Business Dilemmas

GP and MDU phone adviser Dr Rachel Sutcliffe responds to a request to discuss what to do if family members disagree about what is best for a patient.

 

 

 

 

Dilemma 1

How can I settle siblings’ spat?

QI’m a private GP who has an older patient who recently moved into a nursing home following a stroke. 

The patient is unable to speak or communicate, has a dense hemiplegia and is being fed via a percutaneous endoscopic gastrostomy (PEG). As such, the family and I agree that the patient lacks capacity to make decisions about their health and welfare, and that a care plan should be put in place to facilitate their care.

During the patient’s hospital admission, a DNACPR decision was agreed upon. Further to this, I believe it to be appropriate to prescribe antibiotic therapy for chest, skin or urine infections, but I don’t feel it is in the patient’s best interests to be admitted to hospital if they failed to respond to antibiotic therapy administered at home.

However, the patient’s daughter has told me that she disagrees with this view, saying that the patient has ‘no quality of life’ and is ‘being kept alive by the PEG’. 

‘Allowed to die’

She feels this is cruel, not what the patient would have wished, and that they should be ‘allowed to die’. 

The daughter has told both me and the care staff that she did not want the patient to have any active treatment, including antibiotics, and that she felt the PEG feed should be stopped.

The patient’s son, on the other hand, agrees with my approach and feels that the patient is comfortable and well cared for at the nursing home, but that the patient would not have wanted to be re-admitted to hospital. 

He wants the patient to have treatment to keep them comfortable – including antibiotics – at the nursing home. 

I also understand that the siblings do not get along and that the two of them are unable to agree on how to proceed with their relative’s care. 

I have a meeting next week with the care staff and the siblings and am not sure how to proceed. Can you advise? 

AFirstly, it is positive that both siblings have agreed that the patient lacks capacity as defined by the Mental Capacity Act 2005. 

If you have not done so already, it would be useful to document a capacity assessment and to check there was no advance decision or lasting power of attorney for health and welfare in place.

When this is confirmed, decisions about the patient’s medical care would then need to be made by you, as the decision-maker, in the patient’s best interests. 

The Mental Capacity Act Code of Practice (particularly paragraphs 5.63-5.69) may be helpful when considering how best to approach the meeting and family members who disagree about treatment.

Ideally, as the decision-maker, it is your responsibility to determine the patient’s best interests and you would need to try and find a way of balancing the differing views and to decide between them. 

It might be possible to reach an agreement with the daughter at the meeting, but, if not, involving an advocate to act on the patient’s behalf could be considered. 

If the daughter disagrees with the final conclusions, it might be useful to arrange a more formal ‘best interests’ case conference. 

Ultimately, if all other attempts to resolve the dispute failed, the Court of Protection might need to decide on the patient’s best interests, but this would be unusual.

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Flying in face of danger

So what’s the way to tackle things if you feel it is unsafe for a patient to travel abroad? MDU medico-legal expert Dr Rachel Sutcliffe advises.

 

 

 

 

Dilemma 2

Do I disclose her heart failure?

QI recently had an appointment with an older patient at my private general practice. During the appoint­ment, she also asked for a two-month supply of her medication as she was making ‘one last trip’ to visit her daughter in Spain.

I was quite concerned about the patient’s fitness to fly as she had recently developed severe symptomatic aortic stenosis, and a recent report from her private cardiologist had assessed her as having stage III heart failure using the NYHA functional classification system.

Having checked the UK Civil Aviation Authority (CAA) guidance, I shared with the patient that medical oxygen in flight is needed for those with class III heart failure and that the patient should disclose her diagnosis to the airline so that in-flight oxygen could be arranged. 

I also told the patient she could become seriously unwell and that her life could be at risk without oxygen.

The patient thanked me but said that she had no intention of declaring her health problems to the airline because she was worried they would stop her travelling if she did and could not be persuaded even though I shared the CAA guidance with her. 

I made detailed notes of the conversation, the advice given and that the patient had said she intended to board the flight without declaring her condition to the airline. However, I’m still quite concerned about the patient – is there anything else I can do? 

AThe issue here is whether you could justify any disclosure about the patient to the airline in the absence of her consent. 

This patient is an adult with capacity and has been appropriately informed of the risks to her health and life if she fails to disclose her medical history to the airline. 

While other passengers might suffer inconvenience if a medical emergency occurred during the flight, GMC guidance would be supportive of a decision to maintain confidentiality. Paragraph 59 of the GMC’s confidentiality guidance states that doctors ‘should usually abide by a patient’s refusal to consent to disclosure, even if their decision leaves them (but no one else) at risk of death or serious harm.’

• See ‘When a patient is radicalised’