Treating Family: Liability, Ethics, and Professionalism March 12, 2024 Practice Management, RCMA, Resources, Risk Management 0 This informative article is provided by ProAssurance Download Article Introduction A physician-patient relationship exists solely for the patient’s benefit.1,2 The very first code of medical ethics drafted by the American Medical Association (AMA) in 1847 recommended against physicians treating family members, stating, “the natural anxiety and solicitude which he [the physician] experiences at the sickness of a wife, a child . . . tend to obscure his judgment, and produce timidity and irresolution in his practice.”3 In addition to the current AMA code of ethics, several major medical professional associations generally discourage the provision of medical care for family members.4 Research indicates that treating family is common among physicians.5 When physicians have been surveyed about their perceptions of the benefits of providing care to family, they most commonly cite convenience, cost saving, and their perceived greater knowledge or concern for the patient than colleagues.6 These beliefs align with the ethical principal of beneficence. But good intentions can violate other ethical principles (e.g., nonmaleficence and autonomy); increase the risk of liability and professional misconduct allegations; and instigate familial, social, and workplace conflict.7 Consider the potential outcomes of the following issues that are more likely to arise during the treatment of family: 8,9,10,11,12,13 Questions about sensitive issues may not be asked (e.g., sexual history, drug use, pregnancies, etc.). Intimate aspects of a physical examination may be avoided. Counselling on sensitive issues may be limited or absent. Overtreatment may occur to avoid error, omissions, or delays in healing. Physical examination may be absent or inadequate, and performed without proper equipment. Necessary tests or studies may be avoided because they will cause patient discomfort. Treatment provided may be outside of the physician’s area of expertise and training. Documentation may be absent or inadequate. Medical information may be shared with others in the family or social group. The informed consent process may be absent or abbreviated. Poor prognoses may not be adequately disclosed. The patient may withhold sensitive information due to embarrassment. Furthermore, a physician-patient relationship is formed with family when consultation or treatment occurs. Like any other physician-patient relationship, the duty of care continues until the professional relationship is ended. Unlike traditional patients, after the physician-patient relationship with a family member ends, the personal relationship continues, which—particularly if there is a bad outcome—can create challenges for both the patient and physician. It should be noted, there are emergency and isolation exceptions to ethical prohibitions against treating family.9 For example, in cases of emergency or disaster, it would be unreasonable to expect a physician to avoid providing care because of a pre-existing familiar relationship. It may also be difficult for the family of a physician to find alternatives in a small town with limited healthcare options. In these cases, the well-being of the individual needing medical treatment would outweigh the ethical issues.14 The AMA also makes an exception for short-term, minor problems.9 That being said, physicians should treat their family members in the same manner as they would any other patient under the same or similar circumstances. The case study below is based on a closed medical malpractice claim. It is presented to illustrate how the treatment of family members can and does prompt medical liability claims and medical board disciplinary actions. Strategies are provided for supporting the separation of personal and professional obligations with the objective of maintaining patient safety and reducing liability risk. Case Study Allegation: The physician’s negligent prescribing caused the wrongful death of her daughter. A family physician (FP) started treating her daughter in 2001, when she aged out of health insurance coverage on her parents’ plan and would otherwise not be able to afford the medical care to which she was accustomed. The family physician considered herself her daughter’s primary care physician. She managed her daughter’s acute illnesses (urinary tract infections, sinus infections), and she also prescribed medications for her chronic conditions (lower back and neck pain, depression, anxiety, and insomnia). The physician did not perform annual physical examinations, but referred her daughter for various issues, including gynecology exams and mammograms. Her daughter did not schedule appointments with her mother, but if she had a medical issue, they would arrange to meet after the end of the workday in her mother’s office. The practice was located in a small community where patients and staff moved in the same social circles, potentially causing a patient's medical information to be quickly disseminated throughout the community. An earlier privacy breach had resulted in her daughter’s abusive former partner discovering her medical information. Although privacy education had been provided and disciplinary actions had been taken, the FP was not entirely convinced that she could trust her staff. The physician’s daughter worried that the practice staff would share her medical information with members of the community again, so the FP accommodated her daughter’s request for privacy by not creating any treatment records after 2012. In 2015, the physician’s daughter drove off the road and ran into a building. She died at the scene. Multiple prescription medications were found in her system on autopsy, including therapeutic levels of oxycodone and carisoprodol, and a potentially toxic