Dr A, an anaesthetist at a private clinic, gave a lumbar epidural to a patient in preparation for elective caesarean surgery. The patient, Mrs G, was in her twenties and a heavy smoker, but was otherwise in good health.
There were no technical difficulties with the insertion. Dr A tested the efficacy of the anaesthetic and Mrs G appeared to have a satisfactory block for surgical anaesthesia. However, Mrs G did experience pain during washout of the peritoneal cavity following delivery. This was adequately managed with an epidural top-up and nitrous oxide. Mrs G only required further analgesia more than six hours after the surgery.
Mrs G subsequently complained that insertion of the intravenous cannula and the epidural catheter had been painful and Mr A had “harassed” her during the surgery about her smoking habit.
For his part, Dr A had been concerned that Mrs G’s absence from the ward for a cigarette had disrupted the operating list, and that her coughing perioperatively had made the surgical procedure much more difficult. He expressed his views about smoking – “you’ve seen your daughter born, if you give up smoking you might see her get married too”.
Mrs G refused to discuss her case with Dr A and declined his written suggestion of a meeting. She claimed the experience left her with severe postnatal depression.
Mrs G began a legal claim for pain and psychological distress. She alleged that Dr A had failed to provide the proper preanaesthetic care, failed to ensure adequate surgical anaesthesia, and failed to ensure that she did not suffer unnecessary pain and distress after the delivery. The claim also alleged that Dr A’s manner towards Mrs G had contributed to her postnatal depression.
Experts consulted felt that the technical aspects of the anaesthetic had been carried out in a competent and appropriate manner. This included the intraoperative pain and subsequent management.
The evidence was, however, that Dr A’s manner and poor communication had indeed contributed to Mrs G’s psychological condition. They concluded that there were predisposing factors which were aggravated by Dr A’s behaviour towards Mrs G. Together these may have exacerbated her severe postnatal depression.
- Good medical care demands that the doctor carries out his duties not only competently and safely, but also with respect for the patient.
- Good effective communication between doctor and patient is vital at all times in order to help maintain trust and confidence. This is especially important during caesarean sections carried out under regional anaesthesia. Patients may perceive unpleasant pressure, discomfort and even pain despite evidence of an effective anaesthetic. The latter may occur during washout of the peritoneal cavity and is usually transient. In these situations a good relationship with the patient, reassurance and appropriate supplementary analgesia often alleviates the situation.
- Be aware that patients may perceive well-intentioned lifestyle advice as intimidating or aggressive, particularly if they are in a vulnerable position at the time – eg, while undergoing a procedure. The timing of communication is every bit as important as the mode of communication.
General Medical Council Good MedicalPractice (2001), www.gmc-uk.org
McTigue A, How to Communicate with Care, Casebook 12 (4) 11–12 (2004)