Dr fined $100k for not telling patient possible side effects

[Victor68]

I know what we can do. Have a template on disclaimer. Ask client to sign first before proceeding.

[Wind30]

No it's perfectly fine to have informed consent. All doctors (unless u are a real dinosaur) have been doing it for donkey years.

It's perfectly fine to have informed consent if u say point out the 1-2 most important things.

 

But now, with this ruling. It says u have to inform of ALL side effects before consent is valid.

Earlier last year, another judgement says u have to give ALL options (even ones we deem are useless).

.

Since when did the ruling says that?? Did the ruling ask all doctor to inform all side effects?

 

The doctor in question said NOTHING.

[Lala81]

Since when did the ruling says that?? Did the ruling ask all doctor to inform all side effects?

 

The doctor in question said NOTHING.

 

 

In so far as (a) the materiality of the information was concerned, the Tribunal agreed with the learned Counsel for SMC that the risks and possible complications of the H&L Injection were material information that should be explained to the Patient. However, as rightly pointed out by Mr Chia for SMC, there was no 15 evidence that the Patient would have taken a different course of action had such information been conveyed to her.

 

49. Furthermore, the Tribunal also considered that this was not a case where the doctor had deliberately suppressed the information, or intentionally or deliberately departed from the ethical standards. The Tribunal accepted the submission of the learned Counsel for Dr Lim that this was an isolated one-off incident, involving one patient, and that it was an honest omission on Dr Lim’s part.

 

50. As to (b), the extent to which the patient’s autonomy to make an informed decision on her own treatment was undermined as a result of the failure to convey or explain the necessary information, the Tribunal was of the view that the Patient’s autonomy was not substantially undermined, neither was the Patient “robbed of her autonomy” (in the words of Mr Chia in his submission) to make an informed decision on her own as to whether she was willing to take on the full extent of the risks and possible complications.

51. In our view, the Patient retained much of her autonomy, and as noted above, there is no evidence to suggest that she would not have undergone the H&L Injection if she was informed of the risks and possible complications that could arise.

 

52. More importantly, the Agreed Statement of Facts revealed that Dr Lim had informed the Patient of the results of the MRI scan on her left wrist, and offered the Patient the option of (i) bracing and oral medication; or (ii) the H&L Injections, bracing and oral medication, before he administered the H&L Injection into the Patient’s left wrist.

 

53. In this respect, the Tribunal considered that Dr Lim had offered the Patient the alternative option of conservative treatment without any injection, i.e. “bracing and oral medication”, and that he did not offer the H&L Injection as the sole treatment, nor did he actively recommended or pushed this particular treatment to the Patient. 16 54. As for the point ©, the possibility of harm and where applicable, the materiality of harm which resulted from the doctor’s failure to explain the necessary information, the Tribunal accepted the SMC’s submission that some harm had ensued in that the Patient experienced swelling and pain in the Injected Area about two hours after the H&L Injection, and that she subsequently developed a “paperthink skin with discolouration, loss of fat and muscle tissues” in the Injected area. Suffice to note, the Tribunal observed that these were recognised adverse effects of the H&L Injection, and the Tribunal agreed that the complications experienced by the Patient were complications that Dr Lim should have informed her about.

 

55. However, the Tribunal was of the view that the H&L Injection administered by Dr Lim was nonetheless, an appropriate and reasonable treatment for the Patient, unlike the more egregious cases where the errant doctor should not have recommended an inappropriate treatment or advised the particular treatment option at all. Moreover, the Tribunal considered that the H&L Injection was not a complicated or highly invasive procedure, or one that required sedation or anaesthesia, to be performed in an Operating Theatre setting.

 

56. In other words, the harm to the Patient did not negate the appropriateness or reasonableness of Dr Lim’s treatment, which was clearly guided by the Patient’s symptoms and after proper investigations were done by Dr Lim. As explained above, the H&L Injection administered by Dr Lim was a minimally invasive and commonly performed procedure in the clinic that required no sedation or anaesthesia. The treatment administered by Dr Lim and management option was also one which clearly commensurate with Dr Lim’s area of practice.

