Denise Neal, RN, BSN, MJ, CPHRM, FASHRM
Assistant Vice President, Risk Management Group
AWAC Services Company, a member company of Allied World
There are legal, ethical and organizational frameworks in place to define professional boundaries and to establish a safe working environment for patients and psychiatrists. Even with this framework in place, boundary issues are not black and white; they are often ambiguous and subject to judgment and interpretation. This ambiguity is fraught with risk and may lead to complaints to the medical board, ethics committees, and/or result in potential lawsuits or criminal liability.
This article is intended to provide psychiatrists with an understanding of several common boundary issues related to requests to treat multiple family members, friends, and/or family, which may compromise your duty of care and to provide risk management strategies to implement in your practice.
Treating Multiple Family Members
Dr. Smith was seeing Cindy for treatment related to her anxiety and concerns with her marriage. Cindy brought her husband to several sessions and completed care. A year later Cindy’s husband began to see Dr. Smith after losing his job and after several months started to discuss concerns regarding the strain losing his job has on his marriage. As you listen, you think back to what Cindy had said regarding the issues her husband is now discussing.
With the shortage of psychiatrists and the greater number of people seeking treatment, psychiatrists may be asked by a patient to treat more than one member of a family. Or you may be asked to treat a former patient’s family member such as seeing a husband and then later being asked to treat the wife. Psychiatrists should be cautious when considering whether to enter a treatment relationship with multiple family members. Consider how you will consent to treat an additional family member without breeching patient confidentiality.
All clinical decisions should be based on what is best for each individual patient. In each case, consider the potential risks including blurring the boundaries of the doctor-patient relationship, conflicts of interest, unauthorized sharing of information divulged in confidence, or forgetting which patient gave you the information.
It is important to consider the potential for compromising the quality of professional judgment and to strongly consider whether trust and a therapeutic alliance can be maintained with each respective patient.1 Most often it is in the best interest of everyone to encourage the family member to obtain care from a different psychiatrist and to document these discussions.
In some circumstances the psychiatrist may determine that the risks of treating the family members concurrently may be less than not treating them at all. This may occur when the psychiatrist treats those in underserved populations, practices in a rural area, or has specialized expertise that multiple family members require.2
If you decide to enter into a treatment relationship with multiple family members, it is important to be clear as to who is the patient, your role as the psychiatrist, the goals of treatment and to keep records of each patient individually. This will help to avoid confusion as to who is the patient, establish the duty of care, and help to avoid a lawsuit when a doctor-patient relationship did not exist.
Before entering into a treating relationship with multiple family members:
- Obtain written informed consent to treat from each patient. Include an explanation of the purpose of the proposed treatment, treatment goals, the role of the psychiatrist and potential risks, benefits and alternatives to the proposed treatment.3
- Set clear expectations including professional boundaries and what you expect from each patient.
- Inform each patient of any limits to confidentiality including any mandatory reporting requirements.
- When treating multiple family members address openly with each patient their concerns related to confidentiality and that this may interfere with the doctor-patient relationship.
- When a family member participates in care, make it clear that they are not the patient and will not have access to the medical record without the patient’s written authorization.
- To avoid a breach of confidentiality, obtain each patient’s written authorization prior to disclosing confidential information to the patient’s family member or others as required by federal or state confidentiality laws.4
Medical Records When Treating Multiple Family Members:
It can become very difficult to defend board complaints or lawsuits involving multiple family members when the patient record is not clearly identified or when records of multiple family members who are being treated are commingled.5 In order to avoid this, psychiatrists should be familiar with and follow the legal and ethical requirements for record keeping in their jurisdiction. Psychiatry records should be specific regarding the nature of the relationship and roles and responsibilities of the psychiatrist, the patient, and family members; and treatment provided to the family as a whole.6
A separate medical record should be maintained for each patient. Notes from a family member’s participation in a treatment session should be maintained on a separate page and separate from the patient’s individual treatment session notes. Keeping the notes separate will help maintain clarity in the record and ensure that only information regarding the patient is disclosed when the medical record is requested.
Prescribing for Family Members, Friends or your Friends’ Family Members
Your friend who is a primary care physician calls to ask you to write a 30-day prescription for Adderall for her son Mike who is leaving for college next week and ran out of his medication. Mike is unable to see his psychiatrist to get a renewal of his medication before he goes off to college. You have known Dr. Smith since medical school and are great friends with her and her family. You wrote a prescription one other time for Mike a year ago when he ran out and agree to write the prescription for 30 days of medication to get him through until he can see his own psychiatrist. Twenty-five days later you receive a court order compelling you to turn over your prescription and treatment records to the police at Mike’s college. You do not have a medical record and had not conducted a physical or mental status exam. Later you receive a letter from the Medical Board inquiring about your prescribing practices. After a year-long Board investigation into your prescribing practice and two interviews with the Board, you learn that the police broke up a party at Mike’s dorm and confiscated multiple bottles of prescription medications written for Mike by several physicians, including his mother, his mother’s colleague, his primary care physician and you.
