When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

PLEASE VIEW THE FULL-TEXT PDF.

PLEASE VIEW THE FULL-TEXT PDF.

PLEASE VIEW THE FULL-TEXT PDF.

CHICAGO – A novel technique for ferreting out DNA mutations in circulating plasma appears to be more sensitive than is conventional pathology at detecting drug-resistant mutations in patients with gastrointestinal stromal tumors, said an investigator at the annual meeting of the American Society of Clinical Oncology.

Secondary KIT mutations associated with resistance to tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec) were detected in 47% of plasma samples using "BEAMing" (beads, emulsions, amplification, magnetics) technology, compared with only 12% of tissue biopsy specimens, said Dr. George D. Demetri, director of the center for sarcoma and bone oncology at the Dana-Farber Cancer Institute in Boston.

"We know that tumor cells are constantly turning over, apoptosing, dying, and releasing free DNA into the bloodstream. I want to emphasize that this is not looking at circulating tumor cells; this is looking at free circulating DNA in the plasma, and by looking at that circulating DNA, we may be able to get a more comprehensive assessment of all the mutations from across all tumor burden in any given patient," Dr. Demetri said.

The technique, which some investigators have dubbed "liquid biopsy," involves treating plasma with beads coated with DNA sequences that are complementary to target mutational sequences to create an emulsion polymerase chain reaction (PCR). The PCR amplifies the circulating DNA, which can then be identified with flow cytometry. The test can detect one circulating DNA molecule per 10,000 in plasma, according to the American Association for Cancer Research.

Dr. Demetri and his colleagues used the technology to retrospectively study mutations from patient samples in the GRID (GIST-Regorafenib in Progressive Disease) phase III study. In that trial, regorafenib (Stivarga), a multikinase inhibitor, significantly improved progression-free survival (PFS) compared with placebo (hazard ratio, 0.27; P less than .0001) in patients with metastatic GIST after failure of both standard and targeted therapies, including imatinib and sunitinib (Sutent).

The investigators looked for primary and secondary mutations in KIT in both plasma samples (available for 163 of 199 patients in GRID) and tumor tissue (from 102 patients), and found that BEAMing detected mutations in 58% of plasma samples, compared with 66% of tumor samples analyzed by the Sanger DNA sequencing method.

In addition, BEAMing detected mutations in PDGFRA in 1% of samples, and in KRAS in one of two samples, compared with 3% and 1%, respectively, for sequencing. Neither analysis method detected any BRAF mutations, and the numbers of PDGFRA and KRAS mutations were too small for researchers to draw meaningful conclusions.

When it came to KIT, however, there was a high degree of concordance between the tests where both types of samples from individual patients were available, including 100% agreement for primary KIT exon 9 mutations, 79% for primary KIT exon 11 mutations, and 84% overall for primary KIT exon 9 and 11 mutations.

The BEAMing technology can help determine prognosis of patients with GIST, Dr. Demetri said, noting that in the GRID trial, patients in the placebo arm who had secondary KIT mutations had shorter PFS than did patients without KIT mutations (HR, 1.82; P = .05). Patients with KIT exon 9 mutations had received a shorter course of imatinib than did the rest of the study population (HR, 2.02; P = .002) and a longer course of sunitinib (HR, 0.54; P = .005).

BEAMing analysis also showed that patients with secondary KIT mutations who received regorafenib had significantly better PFS than did patients in the placebo arm (HR, 0.22; P less than .001).

The data Dr. Demetri presented were "very exciting," said invited discussant Dr. Shreyaskumar R. Patel, professor of sarcoma oncology at the University of Texas MD Anderson Cancer Center in Houston.

"The important take-home messages are that there is some very good concordance between the tumor tissue analysis and the plasma analysis," and that regorafenib "appears to be totally agnostic to any of the mutational subsets and seems to equally benefit all patients," Dr. Patel said.

The study was supported in part by Bayer HealthCare. Dr. Demetri disclosed serving as a scientific consultant to the company. Dr. Patel reported having no disclosures relevant to the study.

CHICAGO – A novel technique for ferreting out DNA mutations in circulating plasma appears to be more sensitive than is conventional pathology at detecting drug-resistant mutations in patients with gastrointestinal stromal tumors, said an investigator at the annual meeting of the American Society of Clinical Oncology.

Secondary KIT mutations associated with resistance to tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec) were detected in 47% of plasma samples using "BEAMing" (beads, emulsions, amplification, magnetics) technology, compared with only 12% of tissue biopsy specimens, said Dr. George D. Demetri, director of the center for sarcoma and bone oncology at the Dana-Farber Cancer Institute in Boston.

