To treat or not to treat

As a nurturing and caring midwife, it goes without saying that you will want to help those close to you with answers to their questions and requests for midwifery guidance and care during ante and postnatal periods.  While it is understandable, it is important to appreciate that the risks of dual relationships and blurred boundaries can far outweigh the potential benefits.  Sometimes it really may be better for everyone if you can make saying ‘no’ part of your vocabulary during these conversations.
 
When an extended family member or friend asks for midwifery assistance and what is requested is something within your scope and abilities, midwives’ first response will generally be ‘yes, I’d love to help.’  However, before saying ‘yes’ you should take some time to reflect on what your professional guidelines and boundaries say about this relationship and the inherent complexities of the dual relationship.
 
In the NMBA’s Code of Conduct for Midwives, Section 4.1(c) a clearly states that midwives should:
“..avoid the potential conflicts, risks, and complexities of providing care to those with whom they have a pre-existing non-professional relationship and ensure that such relationships do not impair their judgement.  This is especially relevant for those living and working in small, regional or cultural communities and/or where there is long-term professional, social and/or family engagement.”

Section 2.7 of the Midwifery Standards for practice also says that midwives should  “develop, maintain and conclude professional relationships in a way that differentiates the boundaries between professional and personal relationships.”
 

What are the issues in providing care to family and friends?

MIGA recently offered a Midwives Health activity as part of our Risk Education for Midwives.  The self-assessment questionnaire and subsequent discussion as part of that activity raised some of the pitfalls of providing care to family and friends:

• Dual relationships that cross the family/friend and professional relationship boundaries can lead to a lack of objectivity and related clinical judgement concerns.  Given the personal nature of midwifery care and the emotional nature of the personal relationship, concerns may arise with incomplete examinations and histories, both of which may negatively impact the ability to provide quality care
• Existing relationships with the patient and wider connections within the family and community may lead to blurred boundaries and ethical concerns around privacy and confidentiality
• Existing relationships can also lead to exploitation of yourself with some midwives saying that they find themselves going the extra mile and providing more attention to family and friends, sometimes even reducing fees or even providing care free of charge.

When you know you should say no 

Sometimes providing the best possible care will mean refusing to provide care at all.  Whilst it is ultimately your choice, feeling confident of the reasons for saying ‘no’ may be helpful in managing the conversations around this request.  This is particularly so where your objectivity may be diminished, as this will not assist your “patient”.

• Be careful not to jump in and offer your services out of a sense of duty.  Sometimes the family member or friend may only want someone they trust to listen to their concerns and point them in the right direction.  The RACGP article in the links below speak to this and other options that some GPs use when they are approached by family and friends to provide care
• If a request is made, don’t automatically say ‘yes’.  Take some time to think through all the options and ramifications.  Making some pointers for a discussion with them about the pros and cons may also help you come to a joint decision.  Other things to consider include:
  • Would your midwifery colleagues consider your provision of care to be consistent with good practice, and
  • If issues arise, what impact could this have on your relationship with the individual and extended family members
• When you say ‘no’, do it simply and clearly and direct them to suitable alternatives.

In some cases, providing care to those close to you is unavoidable.  Wherever that is the case, reflecting regularly on evidence of blurred boundaries impacting the care you can provide is essential.
 

Some things to consider when you say ‘yes’.

If you find yourself in a situation where you have to provide care because there is a lack of other options, we recommend:

• Documentation – When its family and friends it is easy to omit some communications from the medical record.  Ensure you maintain comprehensive medical records including documented consents
• Pay attention to privacy and confidentiality given the wider context of relationships.
• Utilise mentors and colleagues to help you feel confident that you are maintaining clear boundaries and providing optimal quality care
• Refer them to other health care providers as soon as you feel you are either being asked to provide care out of your scope or as soon as clinically necessary.

 
If you have a question about providing care to your family and friends don’t forget to call MIGA to help you work through the decision.  In the meantime, MIGA wish you a safe and happy festive season with your loved ones. Please take care.
 

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Other Resources:

NHS Providing maternity care to friends and family
NMBA’s Midwives’ guide to professional boundaries (retired version)
RACGP - When friends and family ask for medical advice