How to avoid trouble when a patient offers you a gift

Dilemma

Mrs H’s daughter has come to the practice with a gift and a card thanking you for your devoted care of her mother.

"Please don’t say no, your conversations meant so much to her and she really wanted you to have it."

Should you say yes?

Considerations

A gift from a patient who has appreciated your care can be a great boost. In most cases, small gifts — a tin of shortbread, flowers, a bottle of wine — will just be a thoughtful gesture. But sometimes a gift can raise professional issues.

Gifts can become an issue if they could affect the doctor–patient relationship, or if they create a perception the relationship was exploited, or care was compromised.

In some cases, questions are asked about gift-giving when the patient complains. Some may feel they should have been given special treatment in consideration for their gift and they were disappointed.

In other cases, concerns may be raised by family members when they believe the patient has been exploited or given inappropriate treatment.

And it is important to stress that bequests or gifts from former patients, or from family members of patients, can also raise similar questions about whether the treating relationship was exploited in any way.

Using your judgement

Your hospital or practice may have a policy on patient gifts — what you can accept, who you need to tell, or how to record gifts.

Policies may say gifts of a nominal amount may be accepted.

Where there is no policy, you need to use your judgement. While monetary value of the gift is one guide, unfortunately there’s not always a clear line to indicate when a gift is inappropriate.

It will often depend on the context.

The starting point is the Medical Board of Australia’s Good Medical Practice. It states that doctors need to be honest and transparent in financial arrangements with patients and to avoid encouraging patients to “give, lend or bequeath money or gifts that will benefit you directly or indirectly”.

Have you encouraged gift-giving?

Could there be any suggestion you exercised undue influence or exploited a power imbalance between yourself and the patient? This is likely to be a particular concern if the patient is vulnerable, or if relationship boundaries have blurred.

If you directly encouraged a patient to lend you their luxury boat or leave you their sportscar in their will you could expect serious questions to be asked.

However, the NSW Professional Standards Committees have indicated it is not enough simply to satisfy yourself the gift was not encouraged.

Even if a gift is unexpected you need to be confident you haven’t offered indirect encouragement.

Something to be aware of here is accepting small but frequent gifts which might become a pattern of gift-giving.

It is important you talk to the patient and stress that gifts are unnecessary.

Who knows about the gift?

Transparency is also important, and another red flag in such cases will be any indication the gift was secret.

So, you can ask yourself whether you are comfortable for the patient’s family members, colleagues, the regulator to know you received this gift.

It can help to talk to colleagues to get another perspective and check your judgement has not been clouded by your relationship with the patient.

Other considerations

Proportionality and context are also important.

An expensive Christmas gift from a wealthy patient who donates frequently and generously to every business in town may be less problematic than a smaller gift from a patient who was struggling to pay household bills.

Another issue is whether anyone else may be affected by the gift.

Bequests can be challenging here and in such cases we advise talking to other beneficiaries and checking whether there are any concerns.

Another problem: will refusal offend?

Declining a generous gift can be distressing or insulting to a patient, or their family members.

Again, the starting point is usually to talk to the patient or family, thank them, stress the gift is unnecessary and explain why it may raise professional concerns.

If it is difficult to refuse a generous gift, it is often most appropriate to find a solution that takes away any suggestion of personal benefit.

A donation to a relevant charity or healthcare service can be a good option.

In summary

Gifts from patients do not necessarily breach boundaries. Before accepting a gift, however, consider how acceptance may be interpreted and whether it may affect your professional relationship with the patient.

Never encourage patients to give gifts or money, and always check your hospital or practice policies.

If you receive a claim or complaint, contact us for medico-legal advice via email at nca@avant.org.au or call 1800 128 268, 24/7 in emergencies.

This article was originally published in AusDoc. on 29 April 2022.