Clinical Dilemma

This is a true story; names and some identifying details have been changed to protect privacy, but I'm having a tough time with this one.

A lady (call her Abigail) came to see me a few weeks ago, very upset: her father had just died. Apparently he had known he had cancer for a year and a half but had told no one. Not his children; not his wife; had not seen a doctor. By the time he came to medical attention it was far too late, and he had died the week before.

She described her family as "not very supportive," including a brother and a sister, as well as her husband. In fact she said she had been talking to a lawyer, mainly to prevent her husband from hiding money if she decided to leave. I tried to get a sense of what the issues were, but she was pretty vague. The patient had taken care of the father in his last days and had been with him when he died. She had not gone to the funeral because, as she said, she and her family just didn't agree on certain things. Besides, she said she didn't want to remember him in a box.

I proffered my usual comfort, offered a small prescription of tranquilizers (there was no history of prescription drug abuse; just scrips for half a dozen Xanax for flying once or twice a year) which she accepted, and a gave her a handout from Family Practice Management called "Mourner's Rights", which I've found quite helpful. She thanked me and, at my request, made another appointment in about two weeks to see how she was doing.

Later that week I saw another patient I'll call Bob. He apologized for being late, as he explained that his father had died a week ago. His mother was having a tough time, so he had just taken her out to lunch. He went on to tell me that his father had known he had cancer for a year and a half but hadn't told anyone. By the time they finally got him to the doctor, it was too late.

That was too odd to be coincidence, so I asked him, "Do you have a sister named Abigail?" It turns out he did. Then he said, "Oh yes; I'd forgotten she comes to you too. We're at the end of our rope with her. She does drugs. Cocaine. She stole our father's hospice meds. She didn't even come to the funeral."

This happens more often than you'd expect. No, not skipping a funeral or stealing hospice meds; but a family member telling me about another's drug use, or drinking, or infidelity, or noncompliance with medical care; all kinds of information that, while potentially useful, is also filled with pitfalls. Is the family member telling me the truth, for starters. I've found myself in the middle of all kinds of family conflicts.

"Bob, are you sure?" Having just seen her, I hadn't detected any signs or warning flags that there might be a drug issue.

"100%. I've seen her with drug dealers. This has been going on so long, we're all just fed up. The problem is that my mother is a nervous wreck, and my sister is really doing a number on her."

"Bob; I'm not very good at keeping secrets." I am, but this is how I broach the topic of sharing uninvited information. "Can I tell your sister that you told me about this?"

"Absolutely not. She's mad at the rest of us anyway, and I'm afraid it would just make things worse." I tried to persuade him. No luck. There was nothing I could do but confront her directly with general questions about drug use and hope she admitted it to me.

I saw Abigail again. I noticed her smiling in the waiting room. When I asked how she was doing, she said, "Fine", but still had this wide grin on her face the whole time she was talking. She said she had another bombshell: "We're getting divorced."

I've been divorced. I never smiled like that.

"Tell me more," I said.

"We just decided. It's been coming for a long time. I've been talking to a lawyer." She went on for a while.

Finally I got a chance to ask some more questions. In the guise of updating her history I asked about any surgeries, new allergies or immunizations in the last year. When I got to the social history I asked about smoking (no), exercise (walking) and drug use: "No."

"Ever?"

"Not since high school, and that was just some experimentation."

"With what?"

"Pot."

"Cocaine ever?"

"No."

She had mentioned she was getting a little cold, so I had a pretext for a brief physical. Nothing abnormal I could detect about her nasal mucosa, pupils or anything else, so I was stuck. There was nothing I could say.

I had the chance to talk with Bob again when I called with his blood tests. He asked if I had seen Abigail and I avoided answering directly. But I said to him, "What can I do if she flat out denies the drug use?" He suggested lying about physical findings, telling her something like "I can tell from your nose you've been doing coke" but those kinds of lies often backfire. I don't do things like that. What if she wasn't snorting it?

I asked again how certain he was.

"Positive. I've seen her with known drug dealers, right up the street from your office." (Oh, great!) "I've seen where the money comes from. I'm certain."

"Have you said anything to her?"

"Like I said; it's been going on so long now, we're all fed up. She won't listen to us."

"Any idea who she would listen to?"

"You, I hope." (Great.)

What if her brother is lying? I don't think so. The balance of credibilty is very much with him (even if I haven't done a very good job in this post of conveying that.)

And that's where it's been left. So what should I do:

1. Confront the patient with the information, along with the name of the informant (against the informant's wishes?)
2. Confront the patient with the information but refuse to tell her how I found out? (This often becomes problematic as the visit devolves into a guessing game about the informant's identity.)
3. Not say anything to the patient unless or until she comes clean on her own? (This becomes more difficult for me as time goes on, as I see things in the context of her drug use but can't address them directly.)

#3 is the obvious ethical default, but it's hard to just stand by and watch when you know someone is doing this to themselves.

Thoughts?