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Ethical Question - using one patient's observations to inform treatment of another patient


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I had a friend tell me this question, and I'd like to see your guys opinions on an appropriate response: You are a physician, and your 40 year old patient comes in for a checkup. During this time, he mentions that he is becoming concerned about his 70 year old mother, who also happens to be your patient. He says that he has noticed that sometimes at home, she is unaware and unobservant of the things going on around her, and is sometimes in a bit of a daze, and he wonders if she should be allowed to drive. He wants you to assess his mother. When she comes in later that week and you talk with her, she does not seem unaware/unobservant.

I'm a bit confused on how far we can push the issue. I know that driving is a public safety issue, and if someone is unfit to drive, you have a duty to report that information. However, in this case, there is nothing to indicate that she is unfit to drive. Is it okay to rely on her son's observations and probe the mother a bit further (more than you would had the son not mentioned anything) in order to see if there is anything amiss? What if she starts getting defensive and making accusations against you and stating that you're 'out to get her license revoked'. Is it appropriate to let her know that her son has shared with you some concerns about her, and you're just following up on them? Any help would be appreciated, thanks!

 

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OK, so I'm just spitballing here, but: if she has agreed to come see you and does come of her own volition, I think it's very likely that her son has already communicated his concerns to her, at least in some limited capacity- people typically don't go to the doctor if they think everything's OK. As the son is also your patient, I think your conversations with him are protected by confidentiality in this case, so I don't think it's appropriate to share that he gave you the information without his prior consent. But you can still use that knowledge in informing your clinical assessment. You can start by asking questions about what brought her in today (i.e. seeing what she thinks the problem is) and build from there. For example, maybe she's noticed these episodes of disorientation too, and is ready/willing to talk about them with you without further prompting about your conversation with the son. If she genuinely has no idea why her son asked her to come in, that does present a challenge, but I think you could do something like talk to her about the importance of early dementia screening and build from there without breaching the son's confidentiality.

It's also important to consider that there are conditions that can cause temporary confusion in seniors (e.g. UTI). So it's genuinely possible that the son observed his mother's confusion but you don't observe any confusion a week later in your exam. Conduct a comprehensive global assessment to evaluate possible causes of confusion/disorientation and if you don't find any evidence that she's not safe to drive, then I don't think there's any cause to revoke her license. While the son's concerns are important and should be investigated, medicine can't be practiced on speculation- our actions need to be grounded in objective evaluation and/or substantiated by evidence. If you did revoke her license but didn't have the evidence to back it up, she would have every reason to believe that you are "out to get her license revoked", and it's very likely that your actions wouldn't stand up to professional/legal challenge. The son's concerns, while valid, are effectively hearsay in this context and don't constitute meaningful evidence in and of themselves. However, you can still follow up with her on this issue on a future visit to see if the confusion has progressed/developed, and then reevaluate possible next steps if your findings cross a clinical threshold. 

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On 2018-03-12 at 3:25 PM, mew said:

While the son's concerns are important and should be investigated, medicine can't be practiced on speculation- our actions need to be grounded in objective evaluation and/or substantiated by evidence. If you did revoke her license but didn't have the evidence to back it up, she would have every reason to believe that you are "out to get her license revoked", and it's very likely that your actions wouldn't stand up to professional/legal challenge.

The answer above is excellent.

The only time you can break confidentiality is if there a harm to self or others. You need to investigate the claims, but if your assessment reveals no signs of confusion or mood disorder (or suicidal thinking for example), then you cannot revoke her license.

You could always suggest a drive test, and she passes that then you have done your duty.

You have to be very careful in these situations not to take sides and to stay objective. What if he  has a grudge against his mother for example?

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