Background     Boundaries in patient care are “mutually understood, unspoken, physical and emotional limits of the relationship between the trusting patient and the caring physician or provider” (Farber 1997).   Health professional boundaries represent a set of culturally and professionally derived rules for how health professionals and their patients interact.  Boundaries serve to establish and maintain a trusting provider-patient relationship and help clinicians maintain “justice and equity in dealing with all of their patients”, not only a special few (Spence 2005).  This Fast Fact reviews issues in health professional-patient boundaries in palliative care.

Causes of Boundary Problems     In caring for seriously ill or dying patients it is common for strong emotional bonds to develop.  However, when the limits of the provider-patient/family relationship are not clear or where normal professional boundaries are not respected, problems are likely to arise.  Common reasons for boundary problems include:

• Personality styles or psychiatric disorders in which normal boundaries are not recognized or respected.
• Health professional stress/burnout (see Fast Facts #167-170).
• Cultural misunderstandings.

Examples     Warning signs and examples of potential boundary blurring include:

• Gift giving from/to patient/family.
• Patients having or wanting access to provider’s home phone number, or other personal information.
• Patient/family expectations that the provider will provide care or socialize outside of clinical care settings.
• Patient/family requests that the provider participate in prayer (See Fast Facts #120).
• The health care provider revealing excessive personal information with patient/family.

Self-Monitoring     Not all ‘boundary issues’ are detrimental to the provider-patient relationship – some clearly enhance compassionate care and serve to reinforce a trusting therapeutic relationship.  However, it is important for the provider to self-reflect when boundaries are approached.

• Am I treating this patient or family differently than I do my other patients?
• What emotions of my own does this patient/family trigger and are the emotions impacting my clinical decision-making?
• Are my actions truly therapeutic for the patient, or am I acting in a manner to meet my personal needs?
• Would I be comfortable if this gift/action was known to the public or my colleagues?
• Could this boundary issue represent a sign that I am experiencing professional burnout?

Managing boundary concerns

• Set clear expectations with patients and families as to your role in the context of their care, your availability and best ways to communicate with you.
• Use professional colleagues or a mental health professional as a sounding board when you are uncertain about your own or your patient/family behaviors.
• Address issues as they arise with the patient/family.  Acknowledge importance of feelings, emphasize the provider-patient relationship and the importance of maintaining objectivity; emphasize that the rejection of a requested behavior does not imply a lack of caring.
• Seek professional counseling for yourself or the patient/family when boundary issues impact your ability to provide objective, compassionate care.

References

1. Gabbard GO, Nadelson C. Professional boundaries in the physician-patient relationship.  JAMA. 1995; 273:1445-1449.
2. Farber N, Novak D, O’Brien M.  Love, boundaries, and the physician-patient relationship. Arch Int Med. 1997;157:2291-2294.
3. Elder W. Erotic undercurrents and boundary violations in medical care.  Clin Fam Prac. 2004; 6:975-82.
4. Spence S. Patients bearing gifts: are there strings attached? BMJ. 2005; 331:1527-1529.
5. Post S, Puchalski C, Larson D.  Physicians and patient spirituality: professional boundaries, competency, and ethics.  Ann Internal Med. 2000; 132:578-583.

Version History:  This Fast Fact was originally edited by David E Weissman MD and published in January 2007.  Version copy-edited in April 2009; then again in July 2015.