Chest X-Ray Refused, Undiagnosed Empyema

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

The patient, a middle-aged Virginia man in good health, awoke one night with chills and body aches. He was seen by the defendant physicians the next day. At that visit, he was offered a chest x-ray but declined. The defendants prescribed amoxicillin and sent the man home.

During the two months that followed, the patient was seen by the defendants several times for continuing respiratory symptoms. The defendants never made a definitive diagnosis.

At the patient’s final appointment with the defendants, he underwent a chest x-ray. After reviewing the x-ray images, the defendants sent the patient to the hospital on an emergency basis. He was diagnosed with empyema (specifically, a collection of pus in the pleural space around the left lung). He underwent a left thoracotomy, left lung decortication, drainage to treat pneumonia and empyema, and a muscle flap procedure in which muscle was taken from his back to encase the affected lung. He was hospitalized for 13 days.

The plaintiff experienced partial loss of his left lung, diminished lung capacity, increased susceptibility to future infections, and psychological injuries.

At trial, the plaintiff and defendants gave conflicting testimony regarding the patient’s reported symptoms and complaints and whether the patient was “offered” or “urged” to have a chest x-ray.

Outcome
According to a published account, a $475,000 settlement was reached.

Comment
While the symptoms and complaints may have been in dispute, the patient clearly refused a chest x-ray at his initial appointment and likely refused subsequent x-ray studies. Managing a noncompliant patient is procedurally difficult and legally risky. Patients who refuse examinations, tests, or referrals may “throw off” the clinician’s diagnostic workup, with inaccurate or incomplete results.

Following a poor outcome, the plaintiff’s attorney will recast clinician–patient interactions to minimize the impact of the patient’s wishes on the clinician’s judgment, and claim that the patient would have consented but for the clinician’s failure to communicate some aspect of the refused intervention.

Therefore, when confronted with a patient refusing care, it is important to fully explain the nature of the recommended intervention. Identify and document the reasons for refusal and response to the refusal (eg, “patient refusing x-ray: concerned about radiation exposure; five-minute discussion with patient discussing relatively small radiation dosage; patient understands but insists: ‘I want no radiation.’”). When care is refused, it is generally helpful to record the patient’s actual words in quotes and the clinician’s response to the assertions.

Further, when family members are present, it is also helpful to record family members’ involvement as the patient’s refusal is addressed. Often this level of attention may change the patient’s mind or serve to enlist the support of a family member to alleviate the patient’s concerns.

Lastly, be sure to record the risks of noncompliance in plain terms (eg, “risk of death and undetected progression of serious illness discussed over 15 minutes with sister, Jane, and nurse, Camille, present”). Be frank with the patient, and be clear in the record. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

The patient, a middle-aged Virginia man in good health, awoke one night with chills and body aches. He was seen by the defendant physicians the next day. At that visit, he was offered a chest x-ray but declined. The defendants prescribed amoxicillin and sent the man home.

During the two months that followed, the patient was seen by the defendants several times for continuing respiratory symptoms. The defendants never made a definitive diagnosis.

At the patient’s final appointment with the defendants, he underwent a chest x-ray. After reviewing the x-ray images, the defendants sent the patient to the hospital on an emergency basis. He was diagnosed with empyema (specifically, a collection of pus in the pleural space around the left lung). He underwent a left thoracotomy, left lung decortication, drainage to treat pneumonia and empyema, and a muscle flap procedure in which muscle was taken from his back to encase the affected lung. He was hospitalized for 13 days.

The plaintiff experienced partial loss of his left lung, diminished lung capacity, increased susceptibility to future infections, and psychological injuries.

At trial, the plaintiff and defendants gave conflicting testimony regarding the patient’s reported symptoms and complaints and whether the patient was “offered” or “urged” to have a chest x-ray.

Outcome
According to a published account, a $475,000 settlement was reached.

