Good Practice: When is it ok to Accept Gifts From Patients?
December 5, 2018
Nancy Littke, PT, Practice Advisor
Over the course of my career, there have been many times when a patient has arrived at the clinic bearing a gift. Often these gifts were related to specific events such as the holiday season or at the end of treatment. Usually they were small gifts of baking, a bottle of wine or a coffee gift card. However, sometimes they have been larger gifts and I have had to decide if it was appropriate for me to accept it or not.
Although, there are no rules that explicitly prohibit accepting gifts from patients, Physiotherapy Alberta cautions members that accepting gifts has the potential to negatively impact the therapeutic relationship.1 Accepting gifts carries some degree of risk of crossing the boundaries between the personal and the professional relationship. Accepting gifts is generally considered part of a personal relationship rather than a professional one.
There is limited literature or research related to the impact of accepting gifts from patients on the patient-provider relationship. Caddell and Hazelton surveyed physicians and found that the most common patient gifts are chocolates, baking, alcohol and money.2
Opinions can be presented for both sides of the argument of whether to accept or decline a gift and with no clear, consistent guidelines to support the provider’s decisions. They recommended that health-care professionals incorporate a “conditionally accept” policy applied on a case by case basis and that the final decision must be left to the discretion of the individual receiving the gift.2
My personal experience would suggest that the circumstances and issues would be similar in physiotherapist/patient relationships. Physiotherapy Alberta takes a more cautious approach to this issue and reminds members to be aware of the risks that accepting gifts carries in a therapeutic relationship.
While it may be acceptable for a physiotherapist to accept a modest gift from a patient during “socially or culturally appropriate times” (such as the holiday season), Physiotherapy Alberta recommends physiotherapists use caution when deciding whether to accept a gift, and to consider both the value and the context in which the gift is being offered.
The Therapeutic Relationship Resource Guide3 suggests asking yourself:
What motivated my patient to give this gift? Is there a desire for a “special relationship,” or future preferential treatment or is this a simple thank you gift with no intended strings attached?
Is this a gift meant for me personally or is it a clinic gift? Is the gift something of a more personal nature?
Did my self-disclosure (i.e., my upcoming birthday) make the patient feel obligated to bring the gift?
Will accepting the gift impact my ability to make objective, unbiased clinical decisions?
Could the patient’s family perceive that accepting the gift constitutes fraud or theft, or be a result of manipulation?
Is the giving and receiving a gift a “cultural norm” from the perspective of the giver and how would declining the gift affect the therapeutic relationship?
When deciding if the gift is modest or lower risk here are a few things to consider:2
For the Group/Clinic
"Thank you" at discharge
Private pay patient
Solicited (real or potential)
Third-party insured patient
Physiotherapy Alberta recommends that physiotherapists and their employers develop a personal or clinic policy that provides clear guidelines as to what gifts may be accepted and what staff are expected to do when a gift has been offered. This policy could include direction such as donating all monetary gifts to charity or placing consumable gifts in a staff room. A predetermined plan will help to ensure consistency and minimize the pressure on patients or staff to give or accept gifts. This will also make it easier to provide justification or clarification to the patients when gifts must be declined.
Your employer policy may allow the acceptance of gifts under specific circumstances; however, if it feels wrong to you, take that as a sign that it may be best to graciously decline the gift. If you decide to decline the gift, be honest and clear with the patient as to why you do not feel comfortable accepting the gift. If the patient insists on giving a gift, make suggestions of things they can do that are consistent with your employer or personal policy, like donating to a specific charity or bringing a food item that all staff can share.
Remember, context and intent are important. The patient may be just trying to say thank you with a modest gift of chocolates, baking or a bottle of wine or it may be culturally expected to present gifts at the end of a professional relationship.
Let’s look at some scenarios and discuss some options.
