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ordering routine/acute studies for family?


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In regard to ethical considerations, there is not much of a difference between prescribing meds or ordering studies. The ethical concern is entering into a patient provider relationship with someone that you will have a hard time being objective with. It is very difficult to approach family members in the frame of mind you need to have with patients. A secondary concern is the temptation to do things without maintaining proper records which is illegal in most places.

 

And I would have concerns about handling potential bad news. What if you do an x-ray on your sister for a cough thinking it is pneumonia and you find metastatic cancer? That is not news you would want to break.

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Most MDs/PAs prescribe routine things for family from time to time, usually antibiotics. Laws vary by state but generally it's not verboten unless it's a controlled substance. 

 

As far as orders, ethically it is the same, but I would tread more carefully here. The question you have to ask yourself is what are you going to do with the result? Never order a test if you cant/wont address a potentially abnormal result.

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In regard to ethical considerations, there is not much of a difference between prescribing meds or ordering studies. The ethical concern is entering into a patient provider relationship with someone that you will have a hard time being objective with. It is very difficult to approach family members in the frame of mind you need to have with patients. A secondary concern is the temptation to do things without maintaining proper records which is illegal in most places.

 

And I would have concerns about handling potential bad news. What if you do an x-ray on your sister for a cough thinking it is pneumonia and you find metastatic cancer? That is not news you would want to break.

Thank you for the reply. =) something I want to say no to but it is getting harder..

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Most MDs/PAs prescribe routine things for family from time to time, usually antibiotics. Laws vary by state but generally it's not verboten unless it's a controlled substance.

 

As far as orders, ethically it is the same, but I would tread more carefully here. The question you have to ask yourself is what are you going to do with the result? Never order a test if you cant/wont address a potentially abnormal result.

Meds I have been firm not to order.. but for an xray or two, I sure was tempted. Never yet.. =). Thanks.

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Never know what you are going to find and how that may influence your relationship and professionalism. Yea I think the influenza and ankle inversion are going to be no problem 99.9% of the time. And I might be tempted to do it. But if that relative is embarrassed to divulge the IVDA last week or the unprotected, sex and you miss an acute HIV infection or order a medication that is contraindicated in someone hiding pregnancy .... that brother in law quickly becomes a plaintiff and ex relative. 

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This is not a good idea from a medicolegal standpoint.

Any clinician, Physician, PA, NP, has a duty to the patient to provide safe care and a continuity of care.

When anything is ordered or prescribed, a relationship is implied.

From that relationship is where one gets in trouble.

So a CXR is ordered, whom is responsible for the result?

A course of amoxicillin is prescribed, whom follows up when that fails or the patient has a side effect or allergic reaction?

A piece of medical equipment is ordered, whom justifies it when insurance wont cover?

This is a rabbit hole that can quickly turn into a nightmare.

Dont do it.

Personally, I tell anyone that seeks that from me that I am a supervised clinician and my scope of practice ends in the ED.

I will give advice on what family members should pursue or discuss with their PCP. 

But I dont serve as their PCP.

Your state medical board will also frown (or worse) on providing medical care to friends and family on the side.

Dont do it.

This a great example of where the public has no insight into the legalities and restrictions we face as health care professionals. Use this as an opportunity to educate them. 

When the response is 'no one will know' or 'just to help me out', they just dont get it. Be firm, this is your livelihood that potentially is at stake.

Good luck.

G Brothers PA-C

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This is not a good idea from a medicolegal standpoint.

Any clinician, Physician, PA, NP, has a duty to the patient to provide safe care and a continuity of care.

When anything is ordered or prescribed, a relationship is implied.

From that relationship is where one gets in trouble.

So a CXR is ordered, whom is responsible for the result?

A course of amoxicillin is prescribed, whom follows up when that fails or the patient has a side effect or allergic reaction?

A piece of medical equipment is ordered, whom justifies it when insurance wont cover?

This is a rabbit hole that can quickly turn into a nightmare.

Dont do it.

Personally, I tell anyone that seeks that from me that I am a supervised clinician and my scope of practice ends in the ED.

I will give advice on what family members should pursue or discuss with their PCP.

But I dont serve as their PCP.

Your state medical board will also frown (or worse) on providing medical care to friends and family on the side.

Dont do it.

This a great example of where the public has no insight into the legalities and restrictions we face as health care professionals. Use this as an opportunity to educate them.

