Business Dilemmas

Dr Kathryn Leask describes a troubling scenario with a patient

 

 

 

 

 

Dilemma 1

Should I report him to police? 

QA patient attended for an annual health check yesterday, which was arranged by his employer. He was in good physical shape, but when I asked him about his mental health, I was quite disturbed by his response. 

The patient said he had been unable to sleep properly since his partner left and was unable to stop thinking about whether she was in a new relationship. 

He confided that he had followed her back to her new flat from work and was now parking outside at weekends to ‘keep an eye on her’.

I’m concerned his behaviour will escalate. He seemed consumed by anger. Should I report him to the police? 

AThis is a situation where disclosing information to the police may be necessary to protect the patient’s ex-partner. 

The big question for you to consider is whether the risk that he might cause her serious harm outweighs his right to confidentiality and the wider public interest in medical care being confidential. 

The GMC’s Confidentiality guidance explains that confidentiality is very important for doctor-patient relationships, but it is not absolute. 

It continues: ‘There can be a public interest in disclosing information if the benefits to an individual or society outweigh both the public and the patient’s interest in keeping the information confidential’; for example, to protect individuals from serious crime. 

In line with NHS guidance, it says this would usually include ‘crimes that cause serious physical or psychological harm to individuals’ whereas ‘crimes that are not usually serious enough to warrant disclosure without consent include theft, fraud, and damage to property where loss or damage is less substantial’.

The GMC says that, if you have already decided to disclose information in the public interest, you do not need to obtain consent,.However, you should tell the patient about your intention to disclose the information, unless it is unsafe to do so (para 67). 

If you do decide to disclose your concerns to the police, this should only be the minimum information necessary to allow the police to protect the ex-partner. 

Whether or not you decide to disclose the information, you should document your reasons for your decision and record any conversation that you have had with the patient and police in the notes.

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

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My diabetic patient won’t be monitored

Dealing with a non-compliant patient puts this consultant in a quandary. Dr Kathryn Leask has some suggestions

 

 

 

 

 

Dilemma 2

Do I prescribe without checks?

Q I am a consultant physician and have a patient who has been on insulin for several years. 

His compliance has never been very good and he has needed a lot of encouragement to ensure his blood sugar is monitored to allow safe dosing and for him to have diabetic reviews. 

Recently, his engagement with monitoring has deteriorated and I am concerned about whether I should continue to prescribe or advise him that I will not prescribe any further insulin without an up-to-date review. 

A It is important to try to establish why the patient isn’t engaging and whether this is something that can be addressed with some reassurance or advice. 

Is he having difficulties getting to the clinic or is something else going on in his personal life to prevent him from engaging?

Is he difficult to contact or avoiding calls from you or not responding to written correspondence? 

If so, it may be helpful to ask the pharmacist to speak to him when he collects his medication or ask the pharmacist to let you or one of your clinic nurses know when he attends the pharmacy in case you are able to speak to him then.

If you are not able to speak to him when he collects his medication, on the phone or during a home visit, and if you feel he hasn’t previously been given all the information he needs with regards to the risks of his actions, it would be a good idea to write to him. 

I recommend that any written correspondence is sent by registered post and preferably signed for, so that there is no question as to whether it has been received. 

The patient should be advised about the importance of taking his insulin but also why the monitoring and diabetic reviews are important. He needs to be aware of the risk he is putting himself at if he does not engage with you so that he can make an informed decision.

Risk assessment

It is also important to satisfy yourself that he has capacity to make treatment decisions for himself. Diarise a review or flag the notes so that there is a prompt to revisit matters at future consultations or when the opportunity arises.

With regards to continuing to prescribe without monitoring taking place, you will need to carry out a risk assessment, balancing the benefits and risks of providing treatment unmonitored against the pros and cons of stopping the medication. 

The decision reached will depend on the patient’s particular circumstances. You may feel, for example, that the patient’s need for insulin, even if this is unsupervised, outweighs the risks associated with not taking it at all, especially if he is able to check his own blood glucose level. 

If, after taking these steps, the patient still won’t engage, make sure he knows that he can contact you at any time and put measures in place that will help him to manage his condition himself as safely as possible.

• See ‘Gauging fitness to drive’

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