Telehealth Ethics: The Role of Care Partners

Introduction

With new applications of telehealth, there are situations where licensed professionals are not available in person and care partners may assist with physical maneuvers or examinations under the direction of a telehealth provider. Care partners are present during the telehealth session with the patient and may include patients' family or friends. There are unique ethical considerations in the use of care partners during telehealth examinations, yet there is limited guidance for such interactions.

Historically, caregivers have helped with wound care, intravenous medication administration, ^1,2 home exercise programs, and palliative care in the home setting after receiving adequate training. Caregivers have also served as interpreters, posing unique ethical challenges, ³ although federal regulations now require the use of professional interpreters during clinical encounters. ⁴ In telehealth, the care partner has become an invaluable extension of the care team. For example, a poststroke patient recovering at home connects weekly with the outpatient poststroke rehabilitation team via videoconferencing. To assess the patient's upper extremity motor function, the occupational therapist directs the spouse to move the patient's plegic arm in a series of movement patterns. Another example is a video-based telehealth encounter between a patient and the cardiology team following hospitalization for congestive heart failure. The patient's son is present and asked to place the electronic stethoscope on his mother's anterior chest for remote auscultation. Each of these scenarios is ethically challenged by placing untrained individuals with close personal relationships to the patients in positions of responsibility as health care providers, potentially placing patients in harm's way if substandard care is provided, and potentially invading the personal space of both patients and care partners.

Technology in and of itself is neither ethical nor does it have moral status in the absence of those who use it; it is the intent and application by those involved in the use of technology that determine ethicality. ⁵ It is in this context that we must seriously consider the appropriate use of care partners in the application of telehealth. As in the dynamic relationship of traditional caregiving, telehealth providers have compelling obligations to the dyad that forms between care partners and their patients. This partnership defines itself morally through both individual and shared values, needs, and dignities. The dyad also functions individually in developing a trust relationship with the telehealth team. ⁶ In securing that trust, the telehealth team must also dedicate itself to meeting the unique and nuanced ethical demands of the patient–partner dyad.

Respect, Dignity, and Self-Determination

Patients should formally consent to having a care partner involved in their care and be fully informed about the activities and responsibilities of that role. Consent should also be obtained to allow telehealth providers to disclose information about the patient's condition. Telehealth providers should be aware and sensitive to the cultural and health literacy needs of both patients and their care partners during telehealth interactions. Care partners should also consent to their active participation in the telehealth intervention. As part of the informed consent process, the patient and care partners must have a clear understanding of what is being asked of them, potential harms (e.g., misinterpretation of findings), available alternatives (e.g., in-person encounter), and the right to discontinue participation at their discretion. The telehealth team should be sensitive and responsive to any concerns about both patient and care partners' physical or mental health.

Seeking Optimal Clinical Outcomes and Avoiding Harm

Telehealth has promise to create value for the patients and their care partners. The primary goal of telehealth is and should always be to optimize the clinical outcome and comfort for the patient. All other goals, including profitability, should remain subsidiary. Goal orientation for care partners should be no less compelling. Telehealth requires more from care partners than in-person care, including the potential need to learn new knowledge and skills. Patients and/or their caregivers may be overwhelmed by using telehealth technology; however, as patients become more familiar with the technology, these concerns tend to subside. ⁷

It is unclear what examinations and maneuvers should be considered appropriate for care partners when participating in telehealth examinations of the patient. The level of expertise and skill needed may guide the selection of maneuvers appropriate for the care partner to perform. While currently the decision as to how to involve care partners at the moment of care is that of the telehealth provider, at present there is no clinical or ethical guidance to assist the provider in making such decisions.

Equity and Fairness

Although admittedly a lofty goal, health care systems and telehealth providers should strive to provide reasonable access to telehealth services wherever needed. Paradoxically, the availability of telehealth can perpetuate inequities in health care access when differences in socioeconomic status, health literacy, or social support exist to create substantive barriers for some patients. Patients should be provided access to in-person services when it has been determined that hands-on physical examination is needed but a care partner is unwilling or unable to participate.

Call to Action

To ensure maximum safety and quality when incorporating the use of care partners in telehealth, it will be increasingly important to ensure that they are reliable and safe members of the telehealth team. A simple rule of thumb is that telehealth providers should not ask family members or other care partners to participate in patient care activities remotely that the provider would not feel comfortable having them perform during an in-person encounter. Evidence-based guidelines that are both generally applicable to all encounters and specific to specialized needs of the particular clinical encounter are needed to ensure maximal safety and quality of telehealth where care partners are used.

As health care systems continue to advance the use of technology for the remote care and management of complex patients, they must also accept that creative additions and modifications to the telecare process will be needed when special needs arise. As with any innovative change, there may be unintended consequences that could have deleterious effects. The discipline of telehealth must thoughtfully consider the use of care partners and guidelines that will ethically guide their use during telehealth encounters.