Communication about treatment and care is a critical component of a solid patient-physician relationship, and important for achieving positive patient outcomes. Lapses in dialogue from healthcare professionals can be harmful to the patient and may be a liability for the provider.
In a case from the U.S. Court of Appeals for the Seventh Circuit,¹ a nurse practitioner, Nurse NP, was found liable for failure to educate a patient, Mr. CL, on the risks of his condition. For four years, Nurse NP treated the plaintiff for hypertension. However, Nurse NP did not educate Mr. CL about his disease or monitor its progression. As a result, Mr. CL developed Stage V kidney disease, requiring dialysis and a kidney transplant.
Background
Mr. CL had failed a pre-employment physical due to high blood pressure. He went to a health clinic where he was seen by Nurse NP and was diagnosed with hypertension and obesity. After his routine lab work was completed, he returned one week later for his follow-up visit. Nurse NP prescribed medication for his hypertension and scheduled another visit for the following week. However, Mr. CL did not return to the clinic for two years when he failed another pre-employment physical due to hypertension.
Mr. CL would go for long stretches without seeing his nurse practitioner and only took his prescribed medication when he was feeling ill. It was discovered that Nurse NP never explained to Mr. CL the importance of taking his medications as prescribed or attending regular medical appointments. Nurse NP did not provide any education about hypertension or its associated risks.
Approximately three years after Mr. CL’s first visit, new lab tests identified early signs of kidney damage, but Nurse NP failed to review or act on the results. It was not until a year and a half later that Mr. CL was diagnosed with end-stage renal disease, requiring hemodialysis and a kidney transplant.
Mr. CL filed a case against Nurse NP, alleging that he deviated from the standard of care by 1) failing to adequately educate his patient about the severity of his condition, 2) failing to refer him to a specialist, and 3) failing to review his lab reports. The court found no comparative negligence on Mr. CL’s part and awarded him nearly $30 million in damages.
The government appealed the case, arguing that the district court failed to apply the correct legal standard for comparative negligence. Specifically, the government argued that the court should have found comparative negligence because Mr. CL did not adhere to his medications and follow-up appointments.² However, the Court reasoned that Mr. CL could only be considered negligent if he was properly informed and educated about his disease, its risks, treatment regimen, and the consequences of noncompliance. In other words, a patient must be adequately educated so he may understand and appreciate the importance of compliance and the dangers of noncompliance. In this case, Nurse NP failed to provide any education at all.³
Takeaways
Patient Education
Before decisions can be made, information must be shared and reviewed with the patient. In this case, there was a lack of education by Nurse NP regarding Mr. CL’s disease and its management. Nurse NP should have discussed the implications of Mr. CL’s hypertension diagnosis, the plan for blood pressure management, and the risks and benefits of medication. Emphasizing the need for regular visits to monitor blood pressure and the importance of medication adherence are crucial. Patients need to understand the potential health problems that can arise from untreated hypertension or other conditions.
How can a physician best determine if the patient understands their condition and health needs? Physicians can use techniques like “teach back” methods to ensure a patient’s comprehension. It is important to communicate with patients by providing information in multiple formats (verbal, written, visual) and using layperson-friendly language. Documenting discussions and providing educational resources are equally important. Check in with the patient at each visit about medication adherence, symptoms, and any concerns.
Informed Consent
Mr. CL was not adequately informed about the importance of medication adherence. Nurse NP failed to provide sufficient information for Mr. CL to make an informed decision about his treatment. Nurse NP did not take the opportunity to further discuss the diagnosis of hypertension and its associated risks with Mr. CL at his one week follow-up visit.
Informed consent involves detailed communication between the healthcare provider and patient about the diagnosis, treatment purpose, risks, benefits, and alternatives. This allows patients to make informed decisions to consent to or decline recommended treatments and/or procedures. Proper documentation of the consent process is crucial to avoid legal issues.
A Serious Diagnosis Lost to Lack of Follow Up
Mr. CL slipped through the cracks after his second visit and proceeded to go for long periods without seeing Nurse NP. Because he also failed to take his medication and because Nurse NP failed to educate Mr. CL on the importance of medication adherence and keeping all scheduled appointments, his case went to court. The takeaway is that regular follow up is necessary for patients with high-risk conditions to prevent complications and ensure proper management.
A no-show policy and and a standardized workflow for notification of test results can prevent missed visits and diagnostic delays resulting in devastating injuries and subsequent lawsuits.
Patient education and discussion of treatment recommendations greatly improve outcomes. Patients-turned-plaintiffs commonly allege that they were never properly educated about their treatment plan or the consequences of deviating from it. “I didn’t know,” I wasn’t told,” or “Had I known, I would have followed the physician’s treatment recommendation,” are comments that resonate with jurors, who are patients themselves.
Managing noncompliant patients can be challenging. Practitioners should consider their role in these situations and assess factors such as patient education, cost, side effects, and barriers to treatment. Thorough documentation of interventions and efforts to address noncompliance are crucial. Termination of care should be a last resort after exhausting all attempts to collaborate with the patient.
Advanced Practice Provider Supervision
The nurse practitioners’ scope of practice is defined by standardized procedures. Consultation with a supervising physician may be necessary when managing non-adherent patients with certain conditions.
Documentation
Documentation is of utmost importance. Patient education and communication efforts should be documented to strengthen the defense against allegations. Engaging patients in their healthcare and ensuring their understanding leads to better compliance and outcomes, even if it requires more time.
Overall, patient education, informed consent, and regular follow up are vital components of providing quality healthcare. Physicians should communicate effectively, provide comprehensive information, and ensure patient understanding to promote better outcomes.
Deborah Kichler, RN, MSHCA, is a Senior Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to DKichler@CAPphysicians.com.
¹Clanton v. United States, No.18-3060 (7th Cir. 2019) https://media.ca7.uscourts.gov/cgi-bin/rssExec.pl?Submit=Display&Path=Y…
²Ibid, at 4.
³Mem. and Order from Chief J. Rosenstengel, Clayton v. U.S., S.D. Ill. at 10 (Apr. 22, 2020) https://www.ilsd.uscourts.gov/opinions/ilsd_live.3.15.cv.124.4513560.0.pdf