The duty of candor, a concept in human medicine, can be defined as a legal duty imposed on the medical practitioner to be open and honest with patients or their families when things go wrong that can cause harm. The rule is designed to provide any patient harmed by the provision of a health care service with the facts and an appropriate remedial course of action regardless of whether the treatment has been questioned or a complaint made. The aim is to help patients receive accurate, truthful information from health providers about their treatment and to encourage open discussions at an early stage when a treatment starts going wrong so that overly defensive approaches to information-sharing can be avoided. The duty of candor as a formal ethical requirement is relatively new in human medicine and a concept the veterinary profession has been grappling with for years. There are mounting public expectations for the veterinary profession to be candid when treatments go wrong. Where It Started Human medicine’s Duty of Candor originated in the United Kingdom after the Parliament’s passage of Robbie’s Law in 2014. In Wales in 1990, 10-year-old Robbie died from Addison’s disease. Medical staff had suspected Addison’s disease, and doctors ordered an ACTH test, but it was never carried out. Instead, Robbie’s family was told he was suffering from gastroenteritis caused by a throat infection. Robbie recovered some and then had a relapse four months later. He was seen seven times by five doctors over the 15 days before he died, but no one performed the basics by checking symptoms, ordering blood tests or referring him to a hospital. Due to a combination of mismanagement, dishonesty and cover-up, none of the doctors were prosecuted. Robbie’s father tried to get answers, but his efforts were met with a seemingly impenetrable veil of silence. Over the next 22 years, Robbie’s father campaigned for a law obliging the U.K. medical profession to tell the truth and be held accountable from the beginning. Practical Limitations The caveat to Robbie’s Law is that in many human medicine cases the facts are yet unknown and expecting medical practitioners to speculate is unreasonable. The only safe avenue open to the practitioner—no matter how frustrating the situation may be to the patient and family—is to inform them that he has insufficient data and that he needs to order more tests before he can provide reliable information. The same caveat applies to the veterinary practitioner. However, the big difference is that the human medical practitioner generally has access to a seemingly infinite number of specialists and sophisticated diagnostic tools, while the veterinary practitioner generally has access to one or two “general practicing” specialists and relatively unsophisticated diagnostic options. A human medicine practitioner has much less reason to be stranded. When the treatment outcomes don’t meet expectations, he can order more tests or refer to as many specialists as he might need to get the required result. In veterinary medicine, the practitioner is likely going to be stranded as financial and logistical factors prevent him from ordering more tests and referring patients until he is off the hook. It is much less risky for a human practitioner to express regret, as the practitioner can quickly steer the conversation toward actions that lead to a correct diagnosis and appropriate treatment. This should divert blame from the practitioner or at least shield him from liability and a malpractice lawsuit. Saying “sorry” in veterinary medicine is riskier, as there is usually no shield in the form of sufficient diagnostics to divert the blame. The duty of candor is not a formal requirement in U.S. medical or veterinary care. If and when it becomes so, state legislators should be made cognizant of the substantial financial and logistical constraints placed on the veterinary profession that make the duty of candor in its U.K. form too onerous for veterinarians to comply with. Likewise, state veterinary regulators should be circumspect about penalizing veterinarians for failing to meet this duty. Even without a formally imposed duty of candor, the animal-owning public expects it, and it often forms part of a veterinary board investigation. What You Can Do So what are some of the do’s and don’ts of managing this risk? Don’t ignore an adverse treatment outcome in the hope the owner will go away. Do manage such outcomes as if they are the subject of a board complaint or civil litigation. Do get advice in each case from an experienced veterinarian trained in veterinary risk management who can assist you in mitigating the weaknesses in your management and reinforce the strong parts. It is preferable to get this advice before you present the bad news to the owner so that you are in control of the situation and can divert the owner’s frustration or anger by launching into your plan of action. Don’t provide a bare apology without having a plan of action to present to the owner. (I believe it is better not to apologize but rather to make the owner aware that you are distressed by the turn of events and that you are focused on her needs and the pet’s.) In my experience, people want action more than they want empty apologies. Offering proper advice will place you in the position of being able to be open and honest with owners, meeting your duty of candor while protecting yourself from unnecessary complaints and litigation. If communications break down, as they often do, then the process of alternate dispute resolution allows a trusted third party to mediate and restore communications in order to reach a result that satisfies both parties. Don’t run the risk of appearing to be unconcerned and unsympathetic, no matter how tired you are or how much compassion fatigue you are suffering at that moment. Do always make a point of delivering bad news personally. Never leave it to your staff. Other Advice Remember to regard clients as partners in the treatment of their pets and to treat your patients as beings, not objects. Take a few minutes to explain the complexities of the condition, as you gently pet the animal, so the owner has a realistic, rather than simplistic, view of the condition and can see that you are in tune with your patients. Good communication from the beginning helps to reduce anger and frustration when things go wrong. It takes a lot of practice, skill and energy to be a good communicator, but if you have solid rapport with the owner from the time treatment commences, owners will be less inclined to lose confidence in you when the case takes an unwanted diversion. Dr. David Carser graduated as a veterinarian in 1982 and obtained his law degree and Certificate in Medicine and Law in 2000. He co-founded the Veterinary Defence Association in 1992 and the Chicago-based Veterinary Defence Association (America) in 2009.