level of lorazepam. For reasons she could not adequately explain later, the physician had denied that her daughter was taking any prescription medications when initially questioned by the police. The police started an investigation of the decedent’s mother, since pharmacy records indicated she was the prescribing physician of the medications found in her daughter’s system at death. Medication bottles listing the physician as the prescriber were found in her daughter’s bedroom and bathroom and collected by the police for evidence. While the criminal investigation was moving forward, the decedent’s husband and sister filed a wrongful death lawsuit, alleging the defendant’s negligent prescribing was the cause of death. The state medical board also opened an investigation into what they alleged was unprofessional conduct. The medical board claimed the defendant’s treatment of her daughter was an “extreme” departure from the standard of care, citing pharmacy records that indicated during the year prior to the patient’s death, she was prescribed 156 tablets of 250 mg carisoprodol, 156 tablets of 2 mg lorazepam, and 120 tablets of 10 mg oxycodone monthly. They further claimed the medications were prescribed with no diagnostic assessment, no referral to specialists, and no pain medication agreement. They requested the revocation of the FP’s license. Discussion There were various theories about why the daughter’s car left the road, and whether the physician’s prescribing practices caused or contributed to her death. The plaintiffs’ experts contended the patient lost control of her car and crashed due to her sedation from medications. They noted there was no evidence the patient had been warned not to drive while taking the various medications prescribed by the FP, which was a violation of the standard of care. They further opined, based on the drugs in the patient’s system at autopsy, that the defendant prescribed an excessive amount of the medications, which was a violation of the standard of care. The defense argued the combination of lorazepam, carisoprodol, and oxycodone was concerning for the sedating effects but was not contraindicated. Furthermore, the patient had most likely developed a tolerance for these drugs (judging from her monthly refills of prescriptions for them over the past several years), which might have reduced the sedating effect of the medications. They would argue that there was a good possibility something other than sedation while operating the vehicle had caused the accident. Unfortunately, lack of medical record documentation made it difficult to advance this defense. It also made it difficult to prove the patient was receiving appropriate follow-up care relative to her multiple medications, and that the patient was advised not to drive while taking the medications. The defendant physician wholeheartedly believed she was providing the best medical care possible for her daughter. Although she did not document it, or recall specifically asking about it, she believed her daughter was taking her medications as directed. She denied any knowledge of her daughter driving while she was sedated from the medications. She also believed her daughter was well aware of the dangers of driving under the influence. However, she had to admit her daughter was likely driving every day while taking a combination of sedating medications. The FP reported her daughter did not appear intoxicated on the day of the accident shortly before she got into the car. However, she had had an intense argument on the phone with her husband and, as a result, most likely was distracted when she went off the road. The FP’s perceptions and testimony about her daughter’s prescription drug use differed significantly from that of her son-in-law and other daughter. The decedent’s sister reported to the police that the decedent frequently drove under the influence of drugs prescribed by her mother. She considered her sister a menace on the road. She would not allow the decedent to babysit for her due to her frequent, obvious intoxication, which she assumed was caused by pills, since the decedent was not known to drink alcohol. The decedent’s husband also told the police his wife was not a drinker but that she had been recently arrested for driving under the influence, which she later explained had been caused by her medications. In the husband’s opinion, the FP had been overmedicating his wife for years. He frequently observed his wife’s intoxicated behavior, which included slurring her words and otherwise being obviously intoxicated. When he had confronted his mother-in-law regarding her prescribing practices for his wife, the FP blamed the apparent intoxication on low blood sugar. The defense team did not believe the chances of prevailing in civil court were strong, based on the evidence already discovered in the criminal action. Settlement prior to the family members being deposed was in the defendant physician’s best interest, given the evolving criminal and disciplinary actions against her. Risk Reduction Strategies Although physicians may consider themselves the best choice for family member medical care, emotional investment can make it easy to lose perspective.15 Family members with psychiatric diagnoses and pain management needs should be treated in the same manner as any other patient, which might include referral to specialists when their care requires a greater training and expertise. In addition to being ethically complicated, and/or violating the standard of care, prescribing controlled substances to family members may be deemed unprofessional conduct by a medical board.16 When approached to provide consultation or treatment to a family member, consider the following:11,17 Urge family members to seek care elsewhere when other qualified physicians are available. As an alternative: Use your knowledge or