Concerned loved one - medical case study

Day 1

Mr T – a 95-year-old war veteran – attends A&E complaining of palpitations. He is accompanied by his son, David. The symptoms have been long-standing and periodic but less tolerated of late. He is otherwise reasonably fit considering his age. Normal rhythm is restored but the A&E doctor decides it is best to keep Mr T in overnight for observation. He also commences the patient on verapamil to prevent further palpitations.

Day 3

Mr T is transferred to a general ward having developed a chest infection. He is given antibiotics and over the next few days he develops appetite loss and symptoms of nausea and vomiting. An ST on the ward, Dr L, prescribes an antiemetic as well as low-dose diazepam to ease Mr T’s anxiety.

Day 9

Mr T’s son requests a meeting with Dr L. David is concerned to hear that his father has been prescribed an antidepressant in addition to his other medications. He has also been on the internet and read about the potential side-effects of verapamil and is of the opinion that this drug in combination with the antidepressant could be the cause of his father’s nausea and increasing listlessness. Dr L says it is more likely due to the antibiotics course which is to finish the next day. The doctor explains that the antidepressant had been prescribed because Mr T’s lethargy, sleeplessness and lack of appetite could be symptoms of low mood at having been confined to a hospital bed for the last two weeks. Dr L agrees to discontinue the antidepressant but to maintain the verapamil dose.

Day 13

David requests another meeting and demands that the diazepam prescription be reduced or stopped as his father is “like some zombie”. He is also still concerned the side-effects of the verapamil are adding to his father’s deterioration. Dr L points out that nausea and lethargy are not common side-effects of verapamil and also that Mr T is under the care of a consultant cardiologist who has advised keeping the patient on the medication. David then produces legal documentation of welfare power of attorney. Dr L seeks further advice and informs David that treatment decisions are his father’s to make as long as he is deemed competent by clinical staff. Mr T has so far expressed no direct objections to the treatment at the hospital.

Day 17

Mr T is transferred to a geriatric rehabilitation unit at another hospital against the wishes of his son. Dr L explains to David that Mr T no longer has “active medical problems” and this will facilitate his discharge home. David leaves his father at the new hospital but not before expressing concern to the ST in charge that his father looks unwell. He wonders if he might have a recurrent bout of pneumonia. The doctor reassures him that he will keep an eye on the patient. Next morning the hospital phones to say Mr T has passed away.

TWO months later David lodges a complaint against Dr L with the GMC. In the letter he alleges that his concerns over the use of verapamil and other medications used to treat his father were ignored and the build-up of verapamil in his system precipitated his later heart failure. He also believes it was clinically inappropriate to transfer his father to the geriatric unit given his serious condition. He believes the hospital disregarded his welfare power of attorney in regard to treatment decisions in the care of his father.

MDDUS assists Dr L in drawing up his written response to the allegations along with the support of the hospital. All relevant documentation is forwarded to the GMC and two months later the regulator responds with its judgement on the matter.

On the allegation of an inappropriate drug regimen the case examiners find that the use and dosage of verapamil was clinically indicated in Mr T’s treatment given his frequent attacks of SVT and that any side-effects had been adequately monitored. They also note that Mr T had previously been treated with diazepam for anxiety and its further prescription in low dose was not inappropriate.

The examiners also find no fault in the decision to transfer Mr T to the geriatric rehabilitation unit – which in any case was not a decision for which Dr L bore sole responsibility.

But the examiners do find fault with the manner in which the judgement over capacity was handled. They cite relevant legislation which indicates that when a clinician disagrees with the welfare power of attorney it would be most appropriate to refer the matter to the Mental Welfare Commission. The examiners acknowledge that Dr L was only acting in what he believed was the patient’s best interests and went to considerable lengths to obtain agreement over the proposed treatment. However, they state it is clear he was unaware of the relevant legislation that applied in this situation.

Despite this one criticism the case examiners judge that this does not call into question Dr L’s fitness to practise or merit any action on his registration. The doctor is directed to the relevant GMC guidance in Good Medical Practice:

“You must keep up to date with and adhere to the laws and codes of practice relevant to your work.”

Key points

• Ensure that you accommodate patient wishes in requests that another person is involved in discussions regarding clinical decisions.
• Ensure clinical decisions are voluntary and not the product of undue pressure from relatives or carers.
• Be aware of and follow relevant legislation in questions of patient capacity.