Aesthetic nurse prescriber and Chair of the BACN Sharon Bennett debates when it is appropriate to treat the complications of other practitioners’ patients
I sometimes find myself with an ethical dilemma when it comes to treating the aesthetic complications of other practitioners. As a nurse and part of ‘the caring profession’, it is in my nature to look after people, but when presented with a patient who is upset and distressed after an adverse event, or a bad outcome, at the hands of another practitioner, I do feel conflicted about whether or not I should be taking this patient on and transferring the responsibility on to my shoulders.
Despite wanting to help, should we be saying yes to a patient when we may not fully know the exact details of the treatment they have had done and don’t have access to their treatment history? I do believe that the practitioner who carries out the cosmetic treatment has a responsibility towards their patient, should be handling their own complications and, ideally, be part of a tri-partide relationship with the patient and other practitioners for support. In this article I shall explain why.
What is the problem?
Working alone in private cosmetic practice is very different from working in the safe haven of the NHS. Problems occurring whilst working within the NHS have the immediate support from a host of people on hand to help. The practitioner involved will be surrounded by other professionals who are able to access all the documentation, and the patient has a clear chain of authority to go to and will be cared for until a resolution is met.
In private cosmetic practice, a patient faced with an unexpected result or an adverse event may not know what to do. Many will return to their original practitioner for correction, advice and further care, until a good outcome is gained. Some will not and will look elsewhere for help. They may even scour the internet in a desperate bid for help.
Why is this an issue?
When a patient presents at clinic with a result they are unhappy with or a complication, it is essential for us to know the full history of the patient. But the truth is, if this is not your own patient then this is almost impossible, and without access to the patient’s notes, medical and psychological profile, you can never be 100% sure you have all the facts. Having this access is very difficult as some patients will often ‘practitioner hop’ and will have seen many different practitioners for treatments.
Patients aren’t always forthcoming with the truth or open about what they have had done; you need to know how many treatments they have had in the past, what they have had, where and when. Perhaps they may not completely understand the treatment they have had and the products they were treated with. Some just say they know they have ‘had fillers somewhere’. Correcting these patients without this information means you are treating blindly.
Contacting the original practitioner is often not an option; we need patient permission due to patient confidentiality. Patients often don’t want the practitioner contacted for fear of reprisal. Even with patient permission, it is a delicate issue to confront a peer, and they may feel angered, embarrassed and defensive. Are you prepared to do this to get the information you need?
Before even considering treating a patient complication from another practitioner, I imagine myself in front of a judge or the Nursing and Midwifery Council (NMC) fitness to practice panel, trying to defend my decision to treat. To have my professional practice picked to pieces and my registration held to question for merely trying to help out another practitioner’s patient makes me think twice before I agree, and ensures I carry out due diligence.
There are always exceptions
There are often valid reasons why the patient may turn elsewhere for help; they may have been left in a vulnerable position or the initial practitioner may not be supportive. I read and hear widely of poor practice with practitioners being dismissive, defensive, avoiding communication and even turning the patient away.
The patient may lose confidence and faith in a practitioners’ skills following a problematic treatment. There may be a personality clash and, even though that practitioner is qualified and capable of correcting, the patient just doesn’t want to go back to them. Then there are those practitioners who were not qualified to treat in the first place, and therefore sending the patient back to them could be disastrous and requires deeper ethical consideration.
The counter argument
So, should we leave these patients with nowhere to turn? Of course not. The patient’s wellbeing is at the heart of what we do and if we have the skills to care for them then it could be argued that it is negligent not to. I do not personally believe it is negligent, but I do believe it is wrong if we turn the patient away without offering support and directing them to others who may be more experienced to help and are happy to take the patient on. Remember we do have an obligation to protect ourselves firstly.
For those merely unhappy with the appearance, and the outcome was not what they expected (not a reportable adverse event) then we must consider closely all the issues. The treatment may be not what they wished, their expectations may have been too high and we may not be able to improve to their satisfaction.
Considerations also to take into account are; what were they like before treatment?, Do they understand that dissolving a product will take them back to what they looked like before treatment? Sometimes worse? Consultation therefore must be thorough, as other problems could occur if they still don’t have the result they expected. There is also the added financial cost for the patient to understand.
Alternatively, there may be an occasion when we are faced with a severe complication of someone else’s doing requiring immediate action, such as a clear impending or acute vascular compromise.
The swift use of hyaluronidase to alleviate and stop its progression prevents a more serious complication occurring. It can also reduce soft tissue compression in the case of swelling when triggered by a non-HA treatment too, so as an emergency treatment, we would be well supported in opting to treat.
The way forward
I believe it is vital to surround ourselves with a multi-disciplinary team of experts, and our regulatory bodies, the General Medical Council (GMC) and NMC, expect us to.
I believe you need to treat each situation on a case-by-case basis. I don’t think you can completely say ‘no, I don’t treat other people’s problems’ or ‘yes, that is what I do’ as each case presents different issues.
I would like to see a culture of engaging with all practitioners and sharing records to become normal practice for the sake of the patient and ourselves. A formal tri-partide partnership or access to documentation, would enable others to have full disclosure.
Having a complication should not be seen as a badge of shame (unless it becomes a frequent occurrence). These things happen in every type of medical treatment and individual lessons can be learnt. Caring for our patients completely, including complete support post treatment, is expected by our regulators and swift management of a complication can usually stop it escalating and becoming someone else’s challenge.
It is a very challenging issue but there are expert groups in the industry, such as the Aesthetic Complication Expert (ACE) group, who can offer support to practitioners faced with complications. Professional associations have regional groups across the country and those within the BACN, for example, are exceptionally supportive should complications arise.
When adopting someone else’s problem the transfer of responsibility for that patient becomes ours and we will be held accountable for any treatment we give, so don’t be too cavalier in accepting a complication unless you know what’s happening under the veil of the skin and are certain you can improve the situation.
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