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Physicians' Responsibility: A Care Plan is Essential for the Treatment of the Patient

Victor Lewin - Thursday, August 11, 2011

A recent medical malpractice Court decision stemming out of the death of a young patient holds responsible doctors accountable when they fail to make appropriate consultations.

It is typical when patients are admitted to hospitals that they have a main doctor assigned to direct their overall care and treatment plan. They are to provide a plan of care and obtaining consultations as appropriate. When a responsible doctor ignores obvious risks and medical knowledge in favour of an unsound consultations, and injury results, to what extent can the doctor absolve himself/herself of liability?

This question was answered earlier this year in the case of Manary v. Strban. The facts are as follows.

While pregnant with her first child, a young 28-year old woman died in hospital when her aorta ruptured. Fortunately doctors were able to save her baby via an emergency Caesarian delivery. The deceased mother's family brought a law suit against her doctors in which they alleged negligence. By the time the case went to trial, her daughter was 7 years old.

The deceased mother had been admitted to hospital 9 days before her death. She was restless, short of breath and in significant pain. She was assessed by a respirologist in the emergency room who noted a prominent heart murmur and what looked like an enlarged heart.

It was undisputed that her symptoms were indicative of two possible medical problems, both of which were very serious: pulmonary embolism or aortic dissections.

She was subsequently admitted to the obstetrical floor and placed under the care of an obstetrician. A CT angiogram was conducted by a radiologist who concluded that there was no evidence of either a pulmonary embolism or aortic dissection. The radiologist did note that there was a large aneurism in her aorta which was at that time 6 by 6 centimetres.

Statistics showed that the incidence of aortic rupture increased with aortic size and that at 6 centimetres, the risk of rupture at was 27.9%. All competent doctors know that when a rupture occurs, death is almost inevitable. Despite this, none of the doctors responsible for the woman's care took any steps to address the heart issues that might result from the presence of a diluted aorta.

Lawyers for the family argued that the obstetrician failed to properly manage the mother's care by not challenging the first diagnosis of pulmonary embolism when an alternative diagnosis was equally available.

The obstetrician's lawyers argued that he acted appropriately by deferring to the respiratory service for management of her medical condition. Although he was the responsible doctor, his lawyers argued that he was not required to question the diagnosis and treatment plan that the respirologists had instituted, or consider any alternative diagnosis.

The Court stated the standard to which the doctor would be judged, as follows:

A doctor is bound to exercise that degree of care and skill which could reasonably be expected of a normal, prudent, practitioner of the same experience and standing. The ultimate decision as to the standard of practice and care is for the court alone. The decision is not for medical experts, although their view is taken into consideration in determining the appropriate standard. The court is required to take into account a great many factors which can vary infinitely with each case. The degree of care that a doctor must exercise and the extent of advice that a doctor must give depends on a long list of varying circumstances.

If the practitioner holds himself out as a specialist, a higher degree of skill is required. When a patient submits to the direction and treatment of a specialist, the specialist owes a duty to the patient to use diligence, care, knowledge, skill and caution.

...

There can be no dispute that [the mother's] diastolic heart murmur combined with her enlarged ascending aorta constituted a serious danger sign. Those responsible for [the mother's] care opted, however, to continue to treat her for a pulmonary embolism because they believed that dissection and the risk of rupture of the aorta had been ruled out.

Should a prudent practitioner have maintained that belief, given the circumstances?

After hearing much expert evidence for both sides, the Court in the end found that the obstetrician acted negligently and that he had committed medical malpractice. As the doctor ultimately responsible for her care, it was unreasonable for the obstetrician to delegate to and rely upon respirologists to care for his patient's heart problem. It should have been clear to the doctor that the enlarged aorta warranted attention. He could have sought further consultation with a cardiologist but, instead, chose to ignore the problem. The Court found this to be negligent. Specifically, the Court stated:

If this court accepts the defence position that [the obstetrician] is to trust the respirology team absolutely and chart on obstetric issues only, this court would be accepting that [the obstetrician] served no function beyond that of an obstetrician. Respectfully, this court does not accept that. The standard of care of [the obstetrician] is not limited to delegating tasks and responsibilities to experts. [The obstetrician] is not absolved of responsibility with respect to a medical condition simply because that medical problem is beyond the expertise of the obstetrician...the obstetrician is responsible for a plan of care. That plan should address the totality of care, not only obstetric issues.

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