Failure to Inform the Patient of Severe Aortic Stenosis Resulting in Death

Allegation

Failure to inform the patient of his severe aortic stenosis, make a timely referral to a cardiologist and send the patient to the emergency department resulting in death.

Case Details

A 72 YOM with a history of hypertension, hyperlipidemia, heart murmur, type 2 diabetes, depression, obesity, and obstructive sleep apnea syndrome presented to his family medicine physician (PCP) for his annual well visit without complaints. His physician ordered a home sleep study and an echocardiogram.

The patient underwent an echocardiogram at a cardiac clinic, which showed severe aortic valve stenosis. The results were faxed to his PCP in a letter that also included contact information for scheduling coordinators if a referral was needed. The patient was not informed of the results.

Three months after the echocardiogram, the patient returned to his PCP with left-sided chest pain and dyspnea on exertion. An in-office EKG was abnormal and showed a new left bundle branch block. Troponin and D-dimer tests were ordered and were within normal limits. The patient was referred to a cardiologist, and the PCP office assisted in getting a future appointment scheduled.

While awaiting the cardiologist appointment, the patient presented to his PCP with chest pain, worsening dyspnea on exertion, and back pain. The patient’s heart rate while sitting was 80 beats per minute (bpm) but dropped to 35 bpm while walking. An EKG completed in office revealed sinus bradycardia, first degree AV block, and left bundle branch block. A pulmonary function test completed at this visit revealed moderate to severe restriction.

The patient asked for help obtaining an earlier cardiology appointment because his scheduled visit was still more than a month away. The PCP would later testify he instructed the patient to go to the emergency department, but the patient declined. Subsequently, the PCP called the cardiovascular center and spoke directly with the on-call cardiologist. After explaining the patient’s symptoms, physical examination findings, and EKG, the cardiologist agreed to see him in the office the following day. The physician informed the patient of the new appointment time.

The following morning, the patient’s wife found the patient unresponsive and EMS was called. Upon arrival EMS evaluated the patient and notified the family that he passed away. The death certificate noted the immediate cause of death to be cardiopulmonary arrest due to consequences of aortic valve disease and hypertension.

Expert Testimony and Resolution

Plaintiff’s experts opined that the standard of care required the PCP to relay the echo results to the patient and order a timelier consultation with a cardiologist based upon these results. They also opined that the standard of care required the physician to send the patient to the ED during his last office visit when he presented with worsening dyspnea on exertion. The experts said that had the patient seen a cardiologist sooner—in either the outpatient or emergency setting—he could have received the treatment necessary to avoid his death.

Defense experts were generally unsupportive. They too opined that the patient should have been informed of his echo results but argued this was not solely the PCP’s responsibility. Further, they suggested an earlier cardiology consult was required based upon the echo results to address the diseased aortic valve surgically, which would have prevented death. They also felt the standard of care required the patient to be sent to the ED during the last office visit in lieu of the call to the cardiologist; however, they argued this may not have resulted in admission or an earlier consultation with a cardiologist. The PCP testified that he told the patient to go to the ED prior to calling the cardiologist and the patient refused, but this was not documented.

This case was ultimately resolved by a confidential settlement due to weak standard of care support.

Risk Reduction Strategies

Tracking and Follow-Up

Tracking diagnostic test results can increase patient safety and reduce liability risks. Diagnostic test tracking systems verify that tests are performed and the results are reported to the office or ordering physician, reviewed, acted upon, entered into the medical record, and communicated to the patient.

Establish a tracking system to document and follow up on patients referred for diagnostic, imaging, or laboratory studies. An effective system will verify that all the following steps are complete:

• The test is performed.

• The results are reported to the office.
• The physician reviews the results.
• The results are acted upon.
• The results are recorded in the medical record.
• The physician communicates the results to the patient.

Informed Refusal

When patients understand the risks of declining recommended treatment including ED referrals, the informed refusal decision must be respected. Thorough documentation of this process can later serve as evidence and strengthen defensibility of a claim. If a patient refuses care after receiving information about risks and benefits be sure to:

• Document the patient’s refusal in the medical record.

• Ask the patient to sign a refusal of treatment form.
• Document the process related to the informed refusal (the main points of the discussions about risks, benefits, and consequences of declining treatment).