December 2015: The Role of Empathy and Apology Following Adverse Events

Publication Quarter: 
Fall 2015 (December)

For many decades, physicians and other health care providers were counseled against engaging with patients and their families following adverse events. Although retreating emotionally in the face of a complication may once have been considered acceptable, however, everyone involved in health care—from medical schools, professional medical organizations, and hospitals to professional liability attorneys—now recognizes the value of a patient-centered, empathetic response to adverse events. This month's tip looks at the value of empathy and how it differs from apology, as well as providing scenarios in which acknowledgment of fault may be appropriate.

Empathy: Always the Correct Response

Empathy is the process that enables individuals to understand and respond to the emotional states of others. In the patient-provider relationship, empathy refers to the provider's ability to engage emotionally with patients, a skill that is never more important than after an adverse event. In the article "Efforts to Instill Empathy among Doctors Are Paying Dividends," Sandra Boodman noted, "Clinical empathy was once dismissively known as 'good bedside manner' and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found that it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship."

Following an adverse outcome, the best thing a physician can do to preserve—and perhaps strengthen—the patient-provider relationship is to engage with the patient and his or her family. The patient needs to understand that he or she has the physician's support, both clinically and emotionally.

Communicating with Empathy 

Two of the most popular tools available to help physicians prepare for a conversation about adverse events are the "ABCDE" mnemonic and the SPIKE approach.

The ABCDE mnemonic stands for:

  • Advance preparation—arrange adequate time and privacy for the conversation, confirm medical facts, review relevant clinical data, and prepare emotionally for the encounter.
  • Build a therapeutic relationship—identify patient preferences regarding the disclosure of bad news.
  • Communicate well—determine the patient's knowledge and understanding of the situation, proceed at the patient's pace, avoid medical jargon or euphemisms, allow for silence and tears, and answer questions.
  • Deal with patient and family reactions—assess and respond to emotional reactions; empathize with the patient.
  • Encourage/validate emotions—offer realistic hope based on the patient's goals.

The SPIKE approach stands for:

  • Setting up the interview. 
  • Assessing the patient's Perception. 
  • Obtaining the patient's Invitation, as shunning information is a valid psychological coping mechanism. 
  • Giving Knowledge and information to the patient. 
  • Addressing the patient's Emotions with Empathetic response. 
  • Summarizing.

An article in Family Practice Management outlined the following six-step approach to communicating after an adverse event:

  1. Assess the patient's understanding: "What do you know about your condition?" or "What have the doctors told you?"
  2. Give a "warning shot": "I'm sorry. I have bad news."
  3. Present the bad news using words the patient will understand.
  4. Be quiet and listen.
  5. Give additional information in layers as requested by the patient or family (i.e., "peel the onion").
  6. Follow up: This is the beginning of a journey with the patient.

Using any of the above methods will help a physician prepare more effectively for what is always a difficult, emotionally charged conversation.

Empathy, Apology, and Adverse Events

Despite the many benefits of effective patient-physician communication, some health care providers may still find themselves reluctant to engage with patients and their families following adverse events. This reluctance stems not from a lack of genuine care, but rather from the concern that empathy could be misconstrued should the event result in a claim.

This is why providers must distinguish between empathy and apology. Empathy is the process that enables a medical provider to understand and relate to the patient's perspectives. An apology, in contrast, is an expression of regret that includes an acknowledgment of failure.

Expressions of empathy such as the following are always appropriate: 

  • "This must be a difficult time, but my staff and I will work to help you through this."
  • "I was saddened to hear of your loss, and my staff and I send our condolences."
  • "Remember when we talked about some of the risks that cannot be anticipated or prevented? Well, this is one of those instances. However, there are several actions that we are going to take to help you, and we will keep you informed at each step in the process and answer any questions you or your family may have."
  • "I am going to do all I can to find out why this happened, and I will keep you informed about what I learn."

Apologies that include admissions of failure are more complicated. New York is one of many states that requires disclosure of adverse events, but New York does not have a so-called "sorry law" to prohibit certain statements, expressions, or other evidence related to disclosure from being admissible in a lawsuit. Therefore, admissions of failure should be made only under the following circumstances:

  • After a full investigation of the adverse event has been completed
  • With input or guidance from the hospital's risk manager or the physician's professional liability insurer

Physicians should consult with their hospital's risk management department for support or advice about how to communicate with a patient about an adverse outcome.

Conclusion

An empathetic physician response is crucial after an adverse event. Remember: Effective physician-patient communication and engagement always lead to a better outcome.

The American Medical Association Code of Ethics (Opinion 8.121 - Ethical Responsibility to Study and Prevent Error and Harm), summarizes this issue as follows:

Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability.