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THE RISK MANAGEMENT MAGAZINE OF THE CANADIAN MEDICAL PROTECTIVE ASSOCIATION
Perspective
VOLUME 6 | NO. 1
F E AT U
MARCH 2014
RE
When medicine and
culture intersect
WHAT’S INSIDE
What physicians can do to deliver culturally
competent and culturally safe medical care
CONSENT
Communicating with
children and parents
SPOTLIGHT
Update on law for
withdrawing treatment
INDUCING LABOUR
Managing the risks
VITAL SIGNS
Key learnings from
3 case studies
WHEN PHYSICIANS
FEEL BULLIED
Effective coping strategies
cienpiesnf, Fotolia
contents
MARCH/SPRING 2014
04 SPOTLIGHT:
Update on law for withdrawing treatment
WHILE A SUPREME COURT OF CANADA decision clarifies
that in Ontario physicians must obtain consent before life support
can be withdrawn, the effect of the decision in other jurisdictions
is uncertain.
05 WHAT’S NEW:
Member resources
FIND OUT what the CMPA is doing to enhance its services and help
you practise medicine safely.
06 Risks with inducing labour
HOW TO BETTER manage the risk of patient harm, adverse birth
outcome, and potential medico-legal problems associated with the
administration of oxytocin during labour.
09 Can a child provide consent?
Effective communication with children and parents
EFFECTIVE COMMUNICATION and awareness of legal
requirements are key to obtaining consent for treatment of children.
12 FEATURE:
When medicine and culture intersect
THIS ARTICLE discusses what physicians can do to deliver
culturally competent and culturally safe medical care.
15 Can I take your vital signs?
Key learnings from 3 case studies
APPROPRIATELY OBTAINING, interpreting, documenting,
reassessing, and acting on vital signs are important parts of
medical care.
18 When physicians feel bullied – Effective coping strategies
PHYSICIANS CAN take steps to address bullying and other abusive
behaviours they may be subjected to by patients and their families,
colleagues and other healthcare workers, and third parties.
2 CMPA PERSPECTIVE
March 2014
CMPA PERSPECTIVE, MARCH 2014
VOL. 6 NO. 1, P1401E
© The Canadian Medical Protective Association
2014 — All reproduction rights reserved.
Publications mail agreement number 40069188.
CMPA Perspective magazine is published
quarterly and is also available in digital
format at cmpa-acpm.ca. A special edition
is also published annually.
Ce document est aussi offert en français.
Address all correspondence to:
The Canadian Medical Protective Association
P.O. Box 8225, Station T, Ottawa, ON K1G 3H7
Telephone: 1-800-267-6522, 613-725-2000
(Monday to Friday, 8:30 a.m. to 4:30 p.m. ET)
Facsimile: 1-877-763-1300, 613-725-1300
Email: [email protected]
Website: cmpa-acpm.ca
The information contained in this publication
is for general educational purposes only and is
not intended to provide specific professional
medical or legal advice, or to constitute a
“standard of care” for Canadian healthcare
professionals. Your use of CMPA learning
resources is subject to the foregoing as well as
the complete disclaimer, which can be found
at cmpa-acpm.ca; enter the site and go to
“Terms of use“ at the bottom of the page.
cmpa-acpm.ca
• Membership services
• Articles and resources
• Educational events
From the CEO
I
WOULD LIKE TO take this opportunity
to welcome you to the newly redesigned
CMPA Perspective and to update you on
some significant developments taking place
this year.
As CEO, I want to ensure the CMPA is
well positioned to respond decisively to
the ongoing changes in the healthcare
environment while remaining at the
forefront of meeting the needs and interests
of Canadian physicians. To this end,
we are renewing our strategic plan, the
roadmap that charts our course for the
next 3 to 5 years. This endeavour includes
an examination of the state of today’s
healthcare environment, and validation of
our work to protect our member physicians,
support risk management training, and
contribute to the safety of healthcare. I look
forward to sharing the final plan with you at
year-end.
I believe the CMPA to be one of the best
healthcare organizations in this country
and I am proud of the important role we
play in supporting physicians. I have the
opportunity to see first-hand how members
take comfort in knowing the CMPA will
FEBRUARY 19
Release of the
Nominating
Committee’s
list of proposed
candidates
APRIL 2
Deadline for
receipt of
nominations
from members
be there when needed. This, in turn,
allows physicians to focus on delivering
the best possible medical care to patients.
As I believe that our contribution to the
healthcare system is certainly worthy of
sharing, in 2014 our focus will also be on
communicating our role more broadly.
I hope you enjoy and benefit from CMPA
Perspective which continues its focus on
managing risk in medical practice, and
includes a variety of cases studies and
evidence-based articles. The digital edition,
available on our website at cmpa-acpm.ca,
now features videos which I invite you to
view at your convenience.
I appreciate hearing from members. I can
be reached anytime at [email protected].
Hartley Stern,
MD, FRCSC, FACS
Backed by over 113 years of service to our
members, you can consider the CMPA to be
your partner in helping you reduce risks and
provide safer care.
2014 REPORT OF THE
NOMINATING COMMITTEE
NOW EXCLUSIVELY ONLINE
Read about the slate of candidates proposed for openings
on the CMPA Council. Terms of office commence
immediately following the 2014 CMPA Annual Meeting.
In addition to those candidates proposed by the
Nominating Committee, all CMPA members in an area and
division with an open position have the opportunity to seek
election to council in 2014.
MAY 7
Release of election
information and voting
platform opens to members
in geographical areas where
elections are required
JUNE 11
Online voting ends
AUGUST 20
Election results
announced at
CMPA Annual
Meeting
LEARN MORE AT CMPA-ACPM.CA
March 2014
CMPA PERSPECTIVE 3
spotlight
or the healthcare facility may need to initiate a
court application or seek intervention from the
local public guardian’s office.
In making its decision on the Rasouli case,
the Court also clarified that when the patient’s
substitute decision-maker and physician(s)
disagree on whether to discontinue life support,
the steps set out in the consent and capacity
legislation must be followed:
1. The physician must determine whether
continuing life support is medically
indicated for the patient.
Aleksandr Bedrin, Fotolia
UPDATE ON LAW FOR
Withdrawing
treatment
T
he recent Supreme Court of Canada decision
in the case of Cuthbertson v. Rasouli1 clarifies
the law in Ontario on whether physicians
need consent to withdraw life-sustaining
treatment that they believe has no medical benefit
for a patient.
The Court’s decision confirmed that under
Ontario’s consent and capacity legislation,
physicians must obtain consent before life support
can be withdrawn.
The decision depended on how the Court
interpreted legislation that is specific to Ontario.
In jurisdictions that have legislation or that enact
legislation comparable to Ontario’s, the decision
applies. Currently, only one other jurisdiction, the
Yukon, has similar legislation.
In jurisdictions that do not have legislation
comparable to Ontario’s, the effect of the decision
is uncertain. Physicians in these jurisdictions
are encouraged to continue to attempt to reach
an appropriate consensus with the substitute
decision-maker(s) through communication
and dispute resolution mechanisms, such as
those established within healthcare facilities.
If consensus cannot be reached, the physician
4 CMPA PERSPECTIVE
March 2014
2. If life support is not medically
indicated, the physician must advise
the patient’s substitute decisionmaker and ask for consent to withdraw
the support.
3. The substitute decision-maker will either
give or refuse consent, in accordance with
the patient’s prior expressed wishes or best
interests, as appropriate.
4. If consent is provided, the physician may
withdraw life support.
5. If consent is not given, the physician may
challenge the decision by applying to the
Consent and Capacity Board.
6. If the board finds that the substitute decisionmaker’s refusal to provide consent was not
in accordance with the requirements of the
legislation (i.e. prior expressed wishes or best
interests), it may substitute its decision for
that of the substitute decision-maker, and
permit the withdrawal of life support.
The CMPA will continue to closely monitor the
situation with end-of-life care and will update
members of any important changes. In the
meantime, members are encouraged to contact
the CMPA for specific advice when there is
disagreement with a patient, family member, or
substitute decision-maker on the recommended
treatment decisions for end-of-life care. n
ADDITIONAL READING:
“Providing quality end-of-life care,” available at
cmpa-acpm.ca, provides more information on
end-of-life care including do-not-resuscitate
orders, withdrawing medical treatment, and
advance directives.
1. Cuthbertson v. Rasouli, 2013, SCC 53, 2013-10-18
WHAT’S
NEW
Join us in
We are excited to bring you the
most up-to-date education
and research information we
are working on RIGHT NOW!
OTTAWA
ACTION fact sheets:
ACTION for Safer Medical Care is a series of fact sheets
now available on the CMPA website. Each fact sheet
examines an issue in depth, providing tips and insights
using the CMPA’s risk management research, to help
reduce risk and improve patient safety. Four fact
sheets are available: Patient handovers, Informed
consent, Intra-operative issues in spinal surgery, and
Medication reconciliation.
GPG video:
Why is the CMPA Good Practices Guide the right resource
for Canadian residents and medical students? Our new
YouTube video provides you with a quick overview
of the benefits of this uniquely Canadian resource to
improve patient safety. Watch, learn, and share! Visit us
on YouTube.
2014 Grant research application now available:
The CMPA provides funding for research projects aimed
at improving patient safety and advancing the quality
of healthcare for Canadians. If you know of a worthy
medical research project that advances patient safety,
applications for the 2014 Grant Research program are
now open on the CMPA website.
More video!
Want more Perspective? We’re adding videos to our
March digital edition of CMPA Perspective. If you want to
know more about why the Rasouli case matters or the
importance of culture within medicine, visit our digital
edition today (cmpa-acpm.ca).
CMPA eBulletin:
The digital bulletin now provides the timely information
you want about CMPA services, risk management
education, and information in a monthly format with a
new crisp, clean design. Provide us with your email and
you’ll receive this resource in your inbox every month.
CMPA ANNUAL MEETING AND
INFORMATION SESSION
This year the focus of
the information session is:
The impact of
BIG DATA
on medical care
Wednesday, August 20, 2014
Ottawa, Ontario
• Annual Meeting
• Information Session
For information:
1-800-267-6522 or
[email protected]
March 2014
CMPA PERSPECTIVE 5
Managing the risks of
labour induction
The induction of labour is
an important approach in
the management of pregnancy.
Oxytocin is a valuable
medication used to induce
or augment labour. As with
all medications, the use of
oxytocin has potential risks.
The Institute for
Safe Medication
Practices includes
intravenous
oxytocin on its
list of high-alert
medications,
recognizing
that its use can
potentially lead
to maternal and
fetal harm.1
A
REVIEW OF THE CMPA’s medico-legal
case files involving the administration of
oxytocin during labour provides insights
to better manage the risk of patient harm, adverse
birth outcome, and potential medico-legal
problems.
The 74 medico-legal cases related to labour
induction or augmentation with an oxytocic agent
opened by the CMPA between 2002 and 2012
confirmed the role played by a broad range of
issues. In these cases, the clinical outcome for the
babies was often a catastrophic injury or death. For
physicians, the legal outcome was unfavourable in
the majority of cases. In the closed legal actions,
75% resulted in a settlement. In the closed medical
regulatory authority (College) cases, 70% ended in
the expression of concern about the patient care.
In these cases, oxytocin was the most
commonly administered medication, followed
by prostaglandin E1 or E2 (i.e. misoprostol,
dinoprostone).
Peer experts identify the issues
Peer experts who provided opinions in these
cases identified a number of issues with induction
of labour, which were similar to the issues
encountered with augmentation.
Assessment
Experts identified pre-induction issues that
included failure to follow up on an atypical nonstress test and commencing inductions when not
medically indicated. The latter reflects the growing
concern in the obstetrical community related to
the rising number of unwarranted inductions.
mmm, Fotolia
6 CMPA PERSPECTIVE
March 2014
Informed consent
Consent problems arose when a physician failed to
inform the patient of the potential risks related to
induction with an oxytocic agent, such as excessive
stimulation of the uterus or fetal bradycardia.
Clear protocols
for induction and
administration of
oxytocin should
be in place at
the facility, and
all staff should
be aware of
these. Regular
review for quality
assurance is
advised.
Medication
Two medication issues were most common in the
cases. The first was the failure to discontinue the
oxytocin infusion in the presence of an atypical
or abnormal fetal heart rate pattern, or in the
presence of tachysystole with corresponding fetal
heart rate decelerations. The second issue was
prescribing the wrong dose of oxytocin. Both
low and high dose protocols exist. Nevertheless
the dose prescribed in some cases was either
higher than permitted by hospital protocols, or
was inappropriately high when restarting the
infusion after recovery of an atypical fetal heart
rate pattern.
Interpretation of fetal heart rate tracing
In more than 70% of the cases reviewed, there was
a delay in diagnosing an atypical or abnormal fetal
heart rate pattern. In these instances, the most
common issues were failure to appreciate and
to act on the severity of an abnormal electronic
fetal monitor tracing, or failure to apply a fetal
scalp clip.
Attendance
The physician-related issues pertaining to
attendance were infrequent or irregular
assessments of a patient with an atypical fetal heart
rate pattern; not attending when informed by a
nurse of concerns with the fetal heart rate tracing;
reviewing only the immediate tracing record and
thereby missing important abnormalities in the
preceding time intervals; leaving the patient’s
bedside when the fetal heart rate tracing was
worrisome; and failing to frequently assess a
high-risk patient who was followed by a less
experienced resident or staff member.
Delivery
In more than half of the cases, the experts were
of the opinion the physician failed to expedite
delivery, usually by Caesarean section, when faced
with an abnormal fetal tracing.
Contributing factors
Communication and system-related factors
contributed to the cases where there was a delay
in performing a Caesarean delivery, including:
• the physician’s attendance on another patient
• the physician’s delay in answering
repeated pages
• the lack of preparation to respond to
an emergency in the situation
Schweinepriester, Fotolia
Very often, other factors contributed to the fetal
harm in the other cases analyzed.
• communication problems between healthcare
professionals about the following:
–– atypical/abnormal fetal hear rate tracing
–– dosage of oxytocin being infused
–– frequency of oxytocin infusion increments
–– transfer of care
• nursing interpretation of the fetal heart
rate tracing
–– inadequate monitoring of the fetal
heart rate
–– failure to act on concerning fetal heart
rate changes following incremental dosing
of oxytocin
• system-related problems
–– failure to follow the hospital’s protocols
and guidelines for induction
–– unavailability of resources, e.g. insufficient
staff to monitor a patient on oxytocin
Documentation
In several cases, peer experts identified inadequate
documentation in the medical record as an issue
for both physicians and nurses. Examples included
an incomplete record of the delivery, and failure
to document the time of chart entries. Expert
comments also included that the use of milliunits
per min provides better clarity on dosage, but if
stating the flow rate of oxytocin in ml/min then
the concentration of the infusion should also
be stated.
March 2014
CMPA PERSPECTIVE 7
CASE EXAMPLE
A woman was admitted for induction at 37+5 weeks
for oligohydramnios and an atypical non-stress test.
Following two doses of dinoprostone, an oxytocin
infusion was started. Electronic fetal monitoring
remained normal at 145 bpm.
One hour later, the physician artificially ruptured
the membranes for clear fluid and applied a scalp
clip. Five hours after admission, an epidural was
established. Within 30 minutes, the fetal heart rate
tracing showed decreased variability and repetitive
late decelerations. One hour later, the nurse noted
increased uterine tone with poor relaxation between
contractions; however, the nurse took no action and
continued to increase the rate of oxytocin infusion.
Eight hours after admission, the nurse noted
3 late decelerations, minimal variability, and fetal
tachycardia. The nurse advised the physician, who
remotely reviewed the electronic fetal monitoring,
but failed to assess the patient in person. The
oxytocin infusion continued to be increased.
Nine hours after admission, the physician attended
the patient and noted persistent minimal variability
in the fetal heart rate tracing. The patient was fully
dilated and instructions were given to start pushing.
The monitor demonstrated late decelerations
which progressively deepened; the physician was
not notified. The oxytocin infusion continued to
be increased. Two hours later, a limp infant was
delivered spontaneously; aggressive resuscitation
was required. The infant experienced early onset
of convulsions and multi-system failure, and died
2 days later. The autopsy demonstrated extensive
cerebral hypoxemic-ischemic changes.
A legal action was initiated, alleging the physician
failed to act on the abnormal electronic fetal
monitor tracing and proceed to an earlier
Caesarean section.
The experts were of the opinion that both the
physician and the nurse failed to intervene in a
timely fashion and that a Caesarean delivery should
have occurred 4 hours earlier.
Peer experts reviewing this case for the defence
concluded that the adverse outcome could have
been prevented if the physician had assessed the
patient in person when the nurse expressed concern
instead of remotely reviewing the electronic fetal
monitor tracing
Without expert support, a shared settlement was
paid by the CMPA, on behalf of the physician, and
by the hospital, on behalf of the nurse.
8 CMPA PERSPECTIVE
March 2014
Managing the risks of labour induction —
Key learnings
The following risk management strategies are based
on the expert opinions in the analyzed cases:
• Discuss with the patient the indication for
induction as well as the risks and benefits.
• Document the informed consent discussion.
• Consider the experience of other healthcare
professionals (e.g. nurses, residents) when
monitoring obstetrical patients on oxytocin.
• Consider applying a fetal scalp electrode if the
external monitoring is problematic or difficult
to interpret.
• When presented with an abnormal tracing,
review the clinical situation and determine if
further testing or delivery is required.
• Assess the availability of resources to adequately
monitor the patient and to respond to an
emergency situation. Anticipate and perform, if
indicated, a timely emergency Caesarean section.
• Communicate effectively with other healthcare
professionals (e.g. consider the use of a
structured communication tool2).
• Clearly and completely document the delivery
in the medical record.
• In cases of adverse events, discuss the
circumstances and outcomes with the patient
and her family.
In addition, clear protocols for induction and
administration of oxytocin should be in place at the
facility, and all staff should be aware of these. Regular
review for quality assurance is advised.
Members should not hesitate to contact the CMPA
for risk management advice if they have questions
related to this topic or need assistance with a
complaint, legal action, or threat. Medical officers,
physicians with extensive medico-legal experience,
are available to guide and support members dealing
with challenging medico-legal difficulties.n
ADDITIONAL READING:
“Communicating with your patient about harm:
Disclosure of adverse events,” available at cmpa-acpm.ca
1. Institute for Safe Medication Practices Canada [Internet]. ISMP’s list of highalert medications. © ISMP 2012. Available at: http://www.ismp.org/tools/
highalertmedications.pdf. Last accessed May 17, 2012
2. The CMPA does not endorse any specific structured communication approach or tool
but encourages their use.
EFFECTIVE COMMUNICATION WITH CHILDREN AND PARENTS
Can a child provide consent?
Monkey Business, Fotolia
T
HE SPECIAL RELATIONSHIP of trust
between physicians and their patients
requires that physicians always act in
their patients’ best interests. While physicians’
responsibilities do not vary according to a patient’s
age, there are medico-legal considerations to keep
in mind when treating children.
The CMPA reviewed its medico-legal case files
that closed between 2007 and 2012 involving
patients between the ages of one and 18. There
were 451 complaints to regulatory authorities
(Colleges) involving child patients, and of
these 55% resulted in an unfavourable medicolegal outcome for physicians. Consent and
communication issues featured prominently in
these cases.
Consent to treatment
Medico-legal issues related to the care of children
often involve the question of who is legally
authorized to provide consent for treatment:
the child patient or the parents.
A patient need not reach the age of majority
to give consent to treatment. In all Canadian
provinces and territories the determining factor
in a child’s ability to provide or refuse consent
is whether the young person’s physical, mental,
and emotional development allows for a full
appreciation of the nature and consequences of
the proposed treatment or lack of treatment —
whether or not the patient has attained the age
of majority.
In Québec, however, the Civil Code generally
establishes the age of consent at 14 years, below
which the consent of the parent or guardian, or
of the court, is required. If the medical treatment
March 2014
CMPA PERSPECTIVE 9
requires a hospital stay of more than 12 hours,
parental notification of the stay is required if
the child is over 14 years of age.
Physicians usually determine whether a child
has the mental capacity (competence) to provide
consent on a case-by-case basis. When a child
is found incapable of consenting to treatment,
the parents or legal guardians are authorized to
provide consent on the minor’s behalf. However,
when the physician determines that the child has
the capacity, parental consent is not required. In
such circumstances, the physician must obtain
consent from the child, even when the child is
accompanied by a parent or other delegated adult.
How does a physician determine whether or not
a child has the capacity to consent? By discussing
with the child, the physician should be reasonably
confident that the child understands the nature
of the proposed treatment and its anticipated
effect. The child should also understand the
consequences of refusing treatment. One way
to gauge this capacity is to use the teach-back
technique: ask the child to re-phrase what they
have just been told and invite the child to ask
questions. More complex medical situations may
require more rigour in determining whether the
child understands. It is prudent for physicians
to also encourage the child to invite a family
member to attend the discussion.
CASE EXAMPLE: CONSENT
College determines physicians acted
in best interests of mature minor
A 16-year-old male saw his family physician
for symptoms of severe depression. In speaking
with the patient the physician determined
that the patient was mature and understood
the seriousness of his symptoms and the need
to address them. The physician referred the
boy to an adolescent day treatment program
where he was followed by a psychiatrist.
He was diagnosed with major depression
and agoraphobia. After learning her son
was undergoing treatment, the patient’s
mother filed a College complaint, alleging
the physicians did not obtain her consent
for her son to attend the treatment program.
The College stated that the family physician
and psychiatrist acted in accordance with the
patient’s instructions not to consult with his
mother, and acted in the best interests of the
patient and according to College practices.
Physicians must use their judgment concerning
a child’s capacity to consent in many different
circumstances, such as when a teen requests a
prescription for birth control without her parents’
knowledge or consent. If the physician can be
reasonably confident that the patient has the
capacity to consent and documents the relevant
details of the consent discussion in the medical
record, it is likely that a College would support
the physician in the event of a complaint from
a parent. Meanwhile, parental involvement is
recommended when the treatment entails serious
risks and may have serious and permanent
effects on the patient.
Age of consent — The legal age of majority has become largely irrelevant
in determining when a young person may consent to his or her medical
treatment. The concept of maturity has replaced chronological age, except in
Québec, where the age of consent is 14 years and older.
10 CMPA PERSPECTIVE
March 2014
iStock, Thinkstock
CASE EXAMPLE: COMMUNICATION
CASE EXAMPLE: COMMUNICATION
Inadequate communication with a child’s
parents gives the wrong impression
A non-custodial parent wants access to
his child’s medical record
A mother attended the emergency department
with her child who was experiencing vomiting
and diarrhea. Viral gastroenteritis was diagnosed.
A few days later the mother and child returned to
emergency and the boy was admitted to hospital
for intravenous rehydration. He was discharged
after 3 days, but his symptoms soon returned
and, after the child suffered a seizure, the parents
returned once again to the hospital emergency.
Following a cursory examination, the physician
requested a consult with a pediatrician but the
parents chose to transfer the child by car to
another hospital. On the way, the child suffered
another seizure. The child was subsequently
diagnosed with hypoglycemia and mild
dehydration secondary to viral gastroenteritis.
The mother of a child patient had sole custody
of the child and the father had visitation rights.
The parents were embroiled in court proceedings
concerning the custody. When the physician
did not release the child’s medical records to the
father, the father lodged a College complaint. The
College supported the physician’s decision not to
release the medical records to the father in the
absence of a separation agreement or court order.
The mother lodged a complaint with the
College, citing unprofessional care received at
the first hospital. She stated that the doctor seen
at their last emergency visit failed to take the
child’s condition, and her concerns, seriously.
The College concluded that there had been a
communication problem on the doctor’s part in
that he failed to adequately listen to the mother
which, combined with the brief examination,
resulted in the parents taking their child to
another facility. The College reminded the
doctor that listening and empathy are essential to
maintaining good doctor-patient relationships,
especially in difficult situations such as the one in
this case.
This case example illustrates how, despite
meeting the standard of care, a physician’s lack of
sensitivity to the parents’ concern for their child
can lead to medico-legal difficulties.
Communication problems can arise when
physicians receive requests for copies of children’s
medical records, as often occurs in the midst of
custody battles. Before releasing medical records
physicians must first consider whether a specific
parent is entitled to the information. This depends
on several factors, including the age of the child,
whether the child is deemed to have the capacity
to control access to the record, and whether the
parents have the right of access. When faced with
time constraints and other stressful factors, these
may be difficult concepts for a physician to explain
fully, but doing so in a respectful and professional
manner can prevent a complaint.
