30 Medical-Legal Issues in the Neurosurgical Intensive Care Unit
Abstract
The central nervous system is the unique person. Through it come memories, emotions, function, social, and spiritual structure. As such, any damage to it changes the person more than damage to any other body system. Therefore, the neurointensivist has the highest medical-legal risk, which can be mitigated by creating an atmosphere of security, confidence, and respectfulness through a caring and professional multidisciplinary team approach. The primary goals should include an effort to minimize confusion and doubt through many health care providers working in unison to provide a free flow of communication and education that is documented in numerous areas of the medical record.
Case Presentation
The police bring into the emergency room an adult Asian man, seemingly in his 40s, who was detained for wandering the streets partially clothed and confused. He is initially placed on a psychiatric 72-hour hold as a result of a mental disorder. While in the emergency room, the patient is observed having complex repetitive movements prior to a grand mal seizure. The patient is taken to the radiology department for a computed tomographic (CT) scan. In the meantime, the police produce his passport, indicating that he is most likely a visitor from China. The CT scan reveals a left temporal lobe lesion with edema. The patient awakens after the seizure; he is deaf and appears to be acting appropriately, but no one, including the telephone translation service, speaks his dialect. What should be the next steps taken by the hospital and the neurosurgical intensive care unit?
See end of chapter for Case Management.
30.1 Introduction
Neurologists and neurosurgeons attempt to treat the systems of the body that make the individual a unique person. If a person suffers almost any permanent neurologic deficit, he or she is usually changed forever. The person may not be able to hold the same employment position, make the same income, or relate to his or her family; be an interacting family member, caregiver, or productive member of society. Or the person may die. Not only does the patient change, but the patient’s family and dynamics change. Therefore, neurologists and neurosurgeons continually face health care situations that put them at the highest medical-legal risks.
Being admitted to the neurosurgical intensive care unit (NICU) may indeed be an intense and tumultuous time for the patient and his or her loved ones. This is especially true if an emergency trip to the hospital was necessary as opposed to being part of an elective procedure. It is therefore of paramount importance to create an atmosphere of security, confidence, and respectfulness through caring, multidisciplinary professionalism. The primary goals should include an effort to minimize confusion and doubt during this very stressful period while providing a free flow of communication and education. This is best achieved through a holistic team approach, which clearly identifies all treating members of the team and their individual areas of expertise. Most important is communication. During the period of patient and family stress, physicians and other health care workers must remain close and unified. They must not back away because of difficulties in care, in family dynamics, or with patients and families relating to the situation. This is even more necessary if complications have arisen.
30.2 Health Care Teamwork
All health care workers must present a united front for the patient and family. There must be clear communication about diagnosis, prognosis, and care from all team members involved in patient care. It is the physician’s responsibility to discuss the patient’s condition with the nurse, the primary patient advocate. It is the nurse’s responsibility to ask any questions so that he or she may understand all the care provided. It becomes severely problematic when the nurse dismisses or belittles any treatment options. If such a situation exists, then changing the lead health care provider should be discussed with the charge nurse and care transferred. Patients and their families, although under great emotional and physical stress, can perceive the discord and will turn that discord into frustration with and a lack of confidence in the health care provided. This situation can lead to medical-legal claims.
At times, patients in the NICU require care from multiple specialties. Although mandatory, it once again provides an opportunity for confusion in communication to patients and their families. The members of the health care delivery team may include trauma service, orthopedists, surgical subspecialists, intensivists, internists, pulmonologists, neurologists, infectious disease specialists, and physiatrists. The hierarchy within the ranks of a service should be delineated as well, appropriately identifying residents, physicians’ assistants, and attending physicians. Besides the doctors involved in the patient’s care, the patient and/or the family should be able to recognize the nursing staff, respiratory therapists, social workers, dietitians, clinical pharmacists, clergy, and therapists from the physical, occupational, and speech services. The best care of the patient involves much input and coordination; everyone should be of one mind and plan. Such coordination is accomplished through the guidance of regularly scheduled interdisciplinary meetings, during which information is updated and shared so that daily treatment plans can be formulated.
30.3 Health Care Workers–Patient/Family Communication
Most legal claims result from a lack or misunderstanding of information. Most patients state that they were not told about an unexpected outcome. This can be defended only by careful communication in the presence of a witness and documentation in the medical record. Health care witnesses need to be present when a physician discusses any planned procedures. The situation for the patient and family is complex, with emotions often drawing concentration away from discussions. Especially when discussing emergent procedures, it is common that the patient and/or family is not retaining all the information being explained due to the stressful situation. In most circumstances, the primary service should discuss the coordinated care with the patient and family, often relying on attendance by a consultant. In the NICU, the captain of the team is usually the neurosurgeon, who should be the primary spokesperson, unless deferring to the expertise of another colleague individually or in a conference setting. References to colleagues and ancillary staff should always be made with professional decorum in mind, as a misinterpretation may undermine the credibility of the unit.