A student is working with one of your elderly clients. At the end of the student’s placement the client presents your student with a thank you note and the envelope contains a $100 bill. The client indicates that she realizes students often have student loans and she wants to assist with a little cash. Is this appropriate? Should the student accept the gift? How could you address the intent of the gift without insulting the patient by simply refusing?
Consider the questions from earlier in this article. What was the intent of the gift? Was there a desire to affect the clinical decision making or the professional relationship? Had the student solicited the gift in any way? It was a monetary gift and was given directly to the student. While it has been suggested that gifts of a nominal value may be accepted, I would suggest that $100 cash given to a student may not be appropriate.
This would be a good time to have a discussion with the student about the ethical considerations and risks involved when accepting gifts. The student may then thank the patient for the thought behind the gift, but clearly indicate that he/she is not able to accept the monetary gift. If the patient is insistent, then suggesting that a donation could be made to a charity such as a hospital foundation, a local seniors center, a student charity at the University or some other charitable organization of the patients’ choice would be a good compromise. The student could also cite any employer direction about what is considered nominal.
A WCB patient you are currently treating has offered to provide you with two tickets to the Grey Cup Game. Should you accept?
In this scenario, the answers to the test questions would strongly suggest that this would not be an appropriate gift to accept from this patient. The treatment is ongoing, there is a third-party payer involved and the patient may well expect more favorable reports or recommendations to facilitate their claim. The value of the gift is significant and personal. There is the potential that the intent of the gift may be to affect the relationship and garner future preferential treatment. Whether consciously or not, the clinician’s objectivity in making clinical decisions may be biased by the gift.
Having transparent and specific policies in the clinic or facility would make it clear for both the clinician and the patient that a gift of this nature cannot be accepted.
Your patient has discovered that it is your birthday and brings in pizzas for the clinic. Can you and the team dig in?
Initial thoughts for this type of gift would probably not raise any red flags. The gift is spontaneous, edible, shareable and clearly meant for the clinic staff. Accepting this with a thank you from the staff members would be reasonable and appropriate.
Your patient presents you with two bottles of wine at their discharge visit. What should you do?
Again, this may be an “it depends on the situation” scenario. Accepting a bottle of wine may be no different than accepting a box of chocolates to many people. Consider the value and the intent of the gift. Showing your appreciation and indicating you will open the wine to share at a staff party or enjoy it at home on a special occasion would be appropriate.
However, if the patient has demonstrated a desire to pursue a more personal relationship with you this gift carries with it the very real risk of crossing professional boundaries and being interpreted as inviting a different relationship and should be politely returned and the reasons for declining clearly communicated.
Patients will continue to offer their therapy team gifts as a means of expressing gratitude, goodwill or just to say goodbye. It is important that each of us exercise sound clinical judgment when we are deciding to accept or respectfully decline a gift. Consider not only the intent, value, and the effect accepting the gift may have on your clinical decision making, but also on the intent of the gift giving from the patient’s personal and cultural perspective. Finally, consider how accepting or declining the gift may affect the therapeutic relationship itself. These scenarios are rarely black and white and should be considered on a case-by-case basis. Employing a cautious, consistent approach to accepting gifts and having clear organizational policies will help most physiotherapists navigate this common occurrence professionally and ethically.
Physiotherapy Alberta College + Association (2017) Standards of Practice: Professional Boundaries. Available at https://www.physiotherapyalberta.ca/files/practice_standard_professional_boundaries.pdf Accessed Oct 29, 2018.
Caddell A, Hazelton L. Accepting gifts from patients. Canadian Family Physician. 2013;59(12):1259-1260. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860914/ Accessed Oct 17, 2018
Physiotherapy Alberta College + Association (2017) Therapeutic Relationships Resource Guide. Available at https://www.physiotherapyalberta.ca/files/guide_therapeutic_relations.pdf Accessed Oct 29, 2018.
Born to Move
Patient Safety. Every Person. Every Time.
Practicing as a Physiotherapist in Alberta
Regulating Alberta's physiotherapy profession and acting as an association by providing member services.