It is not unheard of in the legal arena for a patient who has undergone a colonoscopy to later go back and bring suit against the colonoscopist. There have been many cases in which a few years after such a procedure, that same patient is diagnosed with colorectal cancer. Unfortunately, because a colonoscopy is not always a well-documented procedure, this situation of later diagnosis is a strong possibility in patients who undergo this procedure. Claims brought against colonoscopists generally involve evidence pertaining to a careful examination of the patient, the tumor’s size when the diagnosis was made, as well as the interval since the baseline colonoscopy, and, finally, the knowledge and skill of the colonoscopist and the expert witness. If such information is not available, that will also come into play in deciding the outcome of the suit.
Major issues that should be discussed by colonoscopists in their informed consent paperwork, as well as in discussions they have with patients, include missed cancer, missed lesions, postpolypectomy bleeding, medication reactions, aspiration pneumonia and splenic injury. Aside from educating patients, colonoscopists should also be requiring their patients to split-dose prior to a colonoscopy. Split-dosing is when the patient takes a laxative prior to the procedure. In most cases, patients are required to take the laxative the evening before and the morning before the procedure. Split-dosing has been found to be extremely beneficial in providing efficient results of a colonoscopy. While split-dosing has been endorsed by three different guidelines, and evidence has demonstrated how useful it is in obtaining concise data, it is still not utilized by all colonoscopists. This is due to the fact that split-dosing is not yet the standard of care. However, if a colonoscopist wanted to lessen their likelihood of being sued for malpractice, they should encourage split-dosing to their patients prior to a colonoscopy.
In regard to actual documentation kept by colonoscopists during the procedure, they are required to use one of three systems. They may use a simple term 4-scale system that ranges from excellent to poor, rate the preparation as adequate or inadequate, or, finally, use validated scoring systems including the Boston Bowel preparation score, the Aronchick score, or the Ottawa score. According to the US Multi-society Task Force on Colorectal Cancer, an adequate preparation allows a colonoscopist to be able to detect polyps that are 6mm or larger. Thus, an inadequate preparation is deemed to be one in which solid or semi-solid debris cannot be moved via patient rotation. In addition to the scales utilized by colonoscopists, photography has been found to be helpful. It is standard for colonoscopists to take photos of the cecum and rectum after mucus and bubbles have been “cleaned away.” Photographs also come in handy when looking at cecal intubation, as well as when the cecum distal to the ileocecal valve (ICV). Finally, it is also imperative that colonoscopists make sure they document the results of a rectal exam before the procedure. It is quite common for postcolonoscopy cancers to be found in the distal rectum. Thus, if a colonoscopist has performed such an exam prior to the colonoscopy and have written documentation of the results, this will help better protect them.
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