"We know that tumor cells are constantly turning over, apoptosing, dying, and releasing free DNA into the bloodstream. I want to emphasize that this is not looking at circulating tumor cells; this is looking at free circulating DNA in the plasma, and by looking at that circulating DNA, we may be able to get a more comprehensive assessment of all the mutations from across all tumor burden in any given patient," Dr. Demetri said.

The technique, which some investigators have dubbed "liquid biopsy," involves treating plasma with beads coated with DNA sequences that are complementary to target mutational sequences to create an emulsion polymerase chain reaction (PCR). The PCR amplifies the circulating DNA, which can then be identified with flow cytometry. The test can detect one circulating DNA molecule per 10,000 in plasma, according to the American Association for Cancer Research.

Dr. Demetri and his colleagues used the technology to retrospectively study mutations from patient samples in the GRID (GIST-Regorafenib in Progressive Disease) phase III study. In that trial, regorafenib (Stivarga), a multikinase inhibitor, significantly improved progression-free survival (PFS) compared with placebo (hazard ratio, 0.27; P less than .0001) in patients with metastatic GIST after failure of both standard and targeted therapies, including imatinib and sunitinib (Sutent).

The investigators looked for primary and secondary mutations in KIT in both plasma samples (available for 163 of 199 patients in GRID) and tumor tissue (from 102 patients), and found that BEAMing detected mutations in 58% of plasma samples, compared with 66% of tumor samples analyzed by the Sanger DNA sequencing method.

In addition, BEAMing detected mutations in PDGFRA in 1% of samples, and in KRAS in one of two samples, compared with 3% and 1%, respectively, for sequencing. Neither analysis method detected any BRAF mutations, and the numbers of PDGFRA and KRAS mutations were too small for researchers to draw meaningful conclusions.

When it came to KIT, however, there was a high degree of concordance between the tests where both types of samples from individual patients were available, including 100% agreement for primary KIT exon 9 mutations, 79% for primary KIT exon 11 mutations, and 84% overall for primary KIT exon 9 and 11 mutations.

The BEAMing technology can help determine prognosis of patients with GIST, Dr. Demetri said, noting that in the GRID trial, patients in the placebo arm who had secondary KIT mutations had shorter PFS than did patients without KIT mutations (HR, 1.82; P = .05). Patients with KIT exon 9 mutations had received a shorter course of imatinib than did the rest of the study population (HR, 2.02; P = .002) and a longer course of sunitinib (HR, 0.54; P = .005).

BEAMing analysis also showed that patients with secondary KIT mutations who received regorafenib had significantly better PFS than did patients in the placebo arm (HR, 0.22; P less than .001).

The data Dr. Demetri presented were "very exciting," said invited discussant Dr. Shreyaskumar R. Patel, professor of sarcoma oncology at the University of Texas MD Anderson Cancer Center in Houston.

"The important take-home messages are that there is some very good concordance between the tumor tissue analysis and the plasma analysis," and that regorafenib "appears to be totally agnostic to any of the mutational subsets and seems to equally benefit all patients," Dr. Patel said.

The study was supported in part by Bayer HealthCare. Dr. Demetri disclosed serving as a scientific consultant to the company. Dr. Patel reported having no disclosures relevant to the study.

CHICAGO – A novel technique for ferreting out DNA mutations in circulating plasma appears to be more sensitive than is conventional pathology at detecting drug-resistant mutations in patients with gastrointestinal stromal tumors, said an investigator at the annual meeting of the American Society of Clinical Oncology.

Secondary KIT mutations associated with resistance to tyrosine kinase inhibitors (TKIs) such as imatinib (Gleevec) were detected in 47% of plasma samples using "BEAMing" (beads, emulsions, amplification, magnetics) technology, compared with only 12% of tissue biopsy specimens, said Dr. George D. Demetri, director of the center for sarcoma and bone oncology at the Dana-Farber Cancer Institute in Boston.

"We know that tumor cells are constantly turning over, apoptosing, dying, and releasing free DNA into the bloodstream. I want to emphasize that this is not looking at circulating tumor cells; this is looking at free circulating DNA in the plasma, and by looking at that circulating DNA, we may be able to get a more comprehensive assessment of all the mutations from across all tumor burden in any given patient," Dr. Demetri said.

