Patient doesn’t want visitors

Business Dilemmas.

Dr Kathryn Leask

Dr Kathryn Leask discusses how to remotely manage a patient’s lithium prescription.






Dilemma 1

Should I refuse to prescribe?

Q I am a private GP and have been conducting appointments remotely during the pandemic. I am now seeing more patients face to face; however, some patients have found the remote consultations more convenient. 

I have one patient who is on lithium. He has social anxiety and does not like people coming into his home. He also has other health problems and has spent much of the pandemic shielding. 

Fortunately, he is able to work from home and I have no concerns about his capacity. He hasn’t had his lithium level checked for some time and I am concerned about continuing to prescribe for him, with no recent result. 

I have had phone consultations with him where I have asked about signs or symptoms that could be suggestive of lithium toxicity. 

Should I refuse to prescribe until he has had his level checked? I have mentioned to him that I may have to stop prescribing for him, but he has said he will obtain the medication he needs from the internet.

A There are several important points to consider when bearing in mind the GMC’s updated guidance on prescribing. 

Firstly, is whether the mode of a consultation meets the individual needs of the patient and supports safe prescribing. 

Usually different options will exist, but if it is not possible to have a face-to-face consultation with this patient, a phone or video consultation is the only option. 

As you aren’t able to see the patient, it may be a good idea to consider more regular consultations, done remotely, than you would normally have for this patient if he was being seen for reviews face to face. 

This will allow you to assess any risk and establish whether he has any signs or symptoms of under treatment or toxicity at an early opportunity. 

While the patient is uncomfortable with people going to his home, it is worth seeing if he will compromise and allow a district nurse to visit him to take blood, given that this will probably only be every three months at the most.

Two-way dialogue 

If he prefers, you could suggest that a friend or family member whom he trusts could accompany him when the nurse attends.

The GMC’s updated guidance emphasises the importance of a two-way dialogue with patients when prescribing medications. 

It is important that the patient understands the reasons why monitoring is so important and the risk he is placing himself at if he does not have his lithium level checked. 

He also needs to be advised of any signs to look out for that might suggest he is not taking the right amount and how to seek appropriate advice, particularly in an emergency. 

With the patient’s permission, it would also be helpful to speak to a friend or relative who can also look out for any potential problems and seek assistance on the patient’s behalf if he is unable to do so himself.

When deciding whether to continue prescribing, it is important to weigh up the risks and benefits to the patient. Will the patient be at more risk if you continue to prescribe without monitoring or would he be at more risk if you stopped the medication? 

Talk to others

You also need to take into account the risks associated with the patient obtaining medication from the internet and the fact that you won’t know whether this is, in fact, lithium or what dose he might be taking. 

Whichever decision you make, it is important to be able to justify this and you may, therefore, wish to discuss the situation with a colleague or a mental health professional, particularly if there is one already involved in the patient’s care.

It is important to document your discussions with the patient in detail, noting what information he has been given about the risks and his reasons for not agreeing to monitoring. 

If you do decide to continue to prescribe, it should also be made clear to the patient that he can contact the practice at any time if he has any concerns or should he change his mind and want to have his blood test done.

Dr Kathryn Leask is medico-legal adviser at the Medical Defence Union

A challenge to your expertise

Dr Ellie Mien

Dr Ellie Mein explains how to respond to a solicitor’s request for assistance.






Dilemma 2

Have I exceeded my expertise?

Q I am a private GP who recently received a letter from a patient’s solicitor. The letter, which was sent with the patient’s consent, asked for a letter to confirm that the patient would not be fit to attend court. 

I responded by writing a brief letter detailing the patient’s mental health problems with the conclusion that these would render the patient not fit to attend a court case.

Following this, the patient’s solicitor forwarded correspondence from the solicitor for the other party which asked what experience I had in assessing individuals as being fit for giving evidence. 

They also requested a copy of my CV to clarify my experience of what attending court would entail.

In hindsight, I feel that I may have strayed into giving an opinion in an area that I lacked sufficient knowledge in. 

What should I do? 

AParagraph 74 of the GMC’s Good Medical Practice (2013) states that: ‘You must make clear the limits of your competence and knowledge when giving evidence or acting as a witness.’ 

In these circumstances, it would be advisable to write a letter to the patient’s solicitor explaining that:

  1. You had given your opinion based on the numerous medical conditions as listed in the original letter;
  2. The patient confirms that they would find giving evidence in court extremely stressful to the detriment of their mental health; 
  3. Your opinion was given in the capacity as the patient’s private GP rather than as a specialist with knowledge of legal proceedings and their impact on an individual’s mental health.

Dr Ellie Mein is medico-legal adviser at the Medical Defence Union