What if Patients or Families Are ‘One of Us’? Equity in Critical Care

When we clinicians find ourselves as critically ill patients or visiting family members, the dynamic changes. We often receive more detailed information, additional treatments, extended visiting hours, and other privileges. But is that truly fair?

Introduction

It is very stressful and challenging for both patients and families to be involved in intensive care treatment. One-third of the family members report impaired health (e.g. depression, anxiety, fatigue) far beyond the loved one’s stay (Azoulay et al. 2005; Hoffmann et al. 2020; Kang 2023). To mitigate these negative effects, it is essential to involve the family in the treatment process. An important aspect of this is flexible visiting hours in the intensive care unit (ICU), which allow them to spend as much time together as possible without being restricted by traditional visiting hours (de Souza et al. 2024). Although guidelines recommend family-centred care in the ICU (Davidson et al. 2017; Hwang et al. 2025), which includes flexible visiting hours, shared decision-making, and the option of an ICU diary, many ICUs still maintain strict visiting policies.

In the following paragraph, we describe a case scenario in which we observed differences in the treatment of family members.

Case Study

Mr Jones is in the ICU due to severe sepsis. His wife and daughter come to visit him. Due to the current visitation rules, access for family members is strictly limited, allowing them only brief visits. The attending physician provides them with brief information about the patient’s condition, and then the nurse asks them to leave the unit because it is already 6 p.m. The next day, his wife and daughter return. The daughter identifies herself as a cardiology resident working in the same hospital. Immediately, the staff’s behaviour changes: the physician takes more time for a detailed conversation, explains the ongoing treatments more thoroughly, and allows the daughter to stay by her father’s bedside for an extended period. The nurse in charge provides them with more information, offers coffee and integrates them into Mr Jones’s care. After they leave, one nurse comments to the colleague, “If we had known that earlier, we would have treated them differently.” The nurse replies thoughtfully, “But shouldn't we treat all relatives the same way?"

Being on the Other Side

If patients or relatives are healthcare professionals, the status and relationship between them and the team is even more complex. During the ISICEM Congress 2025 in Brussels, Katarzyna Kotfis said: “This information changes everything, and it is not right!” It changes the number of treatments, the quality of information, the duration of visiting times, and much more. It also changes the views and experiences of the involved persons. But it also has pros and cons (Figure 1), questioning the central value of equity in healthcare (Kotfis et al. 2024).

When Healthcare Professionals Become Family Members

Being a healthcare professional when a loved one is in critical condition is a challenge, especially when they need intensive care treatment. On the one hand, it may have a positive effect on the relatives, as greater knowledge gives them more confidence. On the other hand, the relatives are torn between the roles of a healthcare professional and a relative. Carlsson et al. (2016) identified the following roles of healthcare professionals: the informed bystander, the supervisor, the advocate, and the carer.

The informed bystander has minimal involvement in nursing and medical processes. They seek professional patient information but do not participate. Using their own knowledge, they help the family understand the patient's condition and health status. The supervisor monitors their patients’ health, checks test results, and oversees the quality of care. They don't engage directly but support patients in voicing their needs. Their knowledge of hospital processes helps protect patients and ensure good care. The advocate handles communication with healthcare staff, ensuring patients are monitored and included in key decisions. When excluded, they may feel frustrated or lack access to specific information. They are vital when patients can't decide for themselves, such as during sedation or intubation. The carer assumes significant responsibility, often providing most care when quality is perceived as lacking. They monitor medical parameters and give direct care. This role often arises from a lack of trust in hospital staff. For those with a healthcare background, this can lead to stress and internal conflict between their professional and family roles. Achieving the correct balance between loyalty to the family member and professional distance to the healthcare colleagues in the hospital represents a considerable challenge (Carlsson et al. 2016).

