“I’m Worried that We Didn’t Follow Standard Practices because the Patient was a VIP”

BWH Clinical Ethics Case Review, a monthly newsletter, is published by the BWH Office of Clinical Ethics. Each issue highlights a BWH case that posed an ethical problem for a patient, family members and/or caregivers, leading to an ethics consultation and BWH Ethics Committee discussion. Please note that because cases are based on actual ethics consultations, some details may have been altered in order to protect patient privacy and confidentiality.

This issue of the BWH Clinical Ethics Case Review highlights a case in which a nurse director was concerned that the patient’s “VIP” status had led to deviations in usual clinical practices. Treating patients who are famous or influential differently from other patients can compromise care and raise ethical issues around autonomy, privacy and social justice (equitable distribution of resources). The Boston Globe recently published an article about VIP syndrome.

This case description is based on several different ethics consultations that took place at BWH. Some of the details have been changed to present a single composite scenario while protecting patient privacy. Please note, at BWH, every patient is very important, and the term VIP is used in this review to describe patients who are famous or influential in some way.

The Case
A high-profile patient was admitted to one of BWH’s intensive care units (ICU) for treatment. At the conclusion of her stay in the ICU, the nursing director of the unit asked to discuss the case at an Ethics Committee meeting. Several issues had troubled him during the patient’s course of care. First, clinicians who were not on the treatment team had come to the unit to visit the sedated and delirious patient and inquired about her condition. Second, high-ranking physicians who were not part of the patient’s designated care team had written orders for tests and consults.

VIP syndrome in medicine refers to the tendency to treat influential or famous patients differently. Physicians, celebrities and politicians may all be affected by this syndrome if, by virtue of their occupation, position or social status, they exert influence over a clinician’s judgment or behavior (Alfandre et al., 2016). In some instances, VIPs actively demand preferential treatment for themselves and their families; in others, the clinician assumes that special handling and privileges are required given the patient’s VIP status. In either event, the clinician ends up feeling pressured to deviate from customary clinical and administrative regimens in order to please or appease the VIP.While it may be thought that preferential treatment benefits the patient, in fact, it can lead to inferior care and outcomes (Alfandre et al., 2016). In order to avoid embarrassing or inconveniencing the VIP, the caregiver may conduct a less thorough history or physical exam, or may order fewer diagnostic studies than usual. On the other hand, the caregiver’s anxiety about missing something in a high-profile case may lead to excessive testing and overtreatment (Schenkenberg et al., 2007). Well-meaning colleagues may sidestep the usual chain of command to offer advice to the VIP without the treating physician’s knowledge or approval. Usual rules about privacy and confidentiality may be overlooked by staff who, lured by the temptation of secondary celebrity status, divulge personal information about the VIP under their care. Asking team members to participate in special treatment may cause them to resent the patient if this conflicts with their commitment to providing equal treatment for everyone (Schenkenberg et al., 2007).

In cases where the patient is also a physician, overlapping professional roles add another layer of complexity. The treating physician may feel insecure and anxious about caring for another physician, especially when the physician-patient holds a higher position within the hospital. Perhaps to deal with these feelings, the treating physician may limit meetings and provide only brief explanations, incorrectly assuming the patient possesses sufficient medical knowledge to fill in the gaps (Schneck, 1998). Deference to the physician-patient’s expertise may cause the treating physician to cede too much control over medical decisions. Close identification with the physician-patient may cause the treating physician to lose the sense of distance necessary to maintain clinical objectivity.

Heightened communication is essential when caring for the VIP patient. At the outset, the attending physician should explain to the patient and family the importance of standardized care. “Usually, the VIP is relieved if the physician states explicitly, ‘I am going to treat you as I would any other patient’” (Guzman et al., 2011). This holds equally true for the ill physician, who “is as sick and frightened” as other patients and just as dependent on the attending physician’s expertise (Schneck, 1998). When the patient is a fellow physician, it may be useful to acknowledge the overlapping professional roles by saying, “I want you to know that I will be mindful of our relationship as colleagues so it doesn’t interfere with your care” (Alfandre et al., 2016).

After the Ethics Committee discussion of this case, the nurse director felt that an ethics consultation during the course of care would have been helpful. The consultation would have provided an opportunity to:

  • Identify ethical principles underpinning confidentiality and privacy protections and recommit the team to upholding them.
  • Develop a concrete action plan, endorsed by unit leadership, to ensure proper protocols were followed.
  • Remind the team that deviations from standard practices could result in unsafe and substandard care.

Supporting Literature
Please note that supporting literature is only accessible through BWH’s employee intranet.