping the pain. That’s a bad situation ripe for misunderstanding, rancor, and communication problems."
• Improve communication among the entire care team.
Most of the cases that were investigated (see story, p. 53) were not prosecuted. Alpers says those cases usually came to the prosecutors’ attention only because someone involved in the patient’s care misunderstood the doctor’s efforts to relieve pain. Such reporting often is a common side effect of many types of clinical care, not just palliative care. The necessary hierarchy of clinical care providers sometimes leaves some team members uninformed. If the situation is tense and emotional, that can prompt those team members to make unjustified assumptions.
"If you’re concerned about protecting yourself from liability, one way is to make sure everyone involved with caring for the patient agrees with what you’re doing," Alpers says. "Opiate dosing is very difficult in some of these cases, and it would be worthwhile in such a case to have the doctor explain — explicitly — what’s going on to nurses and everyone else involved."
Team meetings can be a good way to improve communication, she says. Caregivers and family should be briefed on how long death can take, common occurrences such as labored breathing, and the importance of relieving pain.
That approach is endorsed by Grena Porto, RN, ARM, DFASHRM, director of clinical risk management and loss prevention services at VHA Inc. in Berwyn, PA, and president of the American Society for Healthcare Risk Manage ment. She says any type of whistle-blower problem indicates poor communication within the unit or the hospital.
"If a nurse has to call the local prosecutor and say she’s concerned, then what does that say about your communications within the hospital?" Porto asks. "You need people sitting around and explaining what is happening with the patient and why this is being done. You really need ongoing education, not just in [the] context of a particular case."
• Work closely with a hospice or palliative care unit.
Not one of the cases investigated or prosecuted involved a hospice or palliative care unit. The reason, Alpers says, is that physicians and staff in those settings have much more experience with terminally ill patients than the average clinician and are better educated about pain management. She also suspects they have a better working relationship.
Even if you do not transfer the patient to a hospice or palliative care unit, a close working relationship with staff at those facilities will help your staff better manage pain.
• Keep accurate records and discourage any effort to fudge them.
Some of the investigated cases involved nurses who were troubled by instructions to enter inaccurate drug notations in the patient record, causing them to report the situation. Those instruc tions may have resulted from a physician’s worries that the actual dosage or drug could prompt an investigation, even if he or she knew that it was justified to relieve pain.
Alpers suggests reminding physicians that such inaccuracies in the record can only cause trouble.
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