Business Dilemmas

Dr Vassiliki Kavadas discusses what to do if a patient has been supplied with home oxygen without a prescription.

 

         

         

         

Dilemma 1

Do I prescribe this oxygen?

QI’m a private respiratory consultant who recently saw a new patient with respiratory disease. During the consultation, the patient requested home oxygen, telling me he had tried it before and felt better with it. 

However, I couldn’t find a reference to who had prescribed this in the records and there is no mention of home oxygen in the GP referral letter. 

I questioned the patient further and discovered that a relative of the patient, also a healthcare professional, had been supplying him with home oxygen cannisters for the last year. 

The patient is a smoker and lives alone – although he does receive some support from social services. 

Now I am concerned that the required and necessary clinical and risk assessments had not taken place before the oxygen was supplied to the patient and that this had been made so readily available without a prescription.

I feel that there is a greater risk given that the fact that the patient is a smoker and lives alone. 

What should I do?  

AThis is a potentially awkward situation given the issues at hand which are severalfold. 

There may be a risk of fire to the patient’s and neighbours’ properties because he is a smoker. He may have a clinical need for home oxygen, as he said he felt better having used it over the last year, and not prescribing it to him may lead to a complaint. 

Additionally, on the face of it, it appears that another healthcare professional had been inappropriately supplying oxygen to their family member. 

In this situation, it may be wise for you to arrange for the patient to be appropriately assessed and refer him to the local home oxygen service.

As you are being asked to prescribe the home oxygen, you need to be satisfied that the prescription is clinically indicated and that you take account of clinical guidelines for its prescribing from relevant bodies. 

Patient’s expectations 

The patient’s expectations may be that you will continue to prescribe the home oxygen.

So a clear discussion with him should include not only a recommendation that he stops using the oxygen canister he has at home, explaining the potential risks to not only himself but also to neighbouring properties and people, but an explanation as to why he has to undergo a detailed assessment before you can safely prescribe it and what that assessment will involve.  

Additionally, in line with the GMC’s guidance on raising concerns, you need to consider whether this is a situation where you have a duty to raise a concern, taking into account patient safety which may have been compromised by the actions of this healthcare professional. 

It may be that this healthcare professional can justify their actions, but that is not necessarily something that you will be able to explore.

As part of your discussion with the patient, it is also worth sharing your concerns in this regard, explaining your duty as a doctor to raise concerns when you are made aware of unsafe practices and seeking consent to disclose the concern to additional individuals. 

You should make a note of exactly what your concerns are and what action you then take in relation to these.

Dr Vassiliki Kavadas is a phone adviser at the Medical Defence Union 

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Teens and birth control

A private GP has concerns for a young patient who asks for contraception. Dr Beverley Ward discusses what she should do.

 

 

 

 

Dilemma 2

Should I give her contraception?

QI’m a private GP who recently had a 13-year-old patient visit the practice to ask for contraception. 

She explained that she was in a relationship with a boy, but
was concerned that condoms weren’t effective, so wanted to use another more reliable method.

We had a long conversation and I was impressed with her level of knowledge and understanding about methods of contraception. I feel she is ‘Gillick competent’ to consent. 

However, she looks younger than her age and I am concerned for her safety, as I think she is particularly vulnerable. 

Given the circumstances, should I prescribe contraception and/or inform social services? 

AThis is an extremely sensitive and difficult situation and it is important to balance your duty of confidentiality to the patient with your safeguarding duties. 

As the patient is 13 years of age, she may be mature enough to consent to treatment or sexual activity. However, it is important to assess this thoroughly and document your opinion in the patient’s records. 

Even if you believed the patient was able to consent to sexual activity, she could still be at risk of abuse, depending on the nature of the relationship she was in. 

It is advisable to arrange a follow-up appointment with the patient to ascertain whether there was a significant difference in the sexual partner’s age, maturity or power, as well as if there was concurrent use of drugs or alcohol or any bribery, payment or pressure to either engage in sexual activity or to keep the relationship a secret.

Seek consent 

If this discussion highlights any concerns, then you should seek consent to disclose this information or consider disclosure without consent in the patient’s and public interests.

Furthermore, it is also worth asking the patient to allow the involvement of a parent or guardian and to discuss this with a child safeguarding lead, documenting any advice given. 

The latter discussion could be on an anonymous basis if the patient had not provided consent to disclose her identity. 

With regards to prescribing contraception, the GMC makes clear that a doctor can provide contraceptive advice and treatment without parental knowledge or consent to patients under 16 as long as certain conditions are met. 

For example, the patient must understand all aspects of the advice, its implications and is very likely to go ahead with sexual activity regardless of treatment, while you must believe it to be in the patient’s best interests and have attempted but failed to persuade them to involve a parent or guardian.

Dr Beverley Ward is a phone adviser with the Medical Defence Union

• See ‘In the interests of a frail patient’