Personal Views Personal views

Great expectations: a relative dilemma

BMJ 2001; 323 doi: http://dx.doi.org/10.1136/bmj.323.7325.1375 (Published 08 December 2001) Cite this as: BMJ 2001;323:1375
  1. Tom Cawood, senior house officer (tcawood{at}dialstart.net)
  1. North Glasgow NHS Trust

    As a busy ward doctor I was finding it increasingly difficult to perform my clinical duties while also satisfying the multiple requests to speak to patients' relatives. At visiting time I walked faster than usual down the ward, eyes fixed firmly on the floor. Talking to relatives is an important part of the delivery of good patient care, but it takes time. Not only does it disrupt already tight working patterns, but also it often requires care, experience, and sensitivity. It is not easy to conduct an emotionally demanding interview, while respecting the patient's rights to confidentiality and addressing relatives' questions, fears, and anger.

    The ward could not safely function if the doctor spent 90 minutes a day talking to relatives

    Doctors spend an important amount of their time talking to patients' relatives. In an increasingly demanding NHS good communication has never been so crucial. The time spent talking to patients' relatives is time not spent attending to the other demands placed upon hospital staff. Improved communication should lead to improved service provision, but if there are numerous family members, each demanding details on separate occasions, at what point do these demands become unrealistic and possibly compromise patient care?

    It is difficult to find clear guidance on how much time doctors should spend talking to relatives. The Hippocratic Oath contains valuable guidance on confidentiality: “Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.”

    However, there is nothing in the Hippocratic Oath about responsibilities to patients' relatives. The General Medical Council's Duties of a Doctor states that the care of the patient should be the first concern. In October 2000 I wrote to the GMC asking for guidance on what doctors' responsibilities towards patients' relatives are. The GMC is currently considering my inquiry and will reply in more detail as soon as possible.

    How much time do you spend talking to relatives? Is this time sufficient for you and/or the relatives? While working in an acute geriatric assessment ward I made a record of interviews with relatives and found that I spent 31 minutes a day talking to relatives. This did not include time preparing for interviews, time spent documenting each interview in the case notes, and time spent discussing the interview content with nursing staff. Balancing performing my clinical duties and finding this time was difficult and a source of much stress. To determine whether the relatives felt that they had enough time to speak to the ward doctor we sent questionnaires to a sample of relatives who documented that they would require 1.6 interviews a week. The interviews actually lasted 12.3 minutes and, calculated on a pro rata basis, this would total 87 minutes of interview time each day. The ward simply could not safely function if the ward doctor spent nearly 90 minutes talking to relatives each day.

    Interestingly, 100% of relatives who answered our questionnaire thought that they were entitled to know “most” or “all” of the information regarding their relative; 75% thought that they were still entitled to this amount of information, even if their relative was opposed to any member of his or her family being informed.

    Doctors hold private and sensitive information about patients. This must not be given to others unless the patient consents or when disclosure can be justified. Reasons for such disclosures include protection of patients or others from risk of death or serious harm, and the public interest, which ultimately only the courts can determine. There is evidence that, as a profession, we do not always practise what we preach with regard to patient confidentiality. A study conducted in the elevators of American hospitals reported that hospital staff were overheard to breach patient confidentiality during 7% of elevator rides that offered opportunity for conversation (American Journal of Medicine 1995;99:190-4). Not only should the medical profession be constantly reminding itself of the issues of patient confidentiality, but there is a strong argument to try to further educate the lay public so that misunderstandings of entitlement to information do not get in the way of good communication.

    The results of my study were recently presented at a clinical meeting. It quickly became apparent that my own difficulties were common to most hospital doctors in the room. I also suspect that most relatives who read this article will have experienced difficulties trying to find a doctor with time to explain what is happening. The experience of the family faced with the terminal diagnosis of a loved one, who eventually managed to speak for five minutes to a tired doctor whose pager kept bleeping, is probably a common one. It is perhaps not surprising that such interviews can be deeply distressing for all concerned.

    Footnotes

    • I would like to thank E Spilg and J MacDonald, consultant physicians, medicine for the elderly, Gartnavel General Hospital, Glasgow, who helped with the study and this article