One Dozen Things
The Role of the Patient’s Family
Scenario Analysis
This scenario deals with the role of the patient’s family in health care decisions, particularly in situations where the patient is elderly. As the doctor is about to explain treatment options to the patient, her adult daughter, who has accompanied her on the visit, interrupts and asks to speak to the doctor outside of the examination room where her mother cannot hear.
The doctor agrees, and when they are out of the room the daughter proposes that she assume all decision-making responsibility with regard to her mother’s medical management. The daughter explains that her mother gets very upset and worried around doctors and implies that her mother would not be comfortable with receiving information or making decisions. The doctor questions whether the patient would actually prefer such an arrangement, and the daughter responds, “Trust me, I know my mother.”
In some cultures, such an arrangement would be entirely acceptable, even expected, both by the family and the patient. As a sign of deference or respect for the elderly, families may attempt to spare them the burden and discomfort of dealing with unpleasant medical information or making difficult decisions and may assume those roles for them. So a request like this daughter’s might not seem unusual to a physician coming from a culture where such practice is common.
In U.S. medical practice, it is the wishes of the patient that are most important. If the patient does indeed prefer to have her daughter act as her medical decision-maker, that would be acceptable, provided that such a preference be stated clearly and freely by the patient herself without pressure from the family. Obtaining the mother’s consent for this arrangement in an ethical and proper manner might require a one-on-one conversation with the patient without any members of the family being present. If, and only if, you are convinced that this is the patient’s choice, you then may proceed to manage the patient’s care with a family member serving as intermediary. It is important to document the patient’s expressed wishes in her medical record.
If the patient does express a desire to defer to her family, the situation may become complicated if more than one family member wants to play the role of decision-maker or there is disagreement among family members regarding the best course of action. In such a case, it may be necessary to go back to the patient for clarification of which family member she prefers to serve as the primary decision-maker.
If the patient expresses a desire to be informed of her condition and participate in making decisions about her medical care, her wishes must take precedence over the family’s preference. This could lead to a difficult confrontation with the family. In such a situation it is important for you to serve as a patient advocate and try to ensure that the patient is not pressured or intimidated by the family.
If the patient continues to take responsibility for her own health care, it is also important to respect the patient’s confidentiality. Unless the patient indicates that it is all right to do so, information about the patient’s condition should not be shared with family members.
All of this discussion assumes that the patient is, in fact, competent and capable of receiving information and making decisions. If the patient is not mentally competent, then another individual—possibly family, possibly not—must be legally designated to make such decisions. Ideally, such an arrangement would have been established previously through the use of a living will or a Power of Attorney (POA).
