March/April 2019

Clinical Matters: Should Physicians Hug Their Patients?
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 12 No. 2 P. 6

Hugs are an obvious way to establish a personal connection or offer comfort to someone who’s struggling emotionally. But in the context of the patient-provider relationship, questions arise: Are hugs consistent with professional ethics? Does an embrace make patients feel valued and validated or does it undermine their dignity?

For Maria Vejar, DNP, GNP-BC, a senior instructor in the division of geriatrics at the University of Colorado School of Medicine, embraces are definitely worthwhile. Vejar, who has a reputation as a “hugger,” began offering hugs when she was an RN and carried over the practice once she became a geriatric nurse practitioner. “I just found that it’s a very special way to make a connection with someone—particularly older adults—because a lot of these patients are widows, they’ve lost children, they’re living alone, depression is a big factor for them,” Vejar says. “For most of them, I think it’s honestly very therapeutic. You can think of it almost as a form of healing and treatment.”

Christopher Stearns, MD, an internist with Austin Geriatric Specialists in Austin, Texas, didn’t start out hugging, but his perspective on the topic has evolved in recent years. He realized after a few instances of witnessing other physicians offering hugs that the embraces had legitimate therapeutic value. “Sometimes a hug was just as important as what was being prescribed,” he says.

Stearns, who now offers occasional embraces to his own patients, senses that his personal evolution reflects a broader trend among physicians. During his medical training, he was encouraged to have a more formal relationship with patients, and hugs were discouraged. (Once, when Stearns was still a student, he offered a hug to a patient after having to break some bad news and was reprimanded by a preceptor for doing so.) But he perceives that the culture of medicine is changing, and that physicians in general are more open to hugs now than they were in previous decades.

The Risks of an Embrace
Although physicians might have good intentions in offering a hug, Ben Rich, JD, PhD, an emeritus professor of bioethics at the University of California, Davis, School of Medicine, says there are ethical concerns if the physician is the one to initiate. “There is a lot of discussion in the literature about the imbalance of power in the physician-patient relationship,” he notes. Even if a physician asks first, he says, patients might feel they have to accept hug, on the grounds that declining could influence the physician-patient relationship and the quality of care.

If the patient is an older adult, Rich says, there are additional concerns. As individuals age, there’s a cultural tendency for those around them to begin speaking and behaving as if the older individual is returning to childhood. “The way they talk to you can sometimes be demeaning,” he says. Thus, physicians who are inclined to hug an older adult patient should do so with care. “The physician should ask herself, ‘If this person were half their age, would I do this?’” Rich says. “If the answer is no, then they really need to engage in further self-inquiry: ‘Then why am I doing it with this person?’”

When Patients Want Hugs
But providers who see a significant portion of older adult patients say that hugs are often welcome. Rosemary Laird, MD, MHSA, a geriatrician at Florida Hospital’s Centre for Senior Health in Winter Park, says she often gets requests for an embrace. According to Laird, some patients are “routine huggers”—they hug even if they’re just in the office for a weight check. But often, patients reach out for physical touch in response to grief situations. “They’ve come in after the death of their husband, or God forbid, one of their kids has died unexpectedly, or they have to move to an assisted living facility, and so there’s this highly charged, emotional event,” she explains. “This is an important moment for me to be empathetic to them and give them some additional comfort,” Laird says.

In Vejar’s case, some patients who have come to know her and are used to receiving an embrace from her will actually remind her if she forgets on a given visit. “If I know them, a lot of patients frankly just expect it,” she says. “They’ll say, ‘Wait a minute, where’s my hug?’”

According to Vejar, hugs might have value for other patient populations, but they are uniquely significant for many older adults. “So many of these patients are isolated. Their big outing is coming out to the doctor’s office maybe every couple of months,” she says. “They don’t have a lot of personal touch, and it’s a nice way to let them know that they’re valued and that I’m just happy to see them.”

Seeking Consent
Although Stearns perceives that many patients appreciate a hug, he’s careful to determine a patient’s comfort level with physical touch before reaching out for an embrace. For him, this is usually a matter of reading a patient’s body language over the course of a few visits.

Others, including Vejar, are inclined to ask explicitly whether the patient is comfortable with a hug. For Vejar, the question typically comes up in situations where she perceives that the patient is struggling in one way or another. If she doesn’t know the person, for example if she’s meeting someone for the first time, she’ll “base it on how they’re doing,” she says. “If we’re talking about something that’s particularly distressing to them, or they’re sad or they’ve been through a loss, or they’re just overwhelmed, you can usually tell based on how the visit’s going. If they’re tearful or sad, then I’ll ask them, is it OK if I give you a hug—would you like a hug?”

Still others stand back and wait for the patient to initiate. “I want to respect their personal space,” Laird says. “We get some allowances during our physical exam to physically touch them, but outside of that, I like to show respect to them for their social-personal space.”

According to Rich, who was a practicing attorney prior to becoming an ethicist, it’s best to err on the side of caution. If the patient has clearly indicated interest, there’s no reason for concern. But if a physician were to hug a patient who had not given prior approval and who did not welcome the action, the embrace could be construed as battery. Particularly given recent media attention to the topic of sexual assault, physicians must have a good faith basis to believe that the patient would appreciate a hug. “I’m making this sound like both a legal and an ethical minefield, but maybe that’s the way it is,” Rich says.

If the provider has previously offered some physical touching that was well received by the patient—such as touching the patient’s hand or arm—then providers could have a good-faith basis to believe a hug is appropriate the next time, Rich says. Still, getting a verbal confirmation is probably better. “There is nothing to stop you from asking them. That doesn’t undermine the gesture,” he says.

Other Considerations
Aside from seeking verbal consent, providers should also consider the context of the hug. Specifically, are the patients dressed in their street clothes or are they wearing a hospital gown? “The latter is particularly problematic,” Rich says. “It’s a posture of extreme vulnerability. They’re exposed. It takes the power differential and exponentially increases it.”

The presence of others in the room can also make a difference, Rich says. If a spouse, a son or daughter, or some other companion of the patient is in the room, patients are more likely to perceive physical touch positively than if they are alone with the provider.

Although providers should be careful to respect a patient’s physical space and privacy, they shouldn’t be intimidated by embraces when the patient is actually open. “Don’t be afraid to show that kind of emotion,” Laird says. “Follow patients’ cues. Let them lead if that’s a way they like to express their gratitude or their emotion.”

Hugging should never be mandatory, Vejar says, but providers should recognize how much a hug might mean to patients. “It lets them know that their presence is welcome, that they are valued, that we care about them, and that they are being heard,” she says.

— Jamie Santa Cruz is a health and medical journalist based in Parker, Colorado.