Abstract The victims of medical error reach far beyond the patient. The aftermath forever changes the lives of the patient’s family and physician alike. We explore the life and death of nineteen-year-old Matt, a stellar athlete and better son, and the cognitive bias that led to an unfortunate and consequential medical misdiagnosis. This story is one of family heartbreak, the harsh reality of second victim phenomenon, and ultimately lessons learned in compassion, vigilance, and candidness for the health care industry. We share this tragedy with the medical community in hopes that we improve the use of post-mortems, transparency and disclosure to heal the wounds of our patients’ families. adverse events, medical errors, human factors, patient-provider communication/information, ethics ‘Not a day passes when I don’t think of Matt, his giddy, upbeat attitude and the relentless work ethic that was admired and revered by friends and teammates alike. I always wish he were still here with me enjoying his sophomore year of college. All of my memories that day before he collapsed provide me with something tangible, something real to hold dear to my heart… But in an agonizing instant, as the basketball ricocheted off the rim and Matt helplessly fell to the asphalt, I knew my life would never be the same.’ Spence Miller One year later, a best friend’s tribute to Matt ’02, The Daily Princetonian Introduction Nineteen-year-old Matt, a Princeton freshman, had just swum a distance race at the Ivy League Championship meet at Harvard, the school his twin sister attended. Shortly thereafter, he lost consciousness in the cool down pool while doing a gentle backstroke. He was pulled from the pool, regained consciousness and denied any memory of the event. He was diagnosed with neurocardiogenic syncope and told to resume all activities without restriction. Two weeks later, Matt would die suddenly from ventricular arrhythmia, a serious cardiac rhythm disturbance that could have been prevented. A search for the truth and legal review would create a rippling aftermath that would impact everyone involved from family to physician (Fig. 1). This story is one of family heartbreak, the harsh reality of second victim phenomenon, and ultimately lessons learned in compassion, vigilance and transparency for the health care industry. Figure 1. View largeDownload slide Flowchart outlining events as experienced by Matt, his family, and his cardiologist. Figure 1. View largeDownload slide Flowchart outlining events as experienced by Matt, his family, and his cardiologist. Case presentation Immediately following the syncopal event (loss of consciousness), Matt underwent cardiac, pulmonary and neurologic exams by paramedics. His vital signs were normal and no abnormalities were found. Etiologies proposed included stress, exhaustion, hypoglycemia, dehydration as well as neurologic or electrolyte abnormalities. Matt had not experienced an episode like this before except may be when he ‘dosed off’ unexpectedly in the passenger seat of a car years earlier. Matt’s father discussed the event with a family physician. The physician agreed that it was not essential to visit an emergency facility in Boston but to return home. Two weeks after the initial incident, Matt was seen by a cardiologist/electrophysiologist and underwent an electrocardiogram (EKG), echocardiogram (ECHO), stress test and tilt table test. The cardiologist determined that Matt had a ‘normal athlete’s heart’ and diagnosed him with neurocardiogenic syncope, a temporary loss of consciousness associated with a drop in arterial blood pressure, quickly followed by a slowed heart rate. He was advised to increase his salt intake and water consumption and was prescribed Fluorinef tablets, a corticosteroid used to regulate blood pressure and blood salt level (with the potential side effect of arrhythmia). There was no recommendation for follow-up evaluation or appointment. Matt’s father repeatedly asked if he should restrict activity and if his son’s condition was life-threatening but the physician assured him there was no signs of a serious underlying medical condition. Aware that Matt was an elite athlete, the doctor advised Matt to resume all activities without restriction. Matt returned to school that day, attended class and participated in his normal athletic training and swimming activities. That same afternoon, while playing basketball with fellow swim teammates, he ‘dropped’ forward, without apparent warning and with enough force to break his teeth in the fall. Resuscitation efforts were started at the scene and continued En route to the hospital, a short distance from the Princeton campus. Matt’s parents and cardiologist were notified. The cardiologist spoke with the treating Emergency Department physician, recommending the immediate administration of beta blockers, altering his initial diagnosis from a neurologic benign condition to a life-threatening cardiac one. All efforts to save Matt were unsuccessful. There was an overwhelming feeling of disbelief as nobody knew exactly why or how his death occurred. The Princeton campus was overcome of grief. Students reflected on their memories with Matt and honored his life and individuality in the Princetonian 25 March 1999. Post-mortem events Matt’s family had many questions but no answers. The initial diagnosis, neurologic in nature, did not match the