Managing Complications Part 2: The Patient and Family 
Richard Davis, Chege Macharia, Chelsea Stilwell 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
 
In Part 1, we discussed the importance of 
being honest with yourself when assessing a bad 
outcome. We discussed the goal, to remain 
emotionally healthy and to become a better surgeon. 
We mentioned that you will take this honesty to your 
hospital’s Audit process, where it will be applied and 
used to make the hospital safer for future patients. 
(See “Quality Improvement.)  
If you have not gone through this important 
process, your discussions with the family will be on 
a shaky foundation. It is likely that at least some of 
the family members will be able to tell that 
something is wrong.  
 
Dealing with the family, it is also important 
to know the results of any hospital inquiry into the 
events, before you share your impression of what 
happened with them. You can be in a difficult 
situation here: they want (and deserve) answers right 
away, but likely the Audit is still ongoing. It is OK to 
tell them that the results are not fully available. But 
do commit to sharing the full results once they are 
available, and do not use this as an excuse to “bury” 
the ultimate findings of the investigation.  
 
If you disagree with the results of the Audit, 
or if you are being told by your superiors to cover up 
the truth, you have a difficult problem. We discuss 
this special situation at the end of this Chapter.  
 
Basic Principles: 
 
Keep in mind some simple rules for 
navigating these difficult situations:  
● Do not try to avoid the patient or the family, even 
though this will be your natural inclination. It is 
best to create open channels of communication so 
that you present yourself as easily approachable 
and transparent.  This will create and encourage 
trust in your relationship with the patient and/or 
their family.  Reestablishing this trust is 
paramount, given there is an assumed breakdown 
in trust due to the fact of the medical 
complication. 
● Talking about difficult or emotional subjects 
takes time. Set aside enough time so that you 
never seem to be rushed, impatient, or annoyed 
that the process is taking so long.  
● If you don’t know what happened, do not speak 
too soon. Tell what you do know, but if it is not 
clear at the time, acknowledge this fact and 
promise full disclosure later on. It is OK not to 
know all of the pertinent details immediately, but 
it is essential to reassure that you will supply all 
the facts and details when they become available.  
● Prepare by reviewing the events. Know the dates 
of every operation and of other important 
milestones. These include when the patient’s 
condition worsened, when any imaging was 
done, and what other physicians did or said. If the 
course of events was complicated, take notes and 
use them when talking with the family. It rebuilds 
trust when you are well versed on the situation. 
Knowing the details reaffirms that you care about 
these details and therefore the care of the patient.  
● Discuss in advance with the rest of the team 
especially if there was another provider involved. 
Make sure that everyone agrees on what 
happened. If there is disagreement, acknowledge 
it when you talk to the family. In such cases, you 
must wait until the Audit is concluded before 
giving them the “final word” on what happened. 
● If the complication was caused by someone 
else’s actions, it is especially important to talk 
with this person and find out what they believe 
happened. The patient or family will be confused 
if they are hearing two different stories. Again, 
hopefully any disagreement will be resolved by 
the Audit process. Especially avoid blaming, 
criticizing, or otherwise “talking down” other 
parties involved; this is unprofessional and 
makes everyone, including yourself, look bad.  
 
The Team  
Consider setting up a team meeting before 
engaging the patient and/or the family. Ideally, this 
should be led by the primary team caring for the 
patient e.g. the primary surgeon. Make sure that any 
residents or interns involved are present, as this event 
serves as a great opportunity for teaching and 
mentorship. It would also be ideal to have other 
teams involved well represented e.g. anesthesia, 
critical care team, nursing staff etc. In some faith – 
based settings, there may also be a chaplain or other 
religious leader available to assist in such situations. 
Managing Complications Part 2: The Patient and Family 
Richard Davis, Chege Macharia, Chelsea Stilwell 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
As mentioned above, discuss with the team in 
advance before meeting with the family. 
The benefits of a team approach include, but 
are not limited to: 
● Communicating to the family that the patient was 
cared for by a team (if indeed it was the case) 
● Sharing the stress and challenge of such a 
meeting among all caregivers 
● Safety in numbers, in the rare event that any 
verbal or physical altercation was to happen 
● Teaching and mentoring for any trainees on the 
team, where applicable 
● Setting the standard for clear and open 
communication in the future 
 
The Conversation with the Family 
Sitting with the family and explaining 
reasons for a poor outcome is an emotionally charged 
event. Expect people to be present whom you have 
never met before, especially if the patient has died. 
Sometimes these new people will be the angriest 
ones and those who ask the most questions. Words 
such as “negligence” or “malpractice” may be 
thrown around by people who have little 
understanding of their meaning.  
You must absolutely keep calm and not 
become angry yourself. Remember that you are well 
trained, you did your best, and now it is your job to 
explain exactly what your reasoning was. Skeptical 
patients or family members may expect you to cover 
up or lie about the outcome. Disarm them by being 
completely honest and professional, while remaining 
even-tempered.  
Start at the beginning- usually when you first 
met the patient. If another family member was 
present at that meeting, acknowledge that you met 
them as well, and recap the discussion. Briefly 
explain why you decided to operate, what concerns 
you had, and what you did to try to mitigate them. If 
you explained the risks of this specific complication, 
remind the patient and family of this fact, but do it in 
a gentle way, not an “I told you so” manner. In 
addition to setting the stage for all present, this 
approach establishes mutual trust and unites you and 
the family with shared memory and experience.  
Explaining the timeline of what happened 
will allow the family to integrate your explanation 
with their experience as they saw their loved one’s 
condition worsen. Even though you will be telling 
some of the family members things that they already 
knew, it is important to make sure everyone 
understands every step of the patient’s progress.  
Remember, the point of this summary is to remind 
everyone that the process started out of sound 
medical diagnosis and with the intent to help.  
Reminding the family that you started with common 
goals will again help reestablish trust and disarm the 
emotionally charged situation.  
To further help explain the situation, It is 
often good to use drawings or other illustrations, 
even for simple anatomy. A line drawing of the 
biliary system, for example, makes it much easier for 
the layman to understand where you think the bile is 
currently leaking from. If you are not gifted 
artistically, download and print an illustration from 
the internet to use as a teaching aid.  
If you use medical terms, be sure to use these 
along with an explanation in layman's terms. . To 
continue the previous example, before you start 
talking about injury to the common bile duct, draw 
or show an illustration of the liver and duodenum and 
explain that there is a system of tubes that carry bile 
from one to the other. If there is one crucial concept 
that includes medical jargon, stop and write down 
those words along with their definition (“Obstructive 
Jaundice- yellowing eyes and itchy skin caused by 
blockage of the bile ducts.”)  
Allow the family to keep the drawings and 
definitions- sign and date them and take a photo for 
your own records, especially if you are concerned 
about litigation.  
 
