Medical knowledge can make it difficult to be an objective relative, as Julie Sladden explains

Many of us will have to face the ordeal of having a close relative in hospital. This is not pleasant for anyone and being medically trained can sometimes make the experience more difficult, rather than easier. How can you be a "good" relative without being, and being labelled, a "problem" or "interfering" relative? Should we ignore our medical training when we see our relative's care being compromised? How do we strike a balance between our head knowledge and our heart? There will always be a dilemma--but there are a few things you can do to help make the experience a more positive one.

Boundaries

The guidelines are clear. The GMC says that "Doctors should avoid treating themselves or close family members wherever possible",¹ and advice from the BMA ethics department states that "There are clearly some cases, such as in emergencies, in which such action would be reasonable, but as a general rule it should be avoided. A confusion of roles can develop and doctors can find it hard to keep the right emotional distance."²

These guidelines are logical and understandable. However, things are not always so clear cut. Sometimes being a relative makes you part of the "care package", for example, with children, when your relative is elderly and infirm, or when there are language barriers. There is also a world of difference between treating your relative and using your skills in observation, communication, and advocacy to promote their care.

Pros

There are quite a few advantages of being a "medical" relative. Firstly, you have the privilege of knowing your relative well. This may make it easier for you to spot small changes in their physical and mental wellbeing that might otherwise go unnoticed. Often on busy wards, or when there is frequently changing staff, there is little time or opportunity to make these observations. For example, one doctor found she could tell when her immunocompromised relative was cooking an infection, even before the temperature changed, by noticing her relative's appearance. "She just looked different--paler, more drawn, tired".

Another positive is that you are a trusted constant in your relative's ever-changing hospital world. Your relative may confide things to you that he or she may not feel comfortable telling medical staff. For example, one doctor found that his mother had included staff in her delusions, a fact that the staff was unaware of. She would behave appropriately while they were in the room but when they left the room, she would whisper, "Can't you see they're all in it together?"

Also, an observer is well placed to identify the shortcomings in present services and help work towards making changes that may benefit future patient care. A medical registrar noted that there had been an 18 hour delay in commencing antibiotics after the medical team had prescribed them for his relative. This was because of the unavailability of the drug on the ward, and the weekend pharmacy arrangements. It turned out many other patients were in a similar position so after consulting with the medical staff, arrangements were made to keep the relevant antibiotics on the ward.

Cons

Being a constant observer with medical skills, and having the patient's interests at heart, are all good and useful things. But where is the line drawn between being an asset in your relative's care, and a difficult relative who has lost perspective?

It is very difficult to remain objective when your relative is the patient, especially if the problems are not straightforward and pain and suffering are involved. We need to constantly remind ourselves that we are not our relative's doctor and perhaps we cannot see the picture as clearly as we would if we were treating one of the patients on our own ward, clinic, or surgery. That said, it is impossible to remove our medical knowledge and training as we step into "relative" mode. Even if the illness is outside of our specialty, chances are we will have at least a rudimentary know-ledge of the illness and what it involves.

Difficulty in remaining objective may be compounded by your relative's expectation for you to be their adviser. This can be complicated further by being treated as a medic by the medical team--that is, they assume that you are informed and so do not give adequate information or expect that your decisions will be based on current evidence rather than emotion.

Another potential pitfall is that as you become more embroiled in your relative's situation, you may be labelled as a difficult relative. In your role as doctor, you may have experienced the heart-sink of seeing a patient's family enter the ward and know that you will soon be given a grilling about the patient's current care and future treatment plans. As a relative the signs are easy to recognise--nurses disappear and medical staff are elusive.

So what can we do to minimise the difficulties and pitfalls of being a medical relative and make our involvement in our relative's care as positive as possible? Here are a few suggestions.

Do

• Be positive--it's likely the medical team are doing their best for your relative
• Praise staff when you see a job well done. Say thank you. Supply with chocolate as necessary
• Find someone on the medical or nursing team you trust and, if they agree, use them as a first contact point
• Arrange a regular time to meet with staff if any issues need to be discussed
• Recognise the "system" is not perfect and make suggestions to help improve it
• Get your relative's permission first if you want to ask questions--they may not want you to
• Mention to staff when you notice that the management plan is not being adhered to as it should be (for example, treatment delays)
• Mention changes you notice in your relative that may not have been spotted by staff
• Accept you may be labelled as a difficult relative--develop a thick skin
• Look after yourself (and your family). Spend time away from the hospital

Don't

• Try to be your relative's doctor
• Complain all the time
• Get personal--many shortcomings are a failure of the system rather than individuals
• Badger everyone you see--try and arrange a single contact person and time (see above)
• Be a martyr. "Being a carer of a relative is emotionally and physically draining. Being a martyr won't help you or the person you are trying to help."³

LP WOODS

Julie Sladden, freelance medical jpurnalist, Leicester
Email: julie.sladden@doctors.org.uk


studentBMJ 2005;13:1-44 January ISSN 0966-6494

1. General Medical Council. Doctors should not treat themselves or their families. London: GMC, 1998. http://www.gmc-uk.org/standards/selftreat.htm (accessed 27 Oct 2004).
2. British Medical Association. Ethical responsibilities in treating doctors who are patients--guidance from the ethics department, March 1995, revised March 2004. www.bma.org.uk/ap.nsf/Content/Ethical±responsibilities±in±treating±doctors±who±are±patients#Treatingfamilyorfriends (accessed 27 Oct 2004).
3. Cross P, Dosani S. Relative support. BMJ 2003;327(suppl):51(Career Focus) http://careerfocus.bmjjournals.com/cgi/content/full/327/7411/s51

As a person who's gone through such an experience, an experience which ended in losing my grandmother this summer, the article brought it all back to me. It is kind of weird writing this entry, because in february 2003 there was a life article on a similar subject and I was at the hospital, my grandmother having her debulking surgery and me sitting in her room as a medical student, writing a rapid response. Almost two years and loads of good and bad memories later, still can't be sure how to handle such situations as a close relative and a healthcare proffessional. I think the article states the facts clearly and has many right points. But the truth is, at the end, the person who is lying there in pain is a part of your family, a part of yourself and no matter how logical and scientific you try to be... you can't...

So instead of calling them "do's" and "don't", would rather call them "recommended" and "not recommended"... Finally, thank you for the article. There are many medics out there who struggle with mixed emotions, and such articles are supportive, eventhough at the very end each one finds his/her own unique way of coping.

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