contacts to refer the person to another physician. Serve as an advisor or health literacy aide by suggesting questions to ask, explaining medical terminology, accompanying the individual to appointments, and advocating for the individual when healthcare recommendations or care provided are inadequate. If there are no alternatives and a family member must be treated, assess and treat the family member like any other patient. To gauge your risk of violating the standard of care, ask yourself the following questions: Do I have the training and expertise to diagnosis and treat the condition? Can I be objective? Will my family member and I be comfortable completing an appropriate physical examination and history? Will I be able to refrain from taking short cuts during the diagnostic process? Explain the policies that govern patient appointments, insurance payments, and prescriptions, and follow the policies as you would for any other patient. Create a medical record for the family member, and then protect your family member’s health information privacy. Carefully consider whether it is appropriate, legal, and within the standard of care to prescribe any medications; including narcotics, stimulants, and other highly addictive prescriptions to family members. Conclusion Prior or current social or emotional attachment to patients―particularly patients who are family―can disrupt professional objectivity and weaken the primacy of the physician-patient relationship during a medical encounter. The disequilibrium can cause or contribute to patient injury. For example, emotional proximity can result in inadequate history and examination, and over- and under-treatment. Patient autonomy may also deteriorate, as family members may not feel comfortable questioning or declining care, and risks and alternatives may not be fully described. Furthermore, tensions may develop when patient and physician do not have a mutually implicit or explicit understanding of the expectations and limits of the treatment relationship. When a treatment outcome is unexpected, these issues can contribute to an individual’s choice to file a legal or medical board claim. As family members are often treated with a more casual approach, lack of documentation and lack of informed consent can complicate the defense. Consequently, when family members seek medical advice or treatment, and alternatives are not available, they should be treated with the same professional expertise and judgment as any other patient. Download Article Endnotes 1. Glen O. Gabbard and Carol Nadelson, “Professional Boundaries in the Physician-Patient Relationship,” Journal of the American Medical Association 273, no. 18 (1995): 1445–1449, doi:10.1001/jama.1995.03520420061039. 2. Leslie Fallowfield et al. “Blurring of Boundaries in the Doctor-Patient Relationship,” The Lancet Oncology 15, no. 13 (2014): 1423-1424, doi:10.1016/S1470-2045(14)71122-2. 3. American Medical Association, Code of Medical Ethics, (Chicago: American Medical Association, 1847), chapter 2, article II. 4. John C. Moskop, “Doctor in, and for, the Family?: Physicians Reflect on Care for Loved Ones,” Narrative Inquiry in Bioethics 8, no. 1 (2018): 41-46, doi:10.1353/nib.2018.0021. 5. Esther Giroldi et al., “Family Physicians Managing Medical Requests from Family and Friends,” Annals of Family Medicine 16, no. 1 (2018): 45-51, doi:10.1370/afm.2152. 6. Jonathan Scarff and Steven Lippmann, “When Physicians Intervene in Their Relatives' Health Care,” HEC Forum 24, no. 2 (2012): 127-37, doi:10.1007/s10730-011-9174-5. 7. Heidi Moawad, “The Joys—and Dangers—of Doctors Treating Family and Friends,” Expert Insights, Wolters Kluwer, February 7, 2020, https://www.wolterskluwer.com/en/expert-insights/the-joys-and-dangers-of-doctors-treating-family-and-friends. 8. Gregory L Eastwood, “When Relatives and Friends Ask Physicians for Medical Advice: Ethical, Legal, and Practical Considerations,” Journal of General Internal Medicine 24, no. 12 (December 2009):1333-5, doi:10.1007/s11606-009-1127-1. 9. “Treating Self or Family: Code of Medical Ethics Opinion 1.2.1,” American Medical Association, accessed July 25, 2022, https://www.ama-assn.org/delivering-care/ethics/treating-self-or-family. 10. Abigail Zuger, “The ECG Is Not Normal,” PSNet, Agency for Healthcare Research and Quality, June 1, 2011, https://psnet.ahrq.gov/web-mm/ecg-not-normal. 11. Lois Snyder Sulmasy and Thomas A. Bledsoe for the ACP Ethics, Professionalism and Human Rights Committee, “American College of Physicians Ethics Manual: Seventh Edition,” Annals of Internal Medicine 170, no. 2 Supplement (2019): S1-S32, doi:10.7326/M18-2160. 12. Committee on Bioethics, “Policy statement―Pediatrician-Family-Patient Relationships: Managing the Boundaries,” Pediatrics 124, no. 6 (December 2009): 1685–1688, doi:10.1542/peds.2009-2147. 13. Joel Martin Geiderman, Catherine A. Marco, and Kenneth V. Iserson, “Emergency Physician Care of Family Members, Friends, Colleagues and Self,” American Journal of Emergency Medicine 37, no.5 (May 1, 2019): 942-946, doi:10.1016/j.ajem.2019.01.046. 14. Colin Hutchison and Paul C. McConnell, “The Ethics of Treating Family Members,” Current Opinion in Anaesthesiology 32, no. 2 (April 2019): 169-173, doi:10.1097/ACO.0000000000000687.> 15. Katherine J. Gold et al., “No Appointment Necessary? Ethical Challenges in Treating Friends and Family,” New England Journal of Medicine 371, no. 13 (September 25, 2014): 1254-1258, doi:10.1056/NEJMsb1402963. 16. See, for example, Ala. Admin. Code 545-X-4-.06 (12), https://casetext.com/regulation/alabama-administrative-code/title-545-medical-licensure-commission-of-alabama/chapter-545-x-4-miscellaneous/section-545-x-4-06-unprofessional-conduct. 17. Crystal Conde, “Treating Your Own,” Texas Medicine 107, no. 10 (October 2011): 33-36, https://www.texmed.org/template.aspx?id=22563. Comments are closed.