The technique, which some investigators have dubbed "liquid biopsy," involves treating plasma with beads coated with DNA sequences that are complementary to target mutational sequences to create an emulsion polymerase chain reaction (PCR). The PCR amplifies the circulating DNA, which can then be identified with flow cytometry. The test can detect one circulating DNA molecule per 10,000 in plasma, according to the American Association for Cancer Research.

Dr. Demetri and his colleagues used the technology to retrospectively study mutations from patient samples in the GRID (GIST-Regorafenib in Progressive Disease) phase III study. In that trial, regorafenib (Stivarga), a multikinase inhibitor, significantly improved progression-free survival (PFS) compared with placebo (hazard ratio, 0.27; P less than .0001) in patients with metastatic GIST after failure of both standard and targeted therapies, including imatinib and sunitinib (Sutent).

The investigators looked for primary and secondary mutations in KIT in both plasma samples (available for 163 of 199 patients in GRID) and tumor tissue (from 102 patients), and found that BEAMing detected mutations in 58% of plasma samples, compared with 66% of tumor samples analyzed by the Sanger DNA sequencing method.

In addition, BEAMing detected mutations in PDGFRA in 1% of samples, and in KRAS in one of two samples, compared with 3% and 1%, respectively, for sequencing. Neither analysis method detected any BRAF mutations, and the numbers of PDGFRA and KRAS mutations were too small for researchers to draw meaningful conclusions.

When it came to KIT, however, there was a high degree of concordance between the tests where both types of samples from individual patients were available, including 100% agreement for primary KIT exon 9 mutations, 79% for primary KIT exon 11 mutations, and 84% overall for primary KIT exon 9 and 11 mutations.

The BEAMing technology can help determine prognosis of patients with GIST, Dr. Demetri said, noting that in the GRID trial, patients in the placebo arm who had secondary KIT mutations had shorter PFS than did patients without KIT mutations (HR, 1.82; P = .05). Patients with KIT exon 9 mutations had received a shorter course of imatinib than did the rest of the study population (HR, 2.02; P = .002) and a longer course of sunitinib (HR, 0.54; P = .005).

BEAMing analysis also showed that patients with secondary KIT mutations who received regorafenib had significantly better PFS than did patients in the placebo arm (HR, 0.22; P less than .001).

The data Dr. Demetri presented were "very exciting," said invited discussant Dr. Shreyaskumar R. Patel, professor of sarcoma oncology at the University of Texas MD Anderson Cancer Center in Houston.

"The important take-home messages are that there is some very good concordance between the tumor tissue analysis and the plasma analysis," and that regorafenib "appears to be totally agnostic to any of the mutational subsets and seems to equally benefit all patients," Dr. Patel said.

The study was supported in part by Bayer HealthCare. Dr. Demetri disclosed serving as a scientific consultant to the company. Dr. Patel reported having no disclosures relevant to the study.

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

Ms. Stout is a 58-year-old divorced mother of two. Her eldest son, Paul, aged 35, has cystic fibrosis and is the recipient of a lung transplant. He has several developmental delays, and his comprehension of medicolegal documents becomes quite limited when he is medically ill and on narcotics. His outpatient medical team is aware of this and includes his mother in all treatment decisions.

However, in the hospital, the medical teams do not appreciate his limitations. In the inpatient hospital setting, he does not retain information presented to him. They question his mother’s continual presence and see her as "overinvolved and enmeshed with her adult son." Ms. Stout says that she has to fight with each new physician team to get them to understand that they need to involve her in all her son’s health care decisions. The younger male physicians, especially, identify with Paul.

Paul presents as a well-adjusted young man. He is agreeable, open, and friendly with the staff. Paul has limited social contacts outside of the hospital. Because of his lengthy involvement in the hospital care system, he is comfortable in the hospital and especially enjoys his interaction with the female nurses. He understands basic procedures because they have been repeated so many times. However, he does not understand his complex health care needs. Unless his comprehension is specifically tested, his deficits go unrecognized.

His mother knows the details of his history and is a better resource than the chart. She insists on being present at all times, despite the demands of her other commitments. Each time her son is admitted, she faces scrutiny, and repeatedly has to explain herself and her son’s limitations to each new physician. She finds this situation exhausting and humiliating. She does not understand why her presence cannot be accepted as helpful.

The toll of caregiving

Family caregivers face many physical, emotional, and financial demands that make them vulnerable to stress-related conditions, both physical and psychological. Caregiving affects caregivers’ health, which, in turn, affects their ability to provide care. The Caregiver Health Effects Study demonstrated a strong link between caregiving and mortality risk, finding that elderly caregivers supporting disabled spouses at home were 63% more likely to die within 4 years than noncaregiving elderly spouses (JAMA 1999;282:2215-9). In addition, family caregivers often lack the time and energy to prepare their own meals, exercise, or engage in their own preventive medical care. Physicians must stress the importance of caregiver self-care for the benefit of both the caregiver and the patient, and identify appropriate sources of community support services, such as home health aides, respite, or adult day care.

