Expert: Ivan Goldberg, M.D. - 11/16/2008

Question
Dear Dr. Goldberg,
I will try to be as brief as possible.  I am a 60 year old woman and have two younger brothers diagnosed with Bi-Polar.  The 51 year-old, Douglas, is making the lives of my 84 year-old parents a living hell. I believe he has some sociopathic tendencies as well as bi-polar.  He has seen psychiatrists, psychologists and psychopharmacologists for many years and been on a cocktail of drugs.  He is divorcing his wife of 25 years and since last May has been down in Florida living in an extra home my parents own.  He has kept his psychologist and psycholpharmacologist in Connecticut - has only been up once in that time to see them in person and conducts all of his sessions by phone - money is not the only issue, but I must say that it has cost at least $50,000 just since the spring - many hundreds of thousands of dollars before that.  Douglas is a very good actor, and our family knows that his doctors do not have a clear picture of Doug's behavior - the raging, the abusiveness, the lack of responsibility - he is totally dependent on them financially. He places blame on everyone but himself. (We could get into my parents not setting boundaries for him, but that's another e-mail!)  My other brother and I have both written his doctors and spoken to them by phone, expressing deep concern not only for Doug's mental health but also the effect this is having on the health of our parents.  My parents recently wrote them expressing the deepest concern for Doug and also their own well-being - they begged them not to share the letter with Doug because they feared for their safety - they were simply asking for guidance.  Yet, the doctors did share it with him with no advance warning to my parents,  and now he is raging against them with the most unbelievable venom.  I know my parents share some of the responsibility for enabling, but my question for you is twofold:
1.  Is it ethical for doctors to be treating a patient as sick as my brother long distance?  We have told both doctors that we think he should be hospitalized or at the very least be told to get a local doctor, but they do nothing.  They are not taking seriously the severity of Doug's symptoms and the effect on his loved ones.
2.  I know because of privacy issues that doctors have to tell their patients about communication from family members, but isn't there a fine line here?  How can they properly treat him without family input, and how can they get that information without putting my older parents at risk?

I would appreciate any advice you can give me.  This is tearing our family apart, and the thought of my parents having this problem at this time in their lives breaks my heart.  My mother is very stubborn and often resemts my advice (like, hang up the phone....don't allow him to rage against you!) - but I may share your response with her and hopefully it will help her cope with this.

Thank you in advance,
Elizabeth  

Answer
Hi Elizabeth . . .

The situation you describe is a very difficult one and one that may require a good deal of effort to improve. Let me take your questions in order:

1.  Is it ethical for doctors to be treating a patient as sick as my brother long distance?  We have told both doctors that we think he should be hospitalized or at the very least be told to get a local doctor, but they do nothing.  They are not taking seriously the severity of Doug's symptoms and the effect on his loved ones. The family's belief that your brother should be treated in a hospital may or may not be correct as it is generally expected that mental health care be provided in the least restrictive setting possible

Doctors are required to treat patients in a manner that is appropriate and that meets the community standards. Without knowing a lot more about your brother and his psychiatric status, there is no way I can comment on the appropriateness of his care.

If you think the care your brother is receiving is substandard, that is the basis of possible disciplinary action by the state against  the doctors or possibility the basis of a lawsuit. Every state has an agency that is responsible for disciplining doctors who practice medicine in a less than adequate matter. Such agencies have the power to censure doctors, or discipline them in many ways including revoking their licenses to practice medicine. A lawsuit is another possible way to go, and a lawyer could advise you regarding the possibility of a lawsuit. You should remember that while a discussion with a lawyer will be kept confidential until a malpractice suit is initiated, a formal complaint to the state will result in the doctors being advised that a complaint has been made against them. This information is likely to be passed on to your brother. If you think your brother is a danger to himself or others, you should also discuss with lawyers and a psychiatrist other then the one your brother is seeing the possibility of his being hospitalized via a commitment procedure in the courts.


2.  I know because of privacy issues that doctors have to tell their patients about communication from family members, but isn't there a fine line here?  How can they properly treat him without family input, and how can they get that information without putting my older parents at risk?

Most professionals will pass on to patients information regarding communications from family members. Doctors also have another responsibility. It is the duty to protect. (See: http://www.medicine.mcgill.ca/mjm/v02n01/crossv2n1.html) This means that if telling the patient about communications from the family puts members of the family at danger, the doctor has a responsibility to protect the family from harm. That duty can include such actions has hospitalizing the patient so no harm ca come to the family, informing the police and/or informing the family that they are in danger. Failing to protect is possibly the basis for disciplinary action by the state and/or the basis for a lawsuit.

I hope you find a solution to this nasty problem.

Best regards . . .

Ivan
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