A 42-year-old man comes to the office due to depression, weight loss, poor concentration, and insomnia. He feels overwhelmed by his troubled marriage and his wife's comments about his failure to provide for the family. The patient asks that the physician not speak with his wife. He has had suicidal thoughts and wished for death over the past month but has no intent or plan for self-harm. He is diagnosed with depression and sent home with a prescription for an antidepressant. Three days later, the patient's wife calls the physician and demands to know the status of her husband's treatment. She says, "I know he comes to the clinic. What are you giving him? I am the mother of his children, and I have the right to know. Let me tell you a few things about him-he is late for work almost every day and I wouldn't be surprised if he is fired soon. All he does on weekends is sleep and he is totally useless when it comes to helping with the kids." Which of the following is the most appropriate response to the patient's wife?

Question

A 42-year-old man comes to the office due to depression, weight loss, poor concentration, and insomnia.  He feels overwhelmed by his troubled marriage and his wife's comments about his failure to provide for the family.  The patient asks that the physician not speak with his wife.  He has had suicidal thoughts and wished for death over the past month but has no intent or plan for self-harm.  He is diagnosed with depression and sent home with a prescription for an antidepressant.  Three days later, the patient's wife calls the physician and demands to know the status of her husband's treatment.  She says, "I know he comes to the clinic.  What are you giving him?  I am the mother of his children, and I have the right to know.  Let me tell you a few things about him-he is late for work almost every day and I wouldn't be surprised if he is fired soon.  All he does on weekends is sleep and he is totally useless when it comes to helping with the kids."  Which of the following is the most appropriate response to the patient's wife?

Quizplus · Accepted Answer

Protecting patient confidentiality is a fundamental duty of physicians and a prerequisite for developing a trusting physician-patient relationship. This patient has explicitly requested that the physician not speak with his spouse. Responding to a demanding spouse is a challenging situation, but the physician is obligated to protect the patient's confidentiality and to politely decline disclosure of any information, even if this is upsetting to the spouse. The only exceptions that justify breaching confidentiality are to prevent a serious and imminent threat to the health and safety of the patient or others (eg, imminent suicide risk, homicidal ideation with plan to harm the spouse). This patient is not at risk for imminent suicide; he has expressed a wish to be dead ("passive" suicidal ideation) but has no suicide plan or intent to harm himself. The presence of passive suicidal thoughts alone is not sufficient basis for overriding confidentiality (Choice A). (Choices C and D) Disclosing that this individual is even a patient at the clinic is a breach of his confidentiality. The physician cannot assume that the spouse is certain as to which clinic her husband has visited (ie, the physician cannot rule out that the spouse has called multiple clinics to find out where her husband obtains care). For the physician to state that the patient's information cannot be disclosed or that permission for disclosure has not been given either implies or indirectly verifies that the individual is, in fact, a patient. At this time, the patient has explicitly prohibited the disclosure of any information to the spouse. (Choice E) An appointment with the patient and his wife may be helpful in educating her and decreasing family conflict, but it cannot be arranged without the patient's permission. Educational objective: Physicians are ethically obligated to protect patient confidentiality. Unless a patient is at active risk of harm to self or others, physicians cannot disclose information to family members without the patient's consent. References: HIPAA and patient care: the role for professional judgment. (http://www.ncbi.nlm.nih.gov/pubmed/15827316)

A 42-Year-Old Man Comes to the Office Due to Depression