Comment
While the symptoms and complaints may have been in dispute, the patient clearly refused a chest x-ray at his initial appointment and likely refused subsequent x-ray studies. Managing a noncompliant patient is procedurally difficult and legally risky. Patients who refuse examinations, tests, or referrals may “throw off” the clinician’s diagnostic workup, with inaccurate or incomplete results.

Following a poor outcome, the plaintiff’s attorney will recast clinician–patient interactions to minimize the impact of the patient’s wishes on the clinician’s judgment, and claim that the patient would have consented but for the clinician’s failure to communicate some aspect of the refused intervention.

Therefore, when confronted with a patient refusing care, it is important to fully explain the nature of the recommended intervention. Identify and document the reasons for refusal and response to the refusal (eg, “patient refusing x-ray: concerned about radiation exposure; five-minute discussion with patient discussing relatively small radiation dosage; patient understands but insists: ‘I want no radiation.’”). When care is refused, it is generally helpful to record the patient’s actual words in quotes and the clinician’s response to the assertions.

Further, when family members are present, it is also helpful to record family members’ involvement as the patient’s refusal is addressed. Often this level of attention may change the patient’s mind or serve to enlist the support of a family member to alleviate the patient’s concerns.

Lastly, be sure to record the risks of noncompliance in plain terms (eg, “risk of death and undetected progression of serious illness discussed over 15 minutes with sister, Jane, and nurse, Camille, present”). Be frank with the patient, and be clear in the record. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

The patient, a middle-aged Virginia man in good health, awoke one night with chills and body aches. He was seen by the defendant physicians the next day. At that visit, he was offered a chest x-ray but declined. The defendants prescribed amoxicillin and sent the man home.

During the two months that followed, the patient was seen by the defendants several times for continuing respiratory symptoms. The defendants never made a definitive diagnosis.

At the patient’s final appointment with the defendants, he underwent a chest x-ray. After reviewing the x-ray images, the defendants sent the patient to the hospital on an emergency basis. He was diagnosed with empyema (specifically, a collection of pus in the pleural space around the left lung). He underwent a left thoracotomy, left lung decortication, drainage to treat pneumonia and empyema, and a muscle flap procedure in which muscle was taken from his back to encase the affected lung. He was hospitalized for 13 days.

The plaintiff experienced partial loss of his left lung, diminished lung capacity, increased susceptibility to future infections, and psychological injuries.

At trial, the plaintiff and defendants gave conflicting testimony regarding the patient’s reported symptoms and complaints and whether the patient was “offered” or “urged” to have a chest x-ray.

Outcome
According to a published account, a $475,000 settlement was reached.

Comment
While the symptoms and complaints may have been in dispute, the patient clearly refused a chest x-ray at his initial appointment and likely refused subsequent x-ray studies. Managing a noncompliant patient is procedurally difficult and legally risky. Patients who refuse examinations, tests, or referrals may “throw off” the clinician’s diagnostic workup, with inaccurate or incomplete results.

Following a poor outcome, the plaintiff’s attorney will recast clinician–patient interactions to minimize the impact of the patient’s wishes on the clinician’s judgment, and claim that the patient would have consented but for the clinician’s failure to communicate some aspect of the refused intervention.

Therefore, when confronted with a patient refusing care, it is important to fully explain the nature of the recommended intervention. Identify and document the reasons for refusal and response to the refusal (eg, “patient refusing x-ray: concerned about radiation exposure; five-minute discussion with patient discussing relatively small radiation dosage; patient understands but insists: ‘I want no radiation.’”). When care is refused, it is generally helpful to record the patient’s actual words in quotes and the clinician’s response to the assertions.

Further, when family members are present, it is also helpful to record family members’ involvement as the patient’s refusal is addressed. Often this level of attention may change the patient’s mind or serve to enlist the support of a family member to alleviate the patient’s concerns.

Lastly, be sure to record the risks of noncompliance in plain terms (eg, “risk of death and undetected progression of serious illness discussed over 15 minutes with sister, Jane, and nurse, Camille, present”). Be frank with the patient, and be clear in the record. —DML