When a friend or relative comes seeking treatment, there is an important boundary to establish for the practitioner. Dr Patrick Clancy discusses what is at stake for all involved.
Ophthalmologist Dr K was phoned at midnight by a family member desperate for pain relief. They had run out of their medication and could not get an after-hours appointment. Dr K felt compelled to help
Five years later, Dr K faced criminal charges and findings of professional misconduct over prescribing and administering Schedule 8 medications for eight patients, including close family members.
Dr K’s story illustrates the reasons codes of conduct warn doctors and optometrists in Australia to try to avoid providing care to anyone with whom you have a close personal relationship.
Lack of objectivity and professional distance
It can be difficult to maintain objectivity if your role as a friend, partner or carer conflicts with your professional responsibilities.
You may feel pressured to provide treatment you would not ordinarily consider to be in the patient’s best interests.
With hindsight, Dr K acknowledged that in his desire to help he may have put patients at risk by continuing to prescribe outside his area of expertise.
He knew he should stop but felt “compelled by his sense of compassion” and acknowledged that it was only “by the grace of God, no one had been harmed”. Other cases where doctors have felt pressured to prescribe drugs of dependence have ended in patient deaths.
Legal and professional obligations
Under the code of conduct, doctors must not prescribe Schedule 8 medications, other drugs of dependence or psychotropic medications to family members. In South Australia, except in a verifiable emergency, prescribing Schedule 8 medications for family members is also against the law.
Doctors are also required to obtain relevant state and territory authorities or permits when prescribing drugs of dependence, something which Dr K failed to do.
Doctors can now also check Real Time Prescription Monitoring (RTPM) systems before prescribing drugs of dependence.
In some states and territories it is mandatory to do so.
Inaccurate diagnosis or inappropriate care
Doctors in similar situations have found a close relationship can compromise patient care in other ways.
Your knowledge of the patient may lead you to make assumptions. Or it can be awkward to take a complete history, ask sensitive questions or conduct an examination. In some cases, this has led to diagnostic error or inappropriate care.
Failure to record prescribing
Like other practitioners in his situation, Dr K considered this informal prescribing separate from his professional role and responsibilities. He failed to comply with his legal and professional obligations to keep appropriate records of his prescribing.
Even for lower-risk treatments and prescriptions, failing to comply with reporting obligations can lead to ethical dilemmas and potential harm.
Consider, for example, you were treating a family member who asked you not to make a record of a prescription or eye condition that may affect their ability to drive.
Discontinuity of care
Dr K did not inform the patients’ other treating practitioners of his prescribing. He made no plans to hand over care, nor did he conduct any further investigations or follow-up.
The tribunal highlighted this not only put patients at risk. It also breached his professional obligations to colleagues, putting them in the position of making treatment decisions without a full picture of the patient’s care.
Is treating family or friends ever appropriate?
In most cases, providing care to family or friends is avoidable. It is important to manage treatment requests from family members carefully. Have a policy in place or consider in advance how you will respond to these requests.
If faced with an emergency, you can provide care until another practitioner becomes available.
And if you find yourself in a situation where one-off treatment is unavoidable, ensure this does not lead to providing ongoing or regular treatment for anyone close to you.
The following tips can help manage prescribing requests from family or friends:
• Set boundaries and expectations about the treatment you will provide
• Be clear which medications you are authorised to prescribe
• Avoid informal consultations. If you need to treat family or friends, try to do so in a practice setting where you have time to make considered clinical decisions
• Always keep a medical record of any treatment provided
• Arrange follow-up if required
• Communicate with the individual’s treating practitioners about treatment you have provided.
About the Author: Dr Patrick Clancy, MBBS FRACGP MHlth&MedLaw is a Senior
Medical Advisor – Advocacy, Education and Research at Avant.