Communication issues
The CMPA’s case files reveal that medico-legal
difficulties can also occur when there are real or
perceived gaps in communication with either
the child patient or the parents. For example,
a dismissive attitude by a physician about a
parent’s concern for her child’s condition,
inadequate explanations of findings given to the
parents following examination of a child, and
non-custodial parents’ disputes concerning the
physician’s inability to release their child’s medical
records can all result in a physician being the
subject of a College complaint.n
ADDITIONAL READING:
These are available at cmpa-acpm.ca.
“Responding to requests for children’s medical records”
“A parent’s demands: Making sound decisions when
facing pressure from patients”
“Protecting children – Reporting child abuse”
March 2014
CMPA PERSPECTIVE 11
feature
CULTURE AND HEALTHCARE
When medicine and culture intersect
Culture incorporates a mix of
beliefs and behaviours that define
the values of communities and
social groups. All physicians have
their own cultural background,
and most doctors practising
in Canada are accustomed to
providing care to patients from
different backgrounds. Moreover,
physicians are increasingly aware
of the way in which culture can
shape the practice of healthcare
and influence health outcomes.
T
cienpiesnf, Fotolia
THERE ARE VISIBLE and non-visible
signs of culture. Visible signs include
language, dress, food, and rituals.
Non-visible indicators include perceptions of
time, notions of modesty, reactions to physical
space, and how emotions are managed.
In Canada, patients and physicians come from
many different cultures. Consequently, it is
possible to unintentionally offend by missing
clues or misunderstanding a cultural viewpoint.
12 CMPA PERSPECTIVE
March 2014
As well, while a patient may appear to be fluent
in the doctor’s language, it may be the patient’s
second or third language and so there may be
gaps in understanding. A trusted translator can
help when appropriate, but physicians should be
cautious in using friends or family members who
could influence or inhibit the discussion.
Culture influences health and the management
of illness, and issues related to culture can
sometimes heighten risk or impact care. Culture
may influence, for example, beliefs about what
causes disease, whether to engage in certain
health promotion activities or seek advice
regarding health concerns, as well as whether
treatment options are followed.
Culture can also impact a patient’s approach
to attending medical appointments in a timely
manner. Some patients prefer not being
informed of a terminal illness or the implications
of not following through with a procedure.
First Nations patients may consult a doctor
and a traditional healer.
Culture can also influence eating and fasting
rituals, even when nourishment is vital to
recovery and overall function. It can also play a
role in the level of family influence in patient care
decisions. Gender differences in a given culture
may also affect health and patient outcomes.1
As well, there may be differences among men
and women seeking treatment for mental health
problems.2 These are just some examples of the
possible effects of culture on individual healthcare
behaviours and choices.
While it is common to speak of cultural awareness
and cultural sensitivity, physicians and other
providers are increasingly recognizing the
importance of cultural competence and providing
cultural safety to patients.
Cultural competence
Doctors who use their knowledge and skills to
provide effective healthcare for patients of diverse
cultural backgrounds are said to be culturally
competent. Competence requires a blend of
knowledge, conviction, and a capacity for action.
Clinical cultural competence includes being
aware of a patient’s and one’s own socio-cultural
background and using skills and strategies
that focus on culturally appropriate healthcare
interventions. It also includes an understanding
of the power differential between patients
and physicians and how to enable patients to
become more active partners in their healthcare
whenever appropriate.3
A lack of cultural competence can affect patient
safety and impact overall health outcomes,
specifically regarding repeat hospital admissions,
misdiagnoses, ordering unnecessary or
inappropriate tests, and patient misunderstanding
of treatment protocols.4 Physicians can practise
in a more culturally competent manner by:
• Being aware of how one’s own cultural
values and potential biases can impact
interactions with patients and families from
diverse cultures.
• Demonstrating understanding and
responsiveness to different values and beliefs.
• Adapting practice style, when practical, to
meet the individualized needs of patients
and families.
• Working collaboratively with people from
diverse populations in a respectful manner.
• Continuing to learn about culture and its
impact on healthcare providers, patients,
and families.
• Adopting inclusive medical practices.5
Culture and
physicians’ care
iStock, Thinkstock
Not only should physicians and other healthcare
professionals provide culturally competent
care, healthcare facilities are also increasingly
expected to do so. This implies that culturally
safe knowledge and behaviour should be
actively encouraged within institutions. For
example, organizations should promote values,
principles, and structures to work cross-culturally;
recognize and respect the cultural contexts of the
communities served; and systematically involve
patients, families, and communities in care.6
Given their important position within the
healthcare system, physicians can be effective
trailblazers for cultural competence among
healthcare professionals and within healthcare
facilities. Strategies to enhance clinical cultural
competence among physicians include discussing
these matters during trainee orientation, medical
grand rounds, interprofessional departmental
rounds, and in dedicated workshops. Information
and presentations should be tailored to the
culture-related issues pertaining to particular
medical specialties such as emergency, pediatrics,
palliative care, and so on.
While physicians have
a duty of care based
on the physicianpatient relationship,
a physician’s culture
and beliefs may
impact their ability
to respond to certain
requests for care in
elective situations.
Physicians must not
discriminate against
patients on grounds
such as gender, race,
religion, or sexual
orientation (among
other factors),
however they may
refer patients to
another doctor if
they feel it is in the
patients’ medical
interest.
Cultural safety
Cultural safety builds on the concepts of cultural
awareness, sensitivity, and competence, but
goes one step further. Cultural safety is based
on actions that enable safe care to be defined by
those receiving the care.
March 2014
CMPA PERSPECTIVE 13
Cultural safety is achieved by building
relationships that focus on increasing the
opportunities and choices of individuals, groups,
and communities to access healthcare.7 It involves
developing a relationship of trust between the
physician and the patient, one that recognizes and
respects individual differences. In many cases,
both the healthcare provider and the patient need
to understand and consider each other’s diversity.
