06 Jul ‘Hospital guidelines wouldn’t allow that’ and other well worn phrases from the birth world. Part 3.
As a doula I am used to hearing that a woman’s wishes in labour cannot be granted because hospital guidelines or policy forbid it. This conversation usually comes up when a birthing woman wishes to use the pool for comfort, or the birthing centre, or would like an elective C section, or wants to move freely but monitoring doesn’t allow it. Sometimes it’s because a woman wishes to decline induction, or a vaginal exam or another intervention.
I often think when I hear this ‘but it is just a guideline. It’s not the law’ and I also see that many midwives would like to help a woman achieve her wishes but are just too afraid. It’s almost as if the guidelines have become a way of thinking ‘if we stick to the guidelines no one can be sued’
The NY Times essayist and author Malcolm Gladwell discusses this common misbelief about medical litigation in his book ‘Blink’. He says:
‘ The overwhelming number of people who suffer an injury due to negligence of a doctor never file a malpractice suit at all. Patients don’t file lawsuits because they have been harmed by shoddy medical care. Patients file lawsuits because they’ve been harmed by shoddy medical care – something else happens to them.’
He goes on to explain ‘ What comes up again and again in malpractice cases is that patients say they were rushed or ignored or treated poorly.’
Gladwell cites a 1997 study by Dr Wendy Levinson, on the subject of why people seek medical litigation. She recorded hundreds of conversations between doctors and their patients. Half of the doctors had never been sued and the other half had been sued at least twice. She noted the differences in the conversations between the two groups of doctors:
- The doctors who had never been sued spent more than three minutes longer with each patient than those who had been sued did (18.3 minutes versus 15 minutes).
- They were more likely to make“orienting” comments, such as “First I’ll examine you, and then we will talk the problem over” or “I will leave time for your questions.”
- They were more likely to engage in active listening, saying things such as “Go on, tell me more about that.”
- They were far more likely to laughand be funny during the visit.
She also found that there was no difference in the quality or the amount of information given between the two groups. The difference was between the often sued group and the never sued group was entirely down to how they spoke to their patients.
Earlier this year I attended a wonderful study day by Birthrights at my local hospital, which gave a human rights perspective on maternity care. Elizabeth Prochaska from Birthrights outlined 3 principle rights that every woman should have honoured by their care providers during their birth: dignity, respect and autonomy.
As individuals I think we instinctively know about these rights and why they are important to us. But institutional guidelines often have no space for these values. They are frequently understood and communicated as fixed rules rather then guides. A guideline too often is placed ahead of these core values of dignity, respect and autonomy. When actually it should be the other way round, those principles should come ahead of everything else. And, I wouldn’t mind betting if they were favoured instead of the guidelines then lawsuits, complaints and traumatic birth numbers would all fall.
At the study day we discussed the landmark lawsuit of Montgomery; a woman from Scotland who had requested an elective c section for her son’s birth because of her concerns about her petite frame and diabetes. Her consultant denied her request and her son suffered cerebral palsy as a result of shoulder dystocia.
The judge suggested it would be a mistake to view patients in the modern world as “uninformed, incapable of understanding medical matters or wholly dependent upon a flow of information from doctors”.
They said social and legal developments “point away from a model of the relationship between the doctor and patient based on medical paternalism”.
The judges added: “An adult person of sound mind is entitled to decide which, if any, of the available forms of treatment to undergo, and her consent must be obtained before treatment interfering with her bodily integrity is undertaken.”
“The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.’’ *
This more than ever suggests a need for care providers to actively listen to what the women using their service want.
It’s isn’t guidelines that prevent births turning in to lawsuits it is listening ears.
11 Mar 2015