fatal cardiac event that had just occurred. Based on the circumstances, sudden unexpected death, the medical examiner was called for independent evaluation. The post-mortem examination is the systematic examination of the dead for medical and legal purposes. It is the gold standard for establishing the cause of death. And the cause of death is defined as the primary disease or injury responsible for the death. The significance is crucial as without a post-mortem, a death certificate will only reflect and repeat pre-mortem thoughts. Physicians are often at a loss why a patient they have cared for has died. They would like to establish what went wrong, hence the need for an audit, and a post-mortem is a powerful audit tool. The post-mortem review revealed a massive cardiac enlargement (cardiomegaly). The cause of death was determined to be ventricular arrhythmia, resulting from the substrate of dilated cardiomyopathy, a disease of the heart muscle. Since the condition is congenital, Matt’s parents were warned about the possibility of a similar event in their surviving children, both competitive endurance swimmers. Matt’s younger brother and twin sister underwent cardiology evaluations to assess their risk for cardiac complications and the risk of sudden death. Fortunately, both had normal cardiology evaluations, neither displaying signs nor symptoms of cardiomyopathy. Results of the post-mortem were communicated to Matt’s cardiologist indicating a clear error in the original diagnosis of neurocardiogenic syncope. Consulting cardiologists considered the failure of the cardiologist to establish the correct diagnosis of the cause of the syncopal episode and the failure to correctly interpret medical studies a breach of medical standard of care. Those physicians believed that failure to establish the correct diagnosis and make appropriate recommendations led to Matt’s death. Matt’s cardiologist was shocked, distraught and overwhelmed with grief. He never contacted the family directly. Following no communication with any colleagues, he left his medical practice to relocate to Florida. When applying for malpractice insurance in the state of Florida, the cardiologist reported that there were no outstanding lawsuits against his license. Legal proceedings The family was advised by the consulting cardiologist to contact an attorney and proceed with litigation. Matt’s parents became plaintiffs and entered into their new world of medical malpractice as active participants in the suit. They spoke to and through their attorneys, fragmenting and compartmentalizing their lives. The legal proceedings were long, arduous and tedious as Matt’s parents focused all of their energy and attention into the search for the truth of Matt’s death. The journey to find justice for their son lasted 3 years and tested their patience and loyalty. The time devoted to legal activity and trial preparations resulted in physical and mental exhaustion, with their ‘legal lives’ playing a prominent role in their new normal lives. The process was draining. Fairness, understanding, acceptance and forgiveness were core family values, therefore the need to maintain anger, necessary to provide fuel and maintain focus in the case, was exhausting and unnatural for them. The economic value and sympathetic nature of the case provided a clear incentive for the legal proceedings, but the goals and desired outcomes were not well aligned. They trusted that in the end, full disclosure of facts and accountability would be established, providing them closure and the answers they so desperately deserved. Matt’s parents were required to work with attorneys while all continued to believe Matt was harmed by his physician. The silence of the physician and his failure to contact the parents was interpreted as ‘a failure to care’ or possibly as an attempt to hide his error. The physician’s life and his relocated practice seemed to indicate success and happiness. They were disappointed by the physician and were forced to ask themselves: ‘why had he not contacted them?’; ‘did he care?’; ‘did he suffer?’; ‘was he a bad doctor?’; ‘was he impaired?’; ‘were they wrong to have trusted him?’; ‘had they failed their son?’ Despite unanswered questions and lingering uncertainty, Matt’s family accepted a confidential, legal settlement; but there was no medical settlement to provide resolution. The legal system may have served the family with ‘settlement’, but the medical system clearly failed. This was compounded by the failure to communicate harm caused by diagnostic medical error. Matt’s family believed that there should have been a promise of ongoing communication, an early disclosure of the facts as known and an apology with expression of sympathy should have been offered. Investigating the medical error The EKG, ECHO, stress test and tilt table test were reviewed retrospectively and all the findings were considered grossly abnormal. The results should have led a reasonable cardiologist, acting within the standard of care, to make the correct diagnosis. The cardiologist should have advised the patient and his parents about the significance of the diagnosis and recommended appropriate management to avoid harm and death. Matt’s physician misinterpreted the ECHO and attributed chamber enlargement to be consistent with findings in an athlete’s heart. The discrepancies noted on the initial EKG were ‘normalized’ during the stress test. Unfortunately, a positive tilt table is consistent with neurologic syncope, but also consistent with cardiomyopathy. It was the strongly positive and dramatic tilt table test results that created his anchoring bias, an over-reliance that led to an incorrect diagnosis. This highly regarded, caring, exceptionally well-trained and competent cardiologist made a fatal error. He failed to diagnose cardiomyopathy in his patient who had suffered a syncopal event following exercise. This error led to the incorrect diagnosis and the failure to make appropriate recommendations for treatment and activity restrictions. If Matt had received aggressive treatment, appropriate follow-up, and had accepted the required limitations of activity, it was likely that his death could have been prevented. Furthermore, had Matt known the true diagnosis and informed his classmates, they may have responded differently during the tragic event. The second victim Matt’s father needed to meet with his son’s cardiologist face to face. He was seeking accountability and wanted only to know that he did not hurt his son. His father was not seeking explanations, details or facts. He did not want excuses, punishment or apology. Matt’s father had trusted the physician and believed the doctor’s words that Matt’s heart was normal, and he had no restrictions on activities. At the time, he was relieved and grateful for the diagnosis. Before Matt’s father could finally meet with the cardiologist, a meeting he so desperately needed, an announcement was made: Matt’s cardiologist committed suicide. His obituary stated that he died ‘suddenly and unexpectedly’ at home and was survived by his two children. Matt’s parents wept upon receiving the news. It is more likely than not that the sorrow was shared by all who had truly loved and cared for Matt. Discussion When a death is likely preventable—as in misdiagnosis, suicide and industrial accidents—the survivors must deal with special challenges that impede healing. The challenge is especially difficult when the death is sudden and unexpected. It challenges our ideas of rightness and wrongness in life. Matt was a son, brother, friend, classmate and teammate. Those that had the privilege of knowing him express how much they will miss the comfort and confidence that Matt provided. The lives of all those who knew Matt had changed forever. The wisdom and cheerfulness that Matt carried with him will no longer be expressed on the Princeton campus or in his household. ‘A Silent Goodbye,’ written by Matt’s teammate, expresses the emotional trauma that is felt by all who had known Matt. Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive. An extensive body of research indicates that diagnostic error accounts for a large percentage of preventable error. Furthermore, subtle cognitive bias in the clinicians’ thought process plays a role in many diagnostic errors, including those associated with failures in perception, failed heuristics and bias in decision making. The tendency to frame a diagnosis around a single piece of information, explaining away other diagnoses, is common, demonstrating the fallibility of being human. It relates to the much-discussed concept of anchoring, a cognitive predisposition that explains the willingness to accept a patient’s diagnosis without further thought. Minimizing cognitive errors, specifically the biases that underlie them, are critical in preventing such errors. The first misstep was the dismissal of the lethal diagnosis of cardiomyopathy, closely followed by the anchoring of a syncope diagnosis. After harm occurs, secondary to medical error, full disclosure is essential. The disclosure of medical error is a professional and ethical responsibility with the duty imposed on all physicians. Medical error which results in death demands that the physician reports the facts known in a timely manner. In addition to early disclosure, communication resolution must be a goal. The failure to disclose Matt’s medical error was fatal and unforgivable. Matt’s life and death became ‘the case’, and the cause of action was medical malpractice. While they arrived at a legal settlement the case concluded, Matt’s family has no resolution and no definitive end to their questions about Matt’s death. Matt’s parents lost the title of plaintiffs. Their son’s doctor lost the title of defendant. However, they were still injured parents needing a resolution. There are questions that may be raised as to why doctors are not communicating thoroughly with patients and the patients’ family. Further studies into cases similar to Matt’s will emphasize the negative effects of cognitive bias and the untold harm associated with a failure to disclose. These studies can increase awareness of errors that can lead to medical malpractice and a negative consequence for the patient, the patient’s family and the physician. Acknowledgements The authors would like to thank Matt’s parents for their permission and support in sharing their son’s story. Author notes We have no non-preferred reviewers. Published by Oxford University Press in association with the International Society for Quality in Health Care 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.
International Journal for Quality in Health Care – Oxford University Press
Published: Oct 1, 2018
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