“Within primary
medicine,
the goal for
practitioners
is to use (…)
self-awareness
to achieve a
patient encounter
that the patient
perceives as
culturally safe.” 8
A physician who embraces a culturally safe
practice keeps different perspectives in mind
when providing treatment to patients. This means
reflecting on the information obtained about
individuals in their care as well as their own
cultural background. Translating this knowledge
into specific actions and practices will enhance the
quality and safety of medical care. Physicians may
also need to model and encourage this approach
in team-based care settings. As in any evaluation
of healthcare quality, the person receiving medical
care is the one who decides whether it was, in fact,
culturally safe.
Minimizing risk
Respect for patients is key to minimizing
the risk of culture-related disagreements or
misunderstandings. Physicians should consider
the following practices:
• Foster strong doctor-patient relationships by
being “intentionally inclusive” in patient care.
This decreases the likelihood of unknowingly
being “accidentally exclusive.”
• Treat every patient encounter as potentially
cross-cultural.
• Watch for potential language barriers,
particularly when communicating in a
patient’s second or third language. A trusted
translator can help, when appropriate, however
physicians should be cautious when relying on
friends or family members who may add their
own interpretation into the discussion.
• Inquire about the patient’s beliefs related to
disease, the reasons for illness, and issues
about treatment.
• Ask patients how they want to be treated
and how care can be provided in a culturally
sensitive way.
• Be aware of how professional boundaries
(i.e. limits to the physician-patient
relationship) are perceived.
• Document any culture-driven patient
accommodations in the medical record.
• Rely on a third party or “cultural broker”
when working in difficult or emotionallycharged situations that may be rooted in
14 CMPA PERSPECTIVE
March 2014
cultural differences, such as inter-generational
value conflicts.
Finding the right balance
While most physicians want to respect every
patient’s culture and work with the patient to
plan care accordingly, doctors must ensure they
provide competent care and meet Canadian
practice standards. Making accommodations for
cultural diversity is important, as is respecting a
patient’s healthcare choices. In all cases, doctors
must provide advice to patients about treatment
and care based on sound medical grounds and
principles. The obligation to obtain informed
consent always rests with the physician who will
carry out the treatment or investigative procedure.
A final thought
Physicians are often known for their
understanding and respect of patients, including
patients whose cultural background differs from
their own. Understanding and respect will serve
CMPA members well as they provide culturally
competent and culturally safe care. Committing to
and encouraging cultural competence and safety
in medical practice is a life-long journey, with
clear benefits for patients and physicians.n
ADDITIONAL READING:
These are available at cmpa-acpm.ca.
“Respecting difference and diversity,”
CMPA Good Practices Guide
“Overcoming bias in medical practice”
“Health literacy — An asset in safer care”
“What to do when patients do not follow the doctor’s
advice – Dealing with non-adherence”
“Cultural and language barriers,”
CMPA Good Practices Guide
1. World Health Organization, “Gender, Women and Health.” Retrieved on December
20 2013 from: http://www.who.int/gender/genderandhealth/en/index.html
2. World Health Organization, “Gender and Mental Health.” June 2002. Retrieved
on December 20 2013 from: http://www.who.int/gender/other_health/en/
genderMH.pdf
3. The Hospital for Sick Children, “Introduction to clinical cultural competence,”
Cultural competence E-learning modules series, 2013 (slide 10). Retrieved
on October 29 2013 from: http://www.sickkids.ca/NISN_ELearning/
IntroductionToClinicalCulturalCompetence/player.html
4. Ibid., slide 12
5. Ibid., slide 11
6. Brascoupé, S., Waters, C., “Cultural safety: Exploring the applicability of the
concept of cultural safety to Aboriginal health and community wellness,”
Journal of Aboriginal Health (November 2009) p.18-19
7. University of Victoria, “Cultural safety: Module 1,” 2013. Retrieved on October 29
2013 from: http://web2.uvcs.uvic.ca/courses/csafety/mod1/index.htm
8. Baker, A.C., Giles, A.R., “Cultural safety: A framework for interactions between
Aboriginal patients and Canadian family medicine practitioners,” Journal of
Aboriginal Health (November 2012) p.1
“Can I take your vital signs?”
Key learnings from 3 case studies
Failing to take vital signs, when
appropriate, and to properly
respond to abnormalities, have
been identified as issues in many
medico-legal cases.
The failure to appropriately
perform and document vital
signs while assessing a patient is
particularly relevant in the case
of an acute, undifferentiated,
systemic illness, especially in the
context of episodic care.
T
HE CMPA CONDUCTED a research study
to identify the scope of problems related to
significant diagnostic delays due to the failure
to obtain or interpret vital signs. During the period
from 2006-2012, 55 closed medico-legal cases were
reviewed. Of these, 29 were legal actions (lawsuits),
21 were complaints to a provincial or territorial
medical regulatory authority (College), and 3 were
inquests, 1 was a threat of legal action, and 1 was a
hospital complaint.
iStock, Hemera, Thinkstock
Unfavourable legal outcomes for physicians were
noted in a high number of cases (80%). Of the legal
cases, 20 of the 29 (69%) were settled. Only one case
proceeded to court where a judgment was made
in favour of the plaintiff. Children under the age
of 10 were disproportionately represented in these
cases. The common themes identified were failure to
obtain, record, acknowledge, interpret, repeat, or act
upon vital signs. The following cases illustrate some
of the themes.
March 2014
CMPA PERSPECTIVE 15
CASE 1
Communication pathway unreliable
Late on a mid-March Friday afternoon, a 65-year-old
female with a history of diabetes and hypertension sees
her family physician about a small ulcer on the dorsum
of her right foot and extensive cellulitis of the lower leg.
Her vitals are: temperature 38 C, pulse 70 bpm, and blood
pressure 160/100 mmHg. She is on an oral hypoglycemic,
beta blocker, ACE inhibitor, and thiazide diuretic. A
culture is taken of the ulcer and arrangements are made
with home care for outpatient intravenous antibiotic.
THE CASES
Peer experts
comment on the care.
The following week all the clinic staff members are on
vacation for mid-term break. The physician has made
arrangements with a colleague to cover calls for this
week. The secretary neglects to leave an out-of-office
phone message on the clinic answering service. Over the
ensuing 3 days the home care nurses note temperatures
of between 38 and 39 C, a consistent pulse of 60, and a
gradual decrease in blood pressure to a systolic of 100.