When Healthcare Professionals Become Patients

Some argue that being a patient themselves may have beneficial effects for clinicians, increasing empathy and changing attitudes (Bein 2017; Campbell 2012). Clinicians as patients are patients, of course, but also critical analysts, observants of themselves and the staff, and researchers in their own suffering and healing. They experience a sense of distance from themselves, observe themselves as patients, evaluate their own symptoms, gather information, experience a loss of control, seek help and treatment, and can be in a conflicted relationship with former colleagues (Tuffrey-Wijne and Williams 2015). And they admit sometimes that they can be terrible patients (Campbell 2012). Caring for them can be a complex challenge for clinicians, often leading to conflicts.

One of Us

When we know that the patient or family members are healthcare professionals themselves, we consciously or unconsciously begin to treat them differently. A possible reason for this could be the shared professional background, similar professional experiences, and understanding of the potential tension between the roles of a healthcare professional and a family member (Everett et al. 2015). They are one of us.

Alternatively, we could assume that a patient or a family member with a healthcare background can process a significant amount of medical information more quickly and communicate it more effectively to other family members. This could exacerbate the problem of role confusion, potentially leading to increased emotional stress for the family member. For this reason, some family members do not disclose their professional background out of fear of being treated differently (Khatib et al. 2022).

As relatives, their professional background offers access and influence. On the other hand, family members with a professional background can take a proactive role in their family member’s health situation because they are familiar with the hospital's structure and have a good overview of medical information. Proactive family members have a greater chance of influencing their family member’s treatment and therefore have a greater chance of getting their needs and concerns accepted (Hoffmann et al. 2023).

Structural and logistical factors also influence the well-being of family members (Hoffmann et al. 2023; Mehta et al. 2025). It might be assumed that healthcare professionals from the same hospital avoid these structural factors because they know the physicians or visit their relatives before or after their shift. Stressful factors, such as not knowing how to navigate the hospital or having to pay for expensive hospital parking, can be eliminated for healthcare professionals.

But … Equality?

Equality (all individuals are treated the same, without discrimination or favouritism) is a core ethical principle and obligation of healthcare professions displayed in their codes of ethics (International Council of Nurses 2021; World Medical Association 2017). However, in everyday healthcare, people are treated unequally – intentionally or not – for very different reasons and underlying motives, such as racial, ethnic, language, and gender characteristics leading to implicit bias (Groves et al. 2021). Unlike these harmful forms of mistreatment, the question now arises as to whether our case is also such a form of inequality. Being ‘one-of-us’ likely increases the chance for more information, extended examinations, more and higher level consults, more exceptions of routine care, possibility of over-care, and less time and resources for other patients. One question from an ethical perspective is, therefore, whether the difference in treatment can be objectively justified.If it is an (un)conscious favouring of one’s own group, whereby members with a medical background receive preferential access or more information (Everett et al. 2015), this behaviour should be prevented.

Another point is that being a healthcare professional typically comes with certain privileges. The ‘duty of care’ and the ‘duty to treat‘ could thus also be accompanied by special rights that we owe to them as a society for their commitment. The question of prioritising healthcare professionals based on their professional affiliation has been widely discussed during the COVID-19 pandemic; however, the arguments (e.g., reciprocity argument) are limited in their applicability to the situation at hand. How can we deal with a situation when a patient or relative purposefully reports their own status of being a healthcare professional to achieve favouritism and related benefits?

Equality When Roles Change

When patients or relatives are healthcare professionals themselves, the situation becomes more complex, often triggering various reactions and presenting emotional, rational, social, and medical-ethical challenges. These processes may have both advantages and disadvantages. While we cannot always avoid them, we should be aware of them and able to raise awareness and relevant questions (Table 1).

To be clear, from an ethical perspective, promoting patients or families with any advantages due to their healthcare profession violates equity in healthcare and is unacceptable. Patients or families from healthcare professions who require special treatment due to their profession should be informed about ethical boundaries and obligations and assured that all patients and families receive the best care, regardless of their profession or other circumstances.

Conclusion

Human beings, regardless of their role in life, bring their own background, knowledge, values, ideas, and (pre)judgments to complex situations, ethical questions, and collaboration. It should be understood that this is also part of the professional conduct of healthcare professionals and their behaviour in a community. Now, it is time for reflection and an open discussion about the latter in our roles and the implementation of necessary changes.

Conflict of Interest

None.