The AMA Journal of Ethics recently published the winning essay of the 2018 John Conley Ethics Essay Contest, discussing the necessity to document, disclose, and, if possible, rectify errors in the care of patients who are unrepresented and incapacitated, which is the case in about 8% of hospital ethics consultations nationwide.

Clinicians often find it challenging to disclose harmful mistakes to patients and their families, in part because of possible underlying fears of retaliation, perceived incompetence, or shame. When a patient is both incompetent and unrepresented, documentation, it is particularly important to disclose and rectify errors are particularly important to consider.

The following fictional case, which was included in the study, highlights the issue: An 82-year-old, presumably homeless man was brought to the emergency department with altered mental status, fever, and cough. The man was admitted to the intensive care unit for severe pneumonia with developing acute respiratory distress syndrome, requiring intubation.

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After admission, the patient had a cardiac arrest, during which a communication error transpired. The family of another admitted patient agreed on a do-not-attempt-resuscitation (DNAR) order, and upon overhearing the nurse’s verbal conveyance, Dr K believed that the order applied to the aforementioned 82-year-old patient and did not realize the mistake for 5 minutes.

Although the team successfully resuscitated the patient, Dr K was concerned about the possibility of recurrent cardiac arrests secondary to hypoxia and irreversible brain injury. Given the erroneous first DNAR and the patient’s unrepresented status, Dr K was concerned that some members of the team might have felt compelled to err on the side of providing more aggressive care.

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In response to an error, “clinicians involved should fully document the incident. Clear and complete documentation enables root-cause analyses of causal factors underlying systemic sources of variation in clinical practice. Hospital policies can be tailored to address these factors in order to prevent similar errors in the future …Disclosure could enable Dr K to mentally organize events leading up to the incident in a manner that is coherent and permits identification of strategies for preventing errors.”

After an act of ownership and contrition has been rendered, learning can be ongoing. In seeking to rectify the error, clinicians can take advantage of a number of resources available to them, including seeking advice from physicians not directly involved in the unrepresented patient’s care and a hospital’s ethics committee whose main purpose is to adjudicate ethically difficult cases.

The author concluded that “in cases in which an error is made in the care of an unrepresented patient, the absence of a surrogate does not preclude the clinician’s ethical responsibilities to document, disclose, and, insofar as possible, rectify the mistake. As suggested here, the obligations of physicians and their organizations to an unrepresented patient are not all that different from those owed to other patients.”


Chiu RG. When there’s no one to whom an error can be disclosed, how should an error be handled? AMA J Ethics. 2019;21(7):E553-558.