 

57. Hence, while the Tribunal recognised that the Patient suffered some side effects and complications resulting from the H&L Injection, as rightly submitted by Dr Lim’s counsel, there is nothing to suggest that the complications experienced by the Complainant were in any way permanent or debilitating. To that extent, the Tribunal agreed with Mr Tin that Dr Lim’s degree of culpability is on the low end, and that the harm that ensured is limited in nature and extent. 17

 

58. The Tribunal also considered the strong mitigation plea submitted on Dr Lim’s behalf by his learned Counsel. In this respect, the Tribunal considered Dr Lim’s unblemished record of 29 years and gave full credit to Dr Lim for having pleaded guilty at the earliest available opportunity, that he was co-operative with the investigations, that he was genuinely remorseful for his error and has apologised to the Complainant. More significantly, Dr Lim has taken remedial steps to improve his consent taking and documentation of the patient medical records.

 

59. It is pertinent to note that according to the report submitted by the SMC’s expert witness, A/Prof PE, Senior Consultant, Hospital A, it was not a universal practice to take a written consent for H&L Injection that is performed in the consultation room setting. However, it was good clinical practice and medical record keeping to document in the case notes that the patient had been adequately informed and was agreeable to the injection. 60. The Tribunal agreed with A/Prof PE that Dr Lim should have informed the Patient about the possible complications arising from the H&L Injection, and that he should have provided adequate information to the Patient and document the details in the case notes to ensure that the informed consent was obtained.

There are 2 parts to this. Implied consent vs Verbal consent.

 

If u stay in the consultation and did not opt to go for the non-invasive treatment. There is implied consent that u are willing to continue with the course of treatment.

 

With the previous rulings,  even if he had taken written consent. As long he and his patient agree that there was 1 side effect that was not mentioned during the consult taking, the consent may not have been taken to be valid.

For example, usually the main major side effect would be risk of infection (as with all needles poking your skin) vs tendon rupture which is serious and mentioned if repeated injections done before.

If u didn't mention SPECIFICALLY the side effect the patient experienced, your written consent may not be defensible as well.

 

 

 

IMPORTANCE OF GOOD CLINICAL PRACTICE FOR INFORMED CONSENT

14. The SMC had been made aware that certain members of the medical profession hold the view that it is not necessary to obtain a patient’s informed consent for an H&L Injection because such consent would be implied, as with cases where blood is drawn from a patient via an injection, and that there is no universal practice to take informed consent in such cases.

 

15. The SMC would like to emphasise the importance of a doctor’s duty to obtain informed consent from his or her patients. Patients need to be adequately informed so that they may meaningfully participate in decisions about their treatment and to provide informed consent. It is also good clinical practice and medical record keeping for doctors to document in the case notes that a patient has been adequately informed and agreeable to the proposed treatment. The SMC draws the profession’s attention to the following observations and findings by the DT:

 

(a) The DT noted the Expert’s opinion that it was not a universal practice to take a written consent for H&L Injection that is performed in the consultation room setting. However, it was good clinical practice and medical record keeping to document in the case notes that the patient had been adequately informed and was agreeable to the injection. (b) The DT agreed with the Expert that Dr Lim should have informed the Patient about the possible complications arising from the H&L Injection, and that he should have provided adequate information to the Patient and document the details in the case notes to ensure that the informed consent was obtained.

 

So if SMC has never laid out specifically the rule that u MUST have informed consent, why are u punishing someone 100k vs a 3 month minimum suspension for what used to be implied consent?

What was best clinical practice is now legal requirement?

 

So if u want to set the bar like this? I don't really see any difference from doing an intramuscular injection for vomiting vs doing a H&L. Both involve drugs. Both are injections. Both can have any number of side effects.

Edited January 28, 2019 by Lala81

[Lala81]

If u want to go down to the nitty gritty of it, I am also not interested except what is needed for me to practice.

 

There are multiple previous rulings, some articles on the implications of Montgomery Test in 2017. They analysed this ruling that will have much deeper and wider implications.

These are just current legal demands on what used to be ethical considerations. 

 

 

 

 

 

 

[RadX]

dei @turboflat4, your mushrooms need consent anot...hahaahah

[1fast1]

dei @turboflat4, your mushrooms need consent anot...hahaahah

You can see from some attitudes reflected in the replies here why I prefer to treat mushrooms.

 

You know what mushrooms grow best in, but even then they seem to be less full of it than some people.

