ANATOMY OF AN OBSTETRIC LOSS HEALING THE FAMILIES AND OURSELVES Cynthia Chazotte, MD, FACOG Montefiore Medical Center Albert Einstein College of Medicine CONFLICT OF INTEREST DISCLOSURE STATEMENT I have no significant financial interest with any commercial or corporate enterprise. I shall not discuss any off-label usage of any FDA-approved medications or other products. SMI Morality case 28 y/o P2 at 31 weeks gestation admitted with superimposed preeclampsia. History of chronic HTN and eclampsia in a prior pregnancy BP s 140-170/80-100, treated with labetalol. Cesarean delivery of live infant to NICU PACU BP 78/50, tachycardic, 1 hour later Pulse 140, BP 48/20 Cardiology consult transfer patient to ICU Transfusion in ICU, cardiopulmonary arrest Bedside exploratory laparotomy revealed hemoperitoneum Resusitative efforts failed and patient died Husband and 3 young children left behind.
After the Death FIRST THINGS FIRST Make sure other patients under your care have another physician and team to care for them Prepare to tell the family Find quiet, comfortable, confidential room Plan what you will say Start to assemble team to help with comforting the family Nurse, social worker, chaplain Breaking the Bad News Fire a warning shot Something terrible has happen and we need to talk Acknowledge suffering and convey empathy We are so sorry that this has happened This must be a nightmare for you I can t imagine how hard this must be for you Respond to family s emotional reactions
What to Say Communicate slowly and clearly Clearly state the facts as they are known Don t speculate Welcome questions Summarize discussion and confirm understanding Next steps Considerations for family Viewing the body Calling in family and/or friends Ask if clergy to be called Discuss postmortem examination Hospital autopsy, Medical examiner case? Arrange a follow up meeting Provide contact information Provide resources for bereavement Next steps Considerations for physicians STAFF Debrief Call patient s primary physician Make sure to discuss with risk management Alert office staff to stop billing Make sure no appointment reminders go out for patient Should you go to the funeral?
Healing Ourselves What is the Second Victim? Defined as a health care provider (HCP) involved in unanticipated adverse patient event medical error patient-related injury HCP becomes victimized in the sense that he/she is traumatized by the Second victim feels personally responsible for unexpected patient outcomes they have failed their patient second-guessing their clinical skills and knowledge base Stages of Recovery 1. Chaos & Accident 2. Intrusive reflection Error realized/ event recognized Re-evaluate scenario Tell someone. Get help. Stabilize & treat patient. May not be able to continue care of patient. Distracted. Self isolate. Haunted reenactments of Feelings of internal inadequacy. How did that happen? Why did that happen? What did I miss? Could this have been prevented? Stages of Recovery 3. Restoring Personal Integrity Acceptance among work/social structure Manage gossip/grapevine. Fear is prevalent. What will others think? Will I ever be trusted? How much trouble am I in? How come I can t concentrate?
Stages of Recovery 4. Enduring the Inquisition Realization of level of seriousness Reiterate case scenario. Respond to multiple whys about the Interact with many different responders. Understanding of Disclosure to patient/family. Litigation concerns. What happens next? Who can I talk to? Will I lose my job/license? How much trouble am I in? Stages of Recovery 5. Obtaining emotional first aid Seek personal/ professional support Getting help/support Why did I respond in this manner? What is wrong with me? Do I need help? Where can I turn for help? Stage 6: Moving On 3 Possible Outcomes Dropping Out Surviving Thriving Transfer to a different unit or facility. Coping but still intrusive thoughts Maintain life/work balance Consider quitting. Feelings of inadequacy. Persistent sadness. Trying to learn from Gain insight/perspective. Does not base practice/work on one Advocates for patient safety initiatives. Is this the profession I should be in? Can I handle this kind of work? How could I have prevented this? Why di I still feel so badly/guilt? What can I do to improve patient safety? How can I learn from this?
Healing ourselves How can we help? Provide support for HCP s Team debrief after adverse event without finger-pointing What did we do well? What could we have done better? How can we change systems to improve outcome? Establish referral source for counseling of HCP s who are not progressing through stages or are dropping out or just surviving. Acknowledgements ACOG/CDC Maternal Mortality Provider, Patient, Family Support Work Group ACOG-DII Richard Waldman Safe Motherhood Initiative D. Montalto ACOG DII C. Morton Sociologist CMQCC Stanford E. Tsigas Preeclampsia Foundation A. Cregna - CDC D. Cheng - Maryland DOH C. Ruhl - AWHONN E. Karkowsky MFM Montefiore M. Davidson CNM George Mason D. Karsnitz CNM Frontier Nursing K. Buckley CNM, ACOG J. Mahoney - ACOG Miranda Klassen - AFE Foundation Montefiore/Einstein Patient Safety Team D. Goffman E. Rivera C. Lee P. Bernstein Resources for Families A Mother s Memory, Bereavement and Advanced Care Planning Services: www.bereavementservices.org/maternaldeath www.amazon.co.uk/mothers-memory-book-record- Family/dp/184786547X#reader_184786547X Rights of the bereaved tip sheet: www.helpstartshere.org/mind-and-spirit/grief-and-loss/grief-and-loss-tip-sheet-thirteenrights-of-the-bereaved.html Amniotic Fluid Embolism Foundation: www.afesupport.org Resolve Through Sharing : www.bereavementservices.org
Resources for Health Care Providers University of Missouri second victim provider support program: www.muhealth.org/secondvictim Resources from AHRQ website: www.psnet.ahrq.gov/resource.aspx?resourceid=20869 Toolkit for staff support (link from AHRQ website): www.mitsstools.org/tool-kit-for-staff-support-forhealthcare-organizations.html Harvard Risk Management Foundation When Things Go Wrong: Responding to Adverse Events www.rmf.harvard.edu/~/media/files/_global/kc/pdfs/adverse_event_guidelines.pdf Canadian Disclosure Guidelines published in 2008 www.patientsafetyinstitute.ca www.cmpa-acpm.ca/cmpapd04/docs/resource_files/ml_guides/disclosure/introduction/index-e.html ACOG Healing Our Own: Adverse Events in Obstetrics & Gynecology http://www.acog.org/about%20acog/acog%20departments/professional%20liability/adverse%20events. aspx