Stop frequently and take questions. Do not be 
impatient with questions. It is also important to make 
sure your body language also shows patience and 
compassion (do not roll your eyes or sigh at 
questions.) This is your chance to make sure 
everyone is on the same page.  
When possible, it is important to explain 
what you propose to do next, including referral to a 
specialist if appropriate. If another operation is 
needed because of the complication, be clear on 
whether you are going to do it yourself, whether 
you’ll be asking another colleague to assist you, or 
whether you’ll be referring to a specialist. Making a 
Managing Complications Part 2: The Patient and Family 
Richard Davis, Chege Macharia, Chelsea Stilwell 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
plan of action will again affirm that you have the 
patient’s best interest and outcome at heart. 
Regardless of whether another physician 
takes over, you must continue to follow the patient, 
be aware of their progress, and explain it to the 
family. Do not “disappear” if another physician takes 
over. Talk regularly to this physician and keep the 
family updated.  
You may think you’re giving a malpractice 
attorney some “fuel” by giving an in-depth 
explanation of the mistakes you made, supplemented 
with drawings of those complications, signed and 
dated by you. Actually, the opposite is true. We know 
from several studies that this kind of in-depth 
explanation is what patients want. Conversely, lack 
of a believable and honest explanation of the events 
that led to a bad outcome is what makes people sue.  
To conclude this section: Physicians are sued 
because of poor communication skills. This is an 
unavoidable fact: 2-8% of physicians by discipline 
have a higher rate of litigation, even though they are 
not less competent, nor do they care for sicker 
patients. The physicians who are sued more often 
are those who have a difficult time creating and 
maintaining rapport with their patients and 
families. If you find this skill difficult, seek a coach 
to help you with people skills.  Open and honest 
communication is more than just the best way to 
avoid a lawsuit: it is what’s best for your patient.  
 
Other Considerations 
Hospitalization Expenses: 
A patient or family who is paying out of 
pocket will face increased expenses due to a 
complication. After a thorough explanation of 
oversights or adverse events, the family may ask for 
a reduction in the hospital’s bill. In our opinion this 
is a reasonable request, though not automatically one 
that should be granted. Some complications are 
unavoidable. The process of informed consent 
includes an explanation that surgery is an 
unpredictable 
process, 
prone 
to 
unexpected 
outcomes.  
 
Nevertheless, if the outcome is a result of an 
oversight, a preventable error, or outright negligence, 
it is reasonable for the hospital to lower the patient’s 
bill. Discuss this matter with the Director of the 
Finance Department and explain to them, as well, 
exactly what happened. Let the family members 
know that you have done this and then leave the 
matter to be settled by them.  
 
Team Disagreement 
 
Not every member of the team will agree with 
the findings of the Audit. Some members may even 
try to manipulate the outcome for their own gain. 
Leadership may expect, openly or tacitly, an 
approach that covers up or confuses the picture. This 
can put you in a very difficult situation. This is 
especially true if you are a junior member of the staff. 
Consider whether your interpretation of the events is 
actually the correct one, especially if you find 
yourself in the minority opinion.  
 
The Audit process depends entirely on the 
integrity and honesty of those involved. A surgeon 
shows great integrity and honesty when they say 
those most difficult words, “I made a mistake.” Over 
the course of your career, you will encounter people 
who are incapable of making such admissions. You 
would be wise to avoid working with them as much 
as possible.  
 
If your “fate” in a poor outcome is linked 
with such a person, or such a group of people, do 
your best to maintain your own integrity. Take the 
opportunity to lead by example, by telling the truth 
and expecting others to do the same. If you have 
trainees, this is an excellent chance to impress on 
them the importance of doing right even when it is 
not easy to do so.  
 
Do you have a chance to change the culture? 
If dishonesty and blame-shifting is being modeled 
from the top down in your organization, you need to 
consider whether it is worth the battle, or whether 
you would be better off working in a different place. 
But do not underestimate your ability, as one person, 
to change the culture by acting in a professional and 
virtuous manner. Though it may not seem so, 
chances are good that most people are disgusted with 
a negative culture and would love to see it change. 
Try to find allies and encourage each other to respect 
patient 
rights, 
healthy 
team 
dynamics, 
and 
accountability. See “Culture Change” for a more in-
depth discussion of this matter.  
 
Managing Complications Part 2: The Patient and Family 
Richard Davis, Chege Macharia, Chelsea Stilwell 
 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Chege Macharia MBBS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Chelsea Stilwell, MD 
Lexington Oncology 
Kentucky, USA 
 
January 2023 
 
