The Physician’s Obligation to Family Caregivers

Limits on the physician-patient relationship by Jalayne J. Arias, JD, MA

FAMILY CAREGIVERS provide an incredible amount of support to patients and serve as an integral part of healthcare delivery. In 2009, more than 42 million Americans served as caregivers. The American Medical Association estimates that family caregivers provide 80% of community care at an economic value of $200 billion annually. This support, however, is matched by adverse physical, psychological, and spiritual effects characterized as “caregiver burden.” Reports of negative psychological effects experienced by caregivers include depression (39%), anxiety (40%), anger, resentment, fatigue, and sleep deprivation.

A recent trend towards “family-centered” care for elderly, pediatric, and chronically ill patients alters clinicians’ relationships with family member caregivers. As a result, caregiver burden may be considered a factor in treatment approaches. Clinicians’ duties must be evaluated when caregiver burden (1) causes physical and psychological harm in the caregiver, or (2) reduces quality of care for patients.

Physical and Psychological Harm
Caregivers have higher rates of physical morbidities than their non-caregiver counterparts. For example, caregiver burden in spouses increases the risk for coronary heart disease and increases the rate of emergency department visits or hospitalization. Most important, negative psychological and physical consequences are compounded by the caregivers’ neglect of their own needs and health in response to their duties. Recent literature and policy statements have emphasized the importance of assessing caregivers and family members for signs of stress and burden. However, these statements fail to characterize a physician’s duty to address caregivers’ needs.

Civil liability, as determined in medical malpractice claims, requires that, (1) the defendant (physician) owes the plaintiff (caregiver) a duty; (2) the duty has been breached; and (3) the breach causes injury. Numerous jurisdictions have extended the reasoning supporting a clinician’s duty to a third party established in Tarasoff v. The Regents of the Board of California. Under this seminal case, the Court found the mental healthcare provider had a duty to warn the third-party about the immediate risk of danger from the patient. In those jurisdictions, a clinician’s duty to address caregiver burden may be an extension of Tarasoff. However, the Illinois Supreme Court has explicitly declined extension of this reasoning. Instead the Court has held that a plaintiff cannot maintain a medical malpractice action against a physician “absent a direct physician-patient relationship” or a “special relationship.” Under this reasoning it is unlikely that a clinician would be found to owe a duty to family caregivers absent a “special relationship,” unless a patient-physician relationship has been otherwise established.

Reduced Quality of Care
Caregiver burden can lead to diminished care for the patient and dangerous or abusive behaviors. Depressive symptoms and resentment in caregivers have been associated with self-reported “potentially harmful behavior.” Such behavior may include psychological harm (e.g., yelling at the patient) or physical harm (e.g., slapping the patient). Potentially harmful behaviors were heightened when the caregiver experienced psychological stress along with anger.

Under the traditional healthcare model, a physician owes a patient numerous primary duties (e.g., maintaining confidentiality). These duties are established through the physician’s fiduciary duty. They may include the duty to provide the caregiver with sufficient information and training to care for the patient. While a physician’s duty to address caregiver burden that results in compromised care may be unclear, a clinician has the duty to report incidents of abuse. This duty is triggered when treating a patient for an injury stemming from physical abuse or if there is suspected abuse of a child or adult protected by adult protective services. Abuse may include physical, verbal, or financial abuse. Under Illinois law, clinicians are protected from civil and criminal liability when they make reports in good faith. Conversely a failure to report abuse may result in referral to the Illinois State Medical Disciplinary Board.

Conclusion
Researchers and clinicians have identified numerous interventions, including referral to a specialist or support and advocacy groups offering necessary services (e.g., respite care), training for caregivers to reduce anxiety associated with medical care, and counseling or psychological services. However, clinicians will continue to be challenged by caregivers’ needs. Incorporation of caregivers’ need will require continued evaluation of the legal duties owed or triggered by a “family-centered” approach.

The author is a fellow in advanced bioethics at the Cleveland Clinic.