Edited January 28, 2019 by Turboflat4

[Lala81]

To lighten up what is a depressing or dull topic.

 

This will be in real life one of these days.

Consultation in hokkien

 

D: "Aunty, want injection for your knee pain?"

A: "I want, pain for many days u know"

D: "Aunty, u really want to inject or you'd rather eat meds for few days then see how"

A: "No i want today"

D: "Ok u wait ... i need to prepare injection. BTW injection sometimes can have infection cos needle enter your flesh, u ok or not?" (MORE SERIOUS SIDE EFFECT)

A: "ok ok... hurry up lah. damn pain u know"

 

Injection occurs ...

 

A: "EH WAH LAO EH, HOW COME SO PAIN NOW OVER BUTTOCK?"

D: "Aunty ... injection sure bit painful one leh (COMMON SIDE EFFECT)"

A: " EH U NEVER TELL ME INJECTION IS PAINFUL, KNN I'M GOING TO SUE U"

D: " .... ...."

[Kusje]

You can see from some attitudes reflected in the replies here why I prefer to treat mushrooms.

 

You know what mushrooms grow best in, but even then they seem to be less full of it than some people.

 

What do you mean you treat mushrooms?

[RadX]

To lighten up what is a depressing or dull topic.

 

This will be in real life one of these days.

Consultation in hokkien

 

D: "Aunty, want injection for your knee pain?"

A: "I want, pain for many days u know"

D: "Aunty, u really want to inject or you'd rather eat meds for few days then see how"

A: "No i want today"

D: "Ok u wait ... i need to prepare injection. BTW injection sometimes can have infection cos needle enter your flesh, u ok or not?" (MORE SERIOUS SIDE EFFECT)

A: "ok ok... hurry up lah. damn pain u know"

 

Injection occurs ...

 

A: "EH WAH LAO EH, HOW COME SO PAIN NOW OVER BUTTOCK?"

D: "Aunty ... injection sure bit painful one leh (COMMON SIDE EFFECT)"

A: " EH U NEVER TELL ME INJECTION IS PAINFUL, KNN I'M GOING TO SUE U"

D: " .... ...."

 

 

eh wasup with u docs, you and that @vratenza like damn good script writers hahahhahaa

[Vid]

eh wasup with u docs, you and that @vratenza like damn good script writers hahahhahaa

 

They same drama school [laugh]

[Lala81]

They same drama school [laugh]

 

drama school of life.

[1fast1]

What do you mean you treat mushrooms?

It's a private joke.

[RadX]

It's a private joke.

 

 

you do mean

 

privateS

 

 

 

anyway this consent thing is sending ripples in the community, and all the other allied health too.  

[Kusje]

It's a private joke.

 

I see. you fellows got something going on together 

[Lala81]

you do mean

 

privateS

 

 

 

anyway this consent thing is sending ripples in the community, and all the other allied health too.  

 

At least we have indemnity insurance to protect us against lawsuits, justified or unjustified.

 

The worst would be those APN giving out medications or treatments. Like it or not, they are nurses, who's going to cover their asses?

The ONLY thing protecting them now is that people haven't caught onto the idea of suing nurses YET.

Would MOH stand up for them? If i were them, i would be very worried. 

[RadX]

At least we have indemnity insurance to protect us against lawsuits, justified or unjustified.

 

The worst would be those APN giving out medications or treatments. Like it or not, they are nurses, who's going to cover their asses?

The ONLY thing protecting them now is that people haven't caught onto the idea of suing nurses YET.

Would MOH stand up for them? If i were them, i would be very worried. 

 

 

yes.  Agree.  Opens a whole new suite of possibilites.  Guess the SNB would need to come into the picture . Not sure if nurses have their own insurance.  I believe the AHPC is looking into it as well.

[Jamesc]

All the companies I work for practice mushroom management.

 

Keep the staff in the dark and occasionally throw them some manure.

 

It has spread to the caring profession as well?

 

Edited January 28, 2019 by Jamesc

[Lala81]

All the companies I work for practice mushroom management.

 

Keep the staff in for dark and occasionally throw them some manure.

 

It has spread to the caring profession as well?

 

 

how come ur MIL hasn't enjoyed such leading mushroom management?