New ethical guidance from ACP for patient-physician-caregiver relationship

The American College of Physicians (ACP) has issued a position paper to guide ethical relationships among patients, physicians, and caregivers.

The Journal of General Internal Medicine has published "Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships." The text and an online appendix of resources to help physicians manage relationships with patients and caregivers are available at http://www.acponline.org/running_practice/ethics/issues/policy.

"The ethical guidance outlined in this paper is intended to heighten physician awareness of the importance and complexity of the patient-physician-caregiver relationship," said ACP President Joseph Stubbs, MD, FACP. "It is essential for physicians to consider quality of life for both patients and caregivers."

The paper -- endorsed by 10 other professional medical societies -- defines caregivers as relatives, partners, friends, and neighbors of patients who assist with activities of daily living and complex health care needs. It outlines four primary principles for physicians, who may face ethical challenges collaborating with patients and caregivers while preserving the primacy of the patient-physician relationship:

• Respect for the patient's dignity, rights, and values should guide all patient-physician- caregiver interactions.
  
• Effective communication and physician accessibility are fundamental to supporting the patient and family caregiver.
  
• The physician should recognize the value of family caregivers as a source of continuity regarding the patient's medical and psychosocial history and facilitate the intellectual and emotional transition to the end stage of serious chronic illness.
  
• When the caregiver is a health care professional, the physician should draw appropriate boundaries to ensure that the caregiver is not expected to function in a professional capacity in relation to the patient and that the caregiver receives appropriate support, referrals, and services.

"Patients depend on caregivers for assistance with managing complex care and communicating with health care professionals," said Virginia Hood, MBBS, MPH, FACP, chair of ACP's Ethics, Professionalism and Human Rights Committee. "Physician recognition of the value of the caregiver role may contribute to a positive care giving experience and decrease rates of patient hospitalization and institutionalization."

Although hospice and palliative care address the impact of illness on both patients and families, the authors write, historically the patient-physician relationship has focused on the patient and his / her rights and interests with less attention to the patient's experience within the context of his / her family and social relationships. Contemporary bioethics with its emphasis on patient autonomy and confidentiality has supported this model but is beginning to recognize the need for a family-centered approach.