It is not uncommon for patients to cross boundaries with requests for prescription medication. Patients may be manipulative or threatening when seeking prescription medication or medication refills. Patients may not be adherent or have limited adherence to taking medications or may not be compliant with follow up with ordered tests, lab work or monitoring. Patients may also cancel or no-show to follow up appointments and then ask for refills to get them to the next scheduled appointment, only to cancel or no-show again.
To be valid, a prescription for a controlled substance must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of his professional practice.7 When prescribing any medication in schedules II-V the physician/provider should follow minimum professional standards of care including issuing the prescription in the usual course of the physician’s professional practice, and within a physician-patient relationship. This includes taking an adequate medical history, conducting a physical and/or mental status examination and documenting the findings.8,9
During the COVID-19 crisis, the Drug Enforcement Administration (DEA), put into place emergency exceptions lessening the requirements for in-person visits when prescribing.10 It is important to keep in mind that the emergency exceptions are temporary.11 Under the exception, practitioners that utilize telehealth to conduct an initial medical evaluation before prescribing schedule II-V controlled substances must use an audio-visual, real-time, two way interactive communication system. Properly assessing the patient and their reaction to medications is especially important when the patient is on psychotropic medication. Psychiatrists should consider limiting the dosage until the patient can be evaluated prior to the refill, either in person or via telehealth.
When prescribing any medication, it is important to document discussions of the risks, benefits, and alternatives of the medication. Once prescribed, the patient should be monitored, including assessment and documentation of the effectiveness of the medication, whether or not the patient is experiencing side effects from the medication, continued discussion of the risks and benefits, and any lack of adherence to the treatment plan. When prescribing opioids there should be documented checks of the prescription drug monitoring program in compliance with your state’s law.
With requests such as the example request from Mike’s Mom, you need to consider your liability risks and whether the risks outweigh any favors for a friend. If you agree to prescribing the medication, you should require a telehealth or in-person appointment for evaluation, start a medical record to document your assessment and evaluation, prescription(s) given, and prescribe only the amount of medication needed to get Mike to his next evaluation and monitoring appointment. This may be a situation where you state that you just cannot order medications for anyone who is not your patient.
Boundary issues may lead to ethical complaints and legal issues if not properly addressed, managed and documented. Psychiatrists should follow the American Psychiatric Association and the American Medical Association Code of Ethics and seek guidance early from colleagues, mentors, or supervisors when concerns around boundary issues occur. Psychiatrists may also seek guidance from their professional organizations, ethics committee, risk manager, or legal counsel.
1 American Psychiatric Association. Opinions of the Ethics Committee on The Principles of Medical Ethics, A 17. APA 2020 Edition.
2 American Psychiatric Association. Opinions of the Ethics Committee on The Principles of Medical Ethics, A 17. APA 2020 Edition.
3 APA. Risk Management What You Need to Know When Treating Multiple Family Members. In Session with Allied World. Fall 2018 Edition. Volume 8.4.
4 U.S Department of Health and Human Services. Office for Civil Rights. HIPAA Privacy Rule and Sharing Information Related to Mental Health. Content last reviewed June 4, 2020. https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf (Last accessed 10/11/20).
5 APA. Risk Management What You Need to Know When Treating Multiple Family Members. In Session with Allied World. Fall 2018 Edition. Volume 8.4.
6 APA. Risk Management What You Need to Know When Treating Multiple Family Members. In Session with Allied World. Fall 2018 Edition. Volume 8.4.
7 21 CFR § 1306.04.
8 21 U.S.C. 829 (e).
9 DEA Diversion Control Division COVID-19 Information Page. Telemedicine. Accessed 10/9/20. While a prescription for a controlled substance issued by means of the Internet (including telemedicine) must generally be predicated on an in-person medical evaluation (21 U.S.C. 829(e)), the Controlled Substances Act contains certain exceptions to this requirement. One such exception occurs when the Secretary of Health and Human Services has declared a public health emergency under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D). Secretary Azar declared such a public health emergency with regard to COVID-19 on January 31, 2020 with an extension to January 2021. https://www.deadiversion.usdoj.gov/coronavirus.html
10 DEA Diversion Control Division COVID-19 Information Page. Telemedicine. Accessed 10/9/20. https://www.deadiversion.usdoj.gov/coronavirus.html