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Confidentiality and the Family: 5 Guidelines for Better Outcomes

on Saturday, 20 April 2013. Posted in General

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Confidentiality and the Family: 5 Guidelines for Better Outcomes

By Michael Ascher, MD, Justine Wittenauer, MD, Alison Heru, MD, and Ellen Berman, MD |April 11, 2013

 
Dr Ascher is MD a fourth-year Resident in the department of psychiatry and behavioral sciences at Beth Israel Medical Center, New York. Dr Wittenauer is a third-year Resident in the department of psychiatry and behavioral sciences at Emory University, Atlanta, Ga. Dr Heru is Associate Professor in the department of psychiatry at the University of Colorado, Denver. Dr Berman is Clinical Professor in the department of psychiatry at the University of Pennsylvania in Philadelphia.
 

Families  are an underutilized resource in psychiatric practice. Given the current practice of brief hospitalizations,  families are expected to provide more illness monitoring and in-home care. When  family members are included and welcomed as members of the treatment team,  patient care improves and the psychiatrist’s job is easier. Reaching out to  the families of patients can help psychiatrists generate clearer diagnostic  formulations, develop more effective treatment, and plan for emergencies.

What  should psychiatrists do when patients don’t give permission to contact their  families?

Many  psychiatrists erroneously believe that the sharing of information with others,  without the patient’s explicit consent, is prohibited by the Health Insurance  Portability and Accountability Act (HIPAA). HIPPA violations may have serious  consequences, so it is important to have a clear understanding of what the  HIPPA 45 CFR 164.510(b) rule entails as well as its intended use.1  The following information is extracted from the website of the US Department of  Health and Human Services and provides  guidance for health care providers. Here are some guidelines:

(1)  Health care information may be shared with relevant individuals present when  the patient has given prior approval, or simply does not object1

(2)  Asking a friend to be in the interview room provides the implicit right to  disclose information in their presence

(3)  Clinicians also have the authority within the Privacy Act to share information  based on their professional judgment, believing that there would be no  objection to its discussion. For example, a clinician may share information  about medication with those providing transportation from the hospital

(4)  If the patient is not present but has requested an individual to gather  information for him or her, or is incapacitated by an emergency, a physician  may once again use best judgment in sharing information. This may include a  proxy picking up of medications from the pharmacy or receiving other protected  information

(5)  Physicians should be aware of state laws within their region of practice that  may affect the use of the Privacy Act within scenarios of emergency or safety  concern

Using  these guidelines, family members (or friends) who accompany the patient can be  invited into the interview and the benefits of their inclusion explained. Most  evidence-based family interventions are psychoeducational, where illness  symptoms and treatments are explained and feelings and beliefs about the illness  are explored. When patients understand the goal of family intervention is  psychoeducational, they are more likely to agree.

Family  involvement is often misunderstood as being a hindrance to individuation, when  in fact family-oriented interventions can improve patient functioning, agency,  and autonomy. This is often the case when young adults are forced, because of  illness, to return home to live with their parents. The use of shared  decision-making may help the patients frame their long-term goals in line with  the goals of the family.2

Psychiatrists  can help the patient prepare for the family meeting. With a clear agenda, the  patient will be less anxious and be more accepting of family members working  with them. Psychiatrists can proceed, using one of the most underutilized  evidence-based interventions in psychiatry—family psychoeducation.

References 1. US  Department of Health and Human Services. Does the HIPAA Privacy Rule permit a  doctor to discuss a patient’s health status, treatment, or payment arrangements  with the patient’s family and friends? http://www.hhs.gov/hipaafaq/notice/488.html. Accessed  April 8, 2013. 2. Swindell JS,  McGuire AL, Halpern SD. Beneficent persuasion: pechniques and ethical  guidelines to improve patients’ decisions. Ann Fam Med. 2010;8:260–264.