Who is the patient/client?
One of the most misunderstood and misused laws in the field of heath care in the United States is the Health Insurance and Portability Act of 1996 (HIPPA) which was passed in August of 1996 by the 104th congress. This law had three rules:
The Privacy Rule
The Security Rule
The Breach Notification Rule
The law instructed the United States Department of Health and Human Services to create the standards for the law. Anyone can go online and obtain a copy of these standards.
Prior to this law health information was often shared by health care officials through careless handing, ignorance of how it might be misused and direct discrimination. An employer, spouse or other person might obtain health information to use to discriminate or even abuse someone. If a heath care professional had a particular bias or prejudice that might be used to limit or even refuse care. For example, early in the AIDS epidemic some doctors I knew would write HOMOSEXUAL on the patient’s chart which could easily adversely affect the quality of care. A spouse might obtain information to abuse their spouse. An adult child’s medical information might be used to attempt to abuse or control the child. Employers might obtain information about medication or medical care to mistreat an employee or potential employee. The records might have been easily obtainable to be misused by an employer. There are numerous examples of community and individual prejudicial , careless or insensitive treatment of patient/client medical information. Sadly, the response was to pass a law which might have protected some patients/clients but also invited a different level of mistreatment. Now, even if patently appropriate and beneficial to the patient/client, the heath care provider can and often does refuse to even acknowledge the person is a client or patient. For example, parents of a seriously mentally ill adult child can be refused information about their son or daughter unless there is an official legal document authorizing them access to the person condition. Until the marriage equality became law (which may be in danger of being repealed) the spouse of a same sex couple could not be involved in decisions or even have access their spouse/partner. In short, fear and the fact that health care providers are often very busy could lead to use of the HIPPA standards to avoid quality and compassionate care based on the needs of the individual and the family.
HIPPA also muddied the rights of a child who has not attained the age of legal consent. In an article in the American Medical Association Journal of Ethics, August, 2003 Sara Taub Me in an article entitled “Learning to Decide: Involving Children in their Health Care Decisions, Ms. Taub reminds her colleagues that the United Nations in its Convention on the Rights of the church, “recognizes the right of every child to self-determination, dignity, respect, noninterference, and the right to make informed decisions…They also serve to acknowledge the physician’s primary obligation is to the child, whose preference and insights are helpful to guide decisions.”
One of most important issues which all of us health care providers must address when we are dealing with individuals and families. (Legal or otherwise) is : “Who is the patient?” In the case of family issues is it the family, the one who initiated treatment, only the parents or the legal guardian or legal primary custodian. What is the involvement or rights of the child? Should the opinions and desires of even young children be considered? If a child is forced into treatment because a professional assessment determined that the child himself or herself and not the parents or legal guardians is struggling to the extent that direct professional help can be beneficial to the child who is the client? If one set of grandparents have temporary legal custody should the other grandparent(s) be involved. What if temporary custody was awarded to one set of grandparents while the other grandparent(s) is dealing with the aftermath of a family trauma? What if the other grandparent(s) was the one most involved with the minor child prior to the trauma? Are the issues of who the client is determined by the law, common sense, history or other factors? How does the health care provider determined what is best for the child assuming, as I have mentioned, that the temporary guardians are the grandparent(s) who were providing temporary care following the trauma?
To be sure there are those very young children who are struggling and who may benefit from individual help but, for the most part, the role of the health care provider is to teach the parenting adults how to help the child. One must not assume that the child needs professional counseling just because there has been a serious trauma; even on as serious as possibly witnessing the violent death of their parent(s). Children do sadly witness such events every day. Millions of children in a country where war is raging may witness such events. Those events will leave scares for adults and children who might or not need some professional guidance.
I have seen children for extended evaluation when parent/guardians are reporting serious academic issue or behavioral issues. For example, one child I saw with his custodial parent had a history of continually setting fires in various places in the house. Nothing the custodial parent did reduced the behavior. Another child might present with need of a program for Autistic children. Another might be reacting to neglect by his parent(s). If at all possible , the goal is to keep the child with parents and to not place them in an institution or make them “the sick member” of the family. Often, the child’s behavior is a symptom of family issues which are not being addressed. As a child ages he or she might need some individual care. One must listen carefully when assessing the family. The more information one can gather from all family members, including the child, the better the chances of an accurate diagnosis and appropriate treatment.
The health care provider must provide a safe space for the child to reveal what he or she is thinking/feeling. This may require some individual time with the child without making the child the identified patient which may be different than considering them the primary client.
If one is doing a court ordered assessment is the client the court or the individual/family? If one is hired by an employer to assess the mental health of an employee, who is the patient/client?
I am not suggesting these are always comfortable or easily answered issues, but I believe it is essential for the health care provider to do one’s best to determine who the client is. As always, a combination of common sense, empathy, active listening skills, and creativity need to be employed. Although the health care provider must be aware of any legal risks that should not be the only or even necessarily the primary concern.
Written July 13, 2022
Jimmy F Pickett
coachpickett.org
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