When the response is 'no one will know' or 'just to help me out', they just dont get it. Be firm, this is your livelihood that potentially is at stake.

Good luck.

G Brothers PA-C

Thank you!! I do understand the point and I do my best to abide by it.

 

When a nurse comes and ask for a tick bite that she had and ask what to do, do you write for a dose of doxy or ask her to sign in? See your pcp?

 

When a CNA you work with calls from out of town, asking to possibly order a couple of zofran at 11pm, do you tell her no?

 

I have stumbled a few times with the questions. Find it easier to say no to family then coworkers. How do you deal with 'em?

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I would never get directly involved in my immediate family member's care, including ordering tests, unless I live in a very remote location and I was the only care giver.

 

 

Here is a good example as why we should not.

 

 

Recently I saw a teenager who had been in severe status migraine for 3 weeks. She was at a level 8-10 pain dialy with nausea and vomiting and the whole works.  Her parents happen to both be NPs.  I am 100% convinced of the diagnosis and every headache clinic in the country would have diagnosed her the same.  We deal with this every single day.

 

 

Her parents though, didn’t believed the diagnosis and thought it had to be zebra A or zebra B because a migraine (and she has a long history of them) "couldn't last more than a day".

 

 

I started a standard first step treatment.  I wanted to do DHE 45 in the office but the parents (who thought they knew better than me) didn’t think that was a good idea. So I started a daily triptan (naratriptan) and if that was not working by day 2, start a prednisone burst.  They stopped the triptan  at day two because the daughter didn’t like it and they said “it wasn’t working.”  It can take a week for this to work but the NP parents knew better.  The NP parents also did not use the steroid burst because they knew it would not work (works 50% of the time in reality and is a standard of care in this situation) and didn't want their daughter on steroids.

 

 

She comes in desperation the next week and her parents are venting frustration at me for not treating this as zebra a or b.

 

 

Per the international standard of care, I then ordered home IV infusions for three days using dihydroergotamine, magnesium, valproate and metoclopramide.  When the home infusion team were setting up her treatments the parents announced that they were NPs and would do it themselves and took the drugs and IV supplies home with them.  So the first thing they do is start substituting meds. They did not want to use metoclopramide.  They gave her one dose of dihydroergotamine.  She was 50% better that day but had persistent nausea (without the metoclopramide) and the parents dced the dihydroergotamine.  The next morning they went to start the IV and it hurt and infiltrated so they never did days 2 and 3.

 

 

Last check, she is still the same. The parents are now mad at me because I did not treat this as a zebra a or b but as migraine (BTW I did do a brain MRI).  They have cancelled all future appointments and are never coming back. The girl missed the remaining school year. Now their insurance is not paying for the $600 bill from the home infusion company because they never did the treatments, but they did supply my original meds.  The family is frustrated over that.  So it is a complete mess because parents who thought they knew more than me and who were emotionally involved with the patient made bad choices. 

 

 

Some of my best patients are physicians, NPs, pharmacists, RNs, PAs and etc. However, some of my worst patients are NPs, RNs, MDs and PAs . . . when they assume they know more about what they have than they really do know.  

 

A few years ago my son had an arrhythmia and I had to take him to a cardiologist.  I would have been a complete moron if I thought I knew more than the cardiologist because I was a PA.  I did exactly what he said to do.

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I won't treat my immediate family (wife & kids) at all because I cannot be subjective (see JMJs post above).  Plus, I want them to have better care than "just me". 

 

I will occasionally give single treatments to self-limiting ailments to extended family and very close friends (inlaws, etc).  Things like steroids for poison ivy, nystatin cream for diaper rash, abx for strep or OM.  But I do a paper note and send it to medical records (who probably has no idea what to do with them). 

 

I also have some in-laws with some chronic and potentially serious health issues that I avoid like the plague....nope, take her to the ED (and NOT my ED).

 

As for studies?  Nope, that's too great a chance it's not going to be a self-limiting ailment.  If they need a CXR, ankle x-ray, or lab work, they need to go to their regular doc. 

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I also have some in-laws with some chronic and potentially serious health issues that I avoid like the plague....nope, take her to the ED (and NOT my ED).

 

Sounds familiar. My mother in law has a pile of chronic illnesses; she is in the hospital so often I've told the residents they can't graduate until they've admitted her at least once. I also will not order any tests or mess for family;?the best I can offer is some educated advice.

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