The cellulitis appears to be spreading. The nurses leave
messages on the physician’s answering service. The culture
is positive for MRSA resistant to the antibiotic being used,
and this result is faxed to the family physician’s office but
not to the community nursing agency. By midweek the
patient is confused and hypotensive, and is transported to
hospital where she succumbs to sepsis.
The family pursues a legal action. Peer expert support
cannot be obtained for the care provided and the CMPA,
on behalf of the member physician, and the community
nursing agency on behalf of the nursing staff, pay a
settlement to the patient’s estate.
Peer experts made the following comments:
• Beta blockers, pacemakers, age, and
dysautonomia related to diabetes may prevent
a tachycardic response to sepsis.
• The systolic blood pressure of 100 might
represent relative hypotension given the history
of hypertension.
• A clearly identified and accessible most
responsible physician (MRP) is necessary when
treatments are being administered at home.
• This patient might have had a better outcome if she
had been identified at a formal handover between the
primary care physician and the
on-call designate.
16 CMPA PERSPECTIVE
March 2014
CASE 2
CASE 3
Team communication of vital signs fails
Monitoring of vital signs is important
A 78-year-old female calls 911 because of recurrent
episodes of near syncope. Her past history is notable
for hypertension, coronary artery disease, and mild
renal dysfunction. When the paramedics arrive, she is
diaphoretic and confused with a pulse of 35 and a systolic
pressure of 60. The paramedics are unable to obtain a
rhythm strip during the bradycardia. By the time she is
placed on the monitor, her pulse increases to 80 and her
systolic pressure to 140. The cardiac monitor shows sinus
rhythm.
At noon a 10 kg, 10-month-old infant is taken to the
emergency department after having been ill for 2 days with
fever, vomiting, profuse diarrhea, and irritability. When
admitted, the child is noted to be mottled and irritable
with a pulse of 180, temperature 38.4 C, respiratory rate
of 40, and oxygen saturation of 98%.
After transporting the patient to a hospital, the
paramedics are quickly dispatched to another call. No
documentation is left with the hospital. A brief history,
including a reference to the bradycardia, is provided to
the emergency department by the bedside nurse. When
the emergency physician sees the patient the nurse is on
break. There is no mention of bradycardia in the nurse’s
notes. The ECG shows a first degree and right bundle
branch block, unchanged from before. After a negative
cardiac work up, the patient is discharged home.
Two days later she presents again with similar symptoms
and a third-degree heart block. A permanent cardiac
pacemaker is implanted. A hospital complaint follows.
Peer experts reviewing this case made the
following comments:
• Lapses in communication occur, but many
are avoidable.
• When possible, pre-hospital vital signs should be
reviewed as they can contain valuable information.
• A conversation between the hospital staff and the
paramedics may have alerted them to the possibility of
a bradyarrythmia.
• As many dysrhythmias are transitory, vital signs
recorded by first responders may aid in the diagnosis.
• Checking a patient’s pulse is often omitted from the
physical examination. This simple measure provides a
wealth of information: skin temperature and perfusion,
volume status, arterial compliance, blood pressure, and
cardiac rate and rhythm. Observing a cardiac monitor
does not obviate the need to palpate a pulse. Lastly,
checking the pulse provides an opportunity to also
assess the patient’s pattern and rate of respiration.
He is triaged to a resuscitation area where he is quickly
assessed by a pediatric resident. Blood work and a fluid
bolus of 200 cc of normal saline are ordered. Intravenous
access cannot be established until an hour after admission
and the fluid bolus is not completed until 1500 hours.
At 1600 hours a lumbar puncture is performed which is
grossly clear. Antibiotics and further fluid are ordered.
The resident then speaks with another resident on the
general pediatric ward and advises him that the child
will need admission for rehydration and observation.
No repeat vital signs have been obtained since admission.
The child is transferred to the ward at 1700. The admitting
nurse notes the child is mottled with a pulse of 180,
respiratory rate of 70, and a temperature of 39 C. He
immediately notifies the resident, but the child arrests
prior to being seen by the physician. Resuscitation is
unsuccessful and an autopsy reveals peritonitis secondary
to a ruptured appendix.
A legal action ensues and at trial the judge finds both the
physicians and the nurses negligent in their monitoring
and treatment of the patient. The CMPA, on behalf of
the resident member, and the hospital, on behalf of
the nursing staff, share in paying a settlement to the
infant’s family.
After reviewing this file, the peer experts observed:
• Vital signs are, as their name suggests, vital to both life
and as indicators of health. They establish the baseline
and provide serial and objective information of the
status of the patient.
• Repeated vital signs are essential components of
diligent monitoring and provide the information
necessary to assess the effectiveness of treatment and
to assist in diagnosis.
• Obtaining vital signs in the pediatric population can
sometimes be challenging.
• Interpreting vital sign abnormalities in pediatrics
requires knowledge of age appropriate normal ranges.
When clinically indicated, obtaining, recording,
interpreting, acting upon, and, when appropriate,
repeating a patient’s vital signs stand as a powerful
testament to quality and conscientious care. n
March 2014
CMPA PERSPECTIVE 17
WHEN PHYSICIANS FEEL BULLIED
Effective coping strategies
Key points:
When faced with abusive behaviour,
physicians should:
• Remain calm, professional, and non-confrontational.
• Take steps to protect patients, staff, themselves, and their
families if there is an imminent and serious threat to safety.
• Take the lead by treating others with respect and compassion.
• Try to identify the root causes of the abusive behaviour.
• Focus on the issues rather than on personalities to reach
a mutually acceptable resolution.
• Seek help from trusted colleagues or contact the CMPA for
advice and assistance.
• Refer to policies governing the management of abusive
behaviour in the workplace, when applicable.
• Document abusive encounters clearly and factually.
A
DAY RARELY PASSES without the CMPA
responding to a request for help from
a physician who reports being bullied,
intimidated, or harassed. The inappropriate
behaviours to which physicians are exposed
may be relatively minor (rudeness, yelling,
verbal threats, personal insults), major
(physical aggression, destructive behaviour), or
severe (assault, stalking).
