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The Power of Apology

photographs of Theresa Malloy-Miller and Daniel

In his book On Apology, Dr. Aaron Lazare, former Chancellor and Dean of  the University of Massachusetts Medical School, described apologies as one of the most profound interactions that can occur between people. They have the power to heal humiliations, free the mind from deep-seated guilt, remove the desire for vengeance, and ultimately restore broken relationships.

For Theresa Malloy-Miller, an apology allowed her to start the process of healing, following the sudden death of her 17-year-old son Daniel.

In January 2003, Daniel died unexpectedly after being admitted to the local hospital for persistent vomiting. The Chief Coroner’s Pediatric Death Review Committee (PDRC) looked at the care that Daniel received and found that his death followed a series of diagnostic, communication, equipment and medication errors. The Committee found that he died of cardiogenic shock secondary to acute viral myocarditis.

Two years after Daniel’s death, one of the physicians involved in his care offered an apology for what had occurred. “He shared with us that what had happened to Dan had deeply affected him,” said Theresa. “He shared that he thought about Dan every day and that he had reflected on and changed his practice as a result. We greatly appreciated the bravery and compassion of this individual and that he had used Dan’s tragedy to work for change. This was all we ever hoped for. 

Two years later — four years after Dan’s death — the hospital’s new CEO also apologized for Dan’s death. “Receiving this apology was crucial,” she said. “This apology acknowledged the importance of Dan’s life.”

Such an acknowledgment supports the process of learning and reassures families there will be system change. And indeed the hospital has since made significant changes. It now has a standard protocol for children with abnormal blood values and for fluid resuscitation, new blood pressure equipment, new protocols for RN-MD communications and new guidelines for sedation. The hospital also set up a patient safety conference and invited Theresa and her husband Tim to make a presentation. She sat on the planning committee for this annual conference after their presentation and went on to serve as a patient/family advisor on the hospital’s Corporate Quality Council. Currently Theresa is a member of Patients for Patient Safety Canada, a working group of the Canadian Patient Safety Institute.

Book cover of "On Apology" by Aaron Lazare

 “Apology contributes to the hope that other families will not experience the same harm. This apology helped us to work towards our own healing and a rebuilding of our trust in the medical system … Ultimately patients, families and health-care providers are all on the same team. It is important that health-care providers are supported through the process of disclosure and apology and reassured that their efforts will lead to system change,” said Theresa.   

The College’s recently approved Disclosure of Harm policy expects physicians to consider whether an apology is appropriate in circumstances where a patient has experienced harm or potential harm, and the accompanying Advice to the Profession addresses how a full and sincere apology may contribute to a successful disclosure discussion.

“Such an apology can be greatly appreciated by patients and their family, and can assist in promoting trust,” states the Advice to the Profession companion document. ”Patients also say that the manner in which an apology is delivered can be extremely important; the most effective apologies demonstrate sincerity, empathy, and genuine concern for the patient’s well-being. Apologies should therefore be tailored in each individual circumstance, avoiding a formulaic approach,” it stated.

Physicians sometimes hesitate to apologize to patients because of concern about legal implications. It is important to note that in Ontario, the law states that an apology is not an admission of legal liability.  In addition, neither an apology nor a disclosure of harm absolve physicians of harm that has occurred or shield them from a finding of liability in the future.

Physicians have identified a number of additional barriers to an apology, including a lack of training and self-confidence in conducting the disclosure discussion effectively. It is common, in the context of a difficult disclosure conversation, to feel uncertain about what to say to patients and their families, and the confidence required to conduct these conversations effectively is often obtained through practice and training. You may wish to access further educational resources and materials regarding the delivery of apologies (and disclosure generally), including the Canadian Patient Safety Institute’s Canadian Disclosure Guidelines: Being Open with Patients and Families and the Canadian Medical Protective Association’s Disclosing harm from healthcare delivery: Open and honest communication with patients. Also consider turning to a more experienced colleague or colleague in a leadership position as a way to understand how to approach and manage these types of conversations.