The key to achieving the primary objective of an environment of trust and security is the demonstration of regard for preserving the patient’s dignity and displaying sensitivity and compassion while making time for daily briefings, particularly when the news is discouraging. It is vital to verify that successful communication has been accomplished. This can be quite challenging when attempting to convey the complexity of the natural history of a disease process or the risks and benefits of an intervention to patients and families from various cultural and socioeconomic backgrounds. The communication to the patient and family must be that the team recognizes the importance of their participation in the treatment plan and eventual outcome. It is especially important for the physician and health care team to speak in terms that the patient and the family understand. Oftentimes, we as physicians use medical terms that the layperson may not understand. During this time it is important to make sure everyone involved understands. This can be demonstrated by asking the patient and/or family members to use their own words to describe the conversation and ask any clarifying questions.
The patient and family must pick a spokesperson for the group, the main contact for the patient and family. Patients and family members will not understand everything told to them. As expected, they will absorb what they understand most. Every person has a different background, and therefore the information that he or she takes away from any conversation will be different. If each person communicates at separate times with the NICU staff, there will be numerous interpretations of what has been told. When that interpretation is transmitted among the family, there will be opportunities for discrepancies. These discrepancies will be turned into stress, hostility, and lack of confidence in the health care team.
During conferences and discussions with the patient and his or her family, it is necessary not only to convey information but to educate. Many people are visually oriented and benefit from seeing pertinent radiographic studies, such as X-rays, computed tomographic (CT) and magnetic resonance imaging (MRI) scans, and angiograms, while encouraging and soliciting questions. At times, patients and families overcome with shock and grief understandably hesitate to ask questions; they should then be invited to write down questions for the next discussion. The importance of establishing and maintaining this rapport cannot be overstated; it can prove to be sustaining, even in the face of a bad outcome or inevitable complications. Striving to create and maintain this type of atmosphere may actually foster trust and may prevent the formation of misunderstandings and misgivings that lead to discontent and possibly litigation.
30.3.1 Documentation
Detailed documentation of all discussions with patients and their families should always be noted in the medical record, preferably dictated because that comes with an electronic time and date in the electronic medical record (EMR). This is strongly recommended in addition to any institutional forms requiring signature. The presence of a witness, preferably the patient’s nurse, for discussion of care and signing of any legal documents is advisable.
Despite best efforts, certain situations involving consent, advanced directives, right to privacy, abuse, and declaration of death may require additional diligence lest they lead to polarization or true confrontation. Should such situations occur, the risk management officer must be informed immediately.
Documentation of communication can be in the form of handwritten notes, collaborating nurses and ancillary staff notes, dictations, hospital forms, and, more recently, EMRs. Each one should document that communication took place and note any additional members of the health care team present during said interaction. Each member of the NICU team must learn to communicate and exist in harmony, not only with patients but also with other members of the team. Physicians cannot and should not stand alone. The duty of the NICU team is to eliminate shame, encourage hope, communicate with respectful, unselfish caring about any emotions, and by logic, build bonds, and teach and inspire others to feel the same. People are different; however, differences build a better and stronger world. The NICU team must ask for opinions and try to empathize with what others are feeling.
With the introduction of the EMR, documentation in real time has become more convenient for both the physician and the nursing staff. Documentation of medications and when they were administered is readily available for the physician and nursing staff to view. This allows for clarification and less miscommunication between team members. In addition, the EMR also allows for physician documentation of any conversations with the patient and/or family members in one location that can easily be accessed by any health care team member. It is important that all health care professionals document any interaction they had with the patient or family as soon as it occurs. The advantage of the EMR is that, whenever the documentation is entered, it allows all team members to see the time and date of said occurrence and does not allow backdating of an interaction. Documentation in the EMR by the nursing staff is also available and is readily accessible for users to view. This can allow for corroboration among health care team members if an important interaction has occurred.
Related posts:
9 Homeostatic Mechanisms in the Neurosurgical Intensive Care Unit Patient
8 Sedation and Pain Management in the Neurosurgical Intensive Care Unit Patient
7 Delayed Intracerebral Hemorrhage
22 Anticoagulation and Antiplatelet Therapy in the Neurosurgical Intensive Care Unit
29 Spiritual Care of the Neurosurgical Intensive Care Unit Patient and Family
28 Family Communication
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