Being the subject of bullying and other abusive
behaviour not only affects the well-being of the
targeted individual, in a healthcare setting it may
impact patient safety and increase the risk of an
adverse event. Physicians who are subjected to
ongoing abuse may suffer mental health issues
and sleep disturbances, and may decide to
change workplaces. Knowing how to respond
appropriately may help defuse such situations
and prevent potential medico-legal difficulties for
the physician.
Patients and their families
Physicians and their staff have the right to work
in a safe environment. Many healthcare settings
post notices of policies indicating zero tolerance of
abusive behaviour.
18 CMPA PERSPECTIVE
March 2014
Nevertheless, when a patient’s or the family’s
expectations are not met, they may resort to
abusive behaviour or threaten to launch a
complaint or go to the news media. Patients
and their families may become frustrated and
stressed by uncertainty, long wait times, or when a
physician denies requests that the physician deems
are unreasonable. The latter may occur when, for
example, the family requests information about
the patient and the doctor denies the request
citing lack of patient consent to release such
information. Or the patient may be uncertain or
may not understand why the doctor is providing a
certain treatment or why a request for a narcotics
prescription is refused.
Difficult as it may be, physicians should
continue to follow the standard of care
and not be intimidated into providing
investigations or treatments they feel are
not in the patient’s best interest.
CASE EXAMPLE
A male comes into the office for a pre-operative
history and physical assessment. The patient is
told his provincial health card has expired. He is
told he can either apply for a new card, or pay for
the visit and seek reimbursement once his new
card arrives. The patient becomes verbally abusive
toward the receptionist and begins throwing
things. The office manager is able to get the
patient to leave. The doctor discharges the patient
from the practice, pointing out the posted zerotolerance-to-violence sign.
The response to abusive behaviour should be calm,
professional, non-confrontational, and preferably
in private, away from other patients. Physicians
should consider and address the security needs of
their staff and themselves. Steps to consider when
dealing with abusive behaviour from patients and
families include the following:
• When safety is not a concern, verbalize
the specific behaviour and clearly tell the
individual that it is unacceptable. If the
behaviour is minor and not recurring, outline
the consequences of continuing or repeating
such behaviour.
• If the abusive behaviours are recurring but
minor, there may be insufficient trust in the
relationship to provide continued quality care
which may lead to ending the doctor-patient
relationship.
• If the abusive behaviours are major or
severe, consider ending the doctor-patient
relationship, in keeping with the applicable
medical regulatory authority (College)
guidelines.
• In hospital or large clinic settings, consider
using other available resources such as social
work, patient advocacy, and pastoral care.
• If there is a serious and imminent threat to
safety, notify the police or a security guard if
in a hospital. A report to police should include
only the name of the threatening individual
and the nature of the incident. Divulging
any patient medical information should be
avoided, if possible.
• Document the abusive behaviours clearly
and factually.
Colleagues and other healthcare workers
Conflict with physician colleagues and other
healthcare workers may result in abusive
behaviour if the conflict is not well managed.
While some of these conflicts arise from
disagreements over patient care, many stem from
power struggles, working conditions, substantive
issues (compensation, office space, support),
and personality differences. Physicians need to
understand the environment in which they are
practising, and ensure their own behaviour does
not contribute to the issue.
CASE EXAMPLE
A member contacts the CMPA because he feels
he is being bullied by his department chief: his
clinic time is being cut. The CMPA medical officer
is able to discern that the reduction in clinic time
is due to the member having a large number of
incomplete medical records and having been
warned there would be consequences if they were
not completed by a specified date. The hospital
has stated it would reinstate the clinic time when
the records were completed. The medical officer
suggests to the member that this is not bullying.
The member is advised to complete the records
in a reasonable time as the hospital is obligated to
have complete records to ensure safer patient care.
• Identify the issues. Is it a new problem or
recurring issue?
• Seek counsel from a respected peer who may
assist the parties to find common ground.
• Refrain from speaking broadly about the
grievance. Rather, physicians may want
to discuss the issue with the appropriate
individuals in the chain of command in
a stepwise fashion (for example, service
head, department chief, director of
professional affairs).
• Document the discussions and share the
documentation with attendees.
Third parties
Lawyers, police officers, insurance company
representatives, and others may request
information about a patient. Even if there is no
authorization for releasing such information,
the requesting individuals may insist it is their
right to obtain the information and may threaten
the physician or staff with consequences if the
physician does not comply.
CASE EXAMPLE
A distraught member calls the CMPA while in the
midst of an encounter with a police officer who
arrived at the clinic and is demanding information
about a patient she had seen the day before. He is
threatening her with obstruction of justice if she
does not answer his questions. The CMPA medical
officer advises the physician that she calmly tell
the officer that she would be happy to assist, but
that she requires consent from the patient or
legal documentation such as a search warrant
or court order. She is able to successfully defuse
the situation.
Member physicians are encouraged
to contact the CMPA for additional
advice and assistance on dealing with
disruptive behaviour.
In the workplace, behaviour that is perceived as
abusive should be addressed in a calm, respectful,
and non-confrontational manner. Steps to
consider when dealing with workplace issues
include the following:
19 CMPA PERSPECTIVE
March 2014
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CMPA PERSPECTIVE 19
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HOTSPOTS
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REGIONAL CONFERENCES
ONTARIO
Barrie
Huntsville
North Bay
2014
YOUR YEAR TO JOIN US!
SYMPOSIA
April 8
April 9
April 10
ALBERTA and BRITISH COLUMBIA
Lethbridge
May 13
Grande Prairie
May 14
Prince George
May 15
MONTREAL
March 28
EDMONTON
May 30
MARKHAM
November 28
(French only)
QUÉBEC and NEW BRUNSWICK
Vaudreuil-Dorion
June 16
Gaspé (French only)
June 17
Bathurst (French only) June 19
NORTHERN CANADA
Whitehorse
September 8
Yellowknife
September 10
Fort McMurray
September 11
NEWFOUNDLAND AND LABRADOR,
and NOVA SCOTIA
Gander
September 29
Sydney
September 30
Yarmouth
October 1
CMPA’s popular medico-legal HOT SPOTS symposia
and regional conferences are travelling to 18 cities
across Canada in 2014. Learn key strategies to
reduce your risk, earn CME credits, and get advice
from CMPA physicians and legal experts. Attend a
full day symposium to take advantage of workshops
and plenaries, or a compact evening conference.
Earn
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