In 2008, according to Suzanne Mintz, a cofounder of the National Family Caregivers Association, the estimated market value of the family caregivers’ services was $375 billion annually. Almost one-third of the U.S. population provides care for a chronically ill, disabled, or aged family member or friend during any given year and spends an average of 20 hours per week providing care for loved ones. Two-thirds of caregivers are women, and 13% of family caregivers are providing 40 hours of care a week or more.

The American Psychological Association has a "Caregiver Briefcase." The briefcase contains caregiving facts; a practice section with common caregiver problems and interventions; and sections on research, education, and advocacy. The website and its contents are useful for family members as well as professionals.

In addition, the American Psychological Association offers ways for family members to integrate into health care teams. For example, electronic medical records can allow family members access to portions such as the patient’s problem and medication lists and most recent laboratory findings. Family caregivers can provide ongoing, real-time observations about the patient through the portal, as well as share information about what it is like to be a family caregiver. Those secure messages become part of the patient’s permanent medical record.

Shifting patient decision making to family members is a delicate negotiation between the patient’s ability to make independent decisions and the family’s desire to protect the patient from potentially poor decisions. At critical times, the family has to step up and assume decision-making responsibility for the patient.

To help physicians understand the ethics of this process, the American College of Physicians offers guidelines to help the physician know how best to collaborate with the patient and the caregiver (J. Gen. Intern. Med. 2010;25:255-60). These guidelines are endorsed by 10 medical professional societies, including the Society of General Internal Medicine, the American Academy of Neurology, and the American Academy of Hospice and Palliative Medicine.

Ethical guidelines for collaboration

When working with patients, making sure that six factors are met will help us do a better job of ensuring that the relationship with caregivers is productive for all three parties involved. Here is a listing:

• Respect the patient’s dignity, rights, and values in all patient-physician-caregiver interactions.

• Recognize that physician accessibility and excellent communication are fundamental to supporting the patient and family caregiver.

• Recognize the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history.

• Facilitate end of life adjustments for the family.

• Ensure appropriate boundaries when the caregiver is a health care professional.

• Ensure the caregiver receives appropriate support, referrals, and services.

Our failure to use patient and family-centered care (PFCC) is tied to attitudinal, educational, and organizational barriers. The first attitudinal barrier is the expectation that families will be unreasonable. The second is that families will compromise confidentiality. The third is that physicians are largely unaware of research on the benefits of PFCC. Finally, physicians believe that PFCC is time consuming and costs too much.

Educational barriers include the lack of skills needed for collaboration among professionals, administrators, patients, and families.

Organizational barriers that get in the way of PFCC are the lack of guiding vision, the top-down approach with insufficient effort to build staff commitment; grassroots effort that lacks leadership, commitment, and support; scarce fiscal resources and competing priorities; and the absence of a funded coordinator.

Psychiatric illnesses are chronic medical illnesses. As more people have experiences as patients and caregivers, the pressure to involve family members such as Ms. Stout increases. Where does the resistance to involving family members in patient care come from? There is an unfounded, unspoken fear on the part of health professionals that families want something that the health care provider cannot guarantee – that their relative "will get well and everything will be fine." Health care providers might limit what they say to family members in order "not to upset them." If the family members perceive that they are being brushed off and dismissed, they can develop feelings of apprehension. A small upset or misunderstanding can then unleash repressed feelings, resulting in family members lashing out. When health care teams include the family and develop collaborative relationships with families, the likelihood of this kind of conflict is reduced.

Resistance also comes from the perception that family involvement is not necessary for patient care. Many of the consequences of isolating patients from their family are invisible, such as relationship strain, role changes, and caregiver burden. The reality is that, for patients such as Ms. Stout’s son, his mother’s involvement helps his medical team do a better job of managing his care.

It is time that psychiatry, and specifically the American Psychiatric Association, develop ethical guidelines outlining how to work with families of patients with chronic psychiatric illness. At the very least, we should sign on with other medical specialties by endorsing the American College of Physicians’ ethical guidelines described above. We have lagged behind the rest of medicine by failing to address this important issue.

This column, "Families in Psychiatry," appears regularly in Clinical Psychiatry News, a publication of IMNG Medical Media. Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).