Consent refused - medical case study

BACKGROUND: A GP practice receives a letter of complaint from Mrs T, the sister of 52-year-old Ms R who died at home of a perforated duodenal ulcer. Ms R was a chronic alcoholic and patient with the practice. In the letter Mrs T explains how a neighbour had called in a few days before her sister’s death and found her very unwell with constant vomiting. She phoned an ambulance and the paramedics arrived but Ms R refused to be taken to hospital.

Two days later the neighbour called in again and found Ms R collapsed on the bathroom floor. She phoned the practice and the on-call GP – Dr K – attended the patient at home. Ms R said that because she had not been feeling well she had not drunk any alcohol for the last few days. Dr K diagnosed alcohol withdrawal syndrome and tried to help Ms R off the floor and back into bed but the patient refused and became aggressive. The neighbour then phoned Mrs T who lived in a distant city and she spoke to Dr K requesting that he have Ms R sectioned but the doctor said that was not possible. He then left the flat with Ms R still lying on the bathroom floor.

The neighbour found a blanket for Ms R to make her more comfortable and returned later after work to find she had died.

In her letter of complaint Mrs T alleges that Dr K was dismissive toward her sister and did not adequately examine her in order to make a diagnosis, nor did he put sufficient effort in trying to convince Ms R of the seriousness of her condition.

ANALYSIS/OUTCOME: The practice contacts an MDDUS adviser who requests a response from Dr K setting out his account of the case. In his note Dr K confirms that he did attend Ms R in her flat and found her lying on the bathroom floor. He offered to help her back to bed but the patient pushed him away saying that she wanted to be near the toilet. When Dr K persisted she became abusive and refused any attempt at examination.

Dr K attempted to reason with Ms R, telling her he thought it essential that she be admitted to hospital for diagnosis and treatment but the patient claimed that once she left the flat the Housing Association would be in to give it away to another tenant. Over time Ms R grew increasingly abusive and demanded that the doctor leave.

Dr K then asked the neighbour if Ms R had any close family and that was when the phone call was placed to Mrs T. The GP explained to the sister that he thought Ms R was suffering alcohol withdrawal symptoms and that she refused to be examined and would not consider hospitalisation – and in the circumstances there was little else he could do, especially as he had been told to leave the flat. He suggested that perhaps Ms R would listen to her sister if she were to visit. Before departing he agreed with the neighbour that she should look in again and phone if Ms R’s condition grew worse. The next he heard the patient had died.

The MDDUS adviser helps the practice manager draft a response to the letter of complaint in which Dr K’s account of the events is presented. In reply to the claim that the GP should have had Ms R sectioned it is pointed out that this was not only possible in the circumstances. Patients have the right to make bad decisions about their health and refuse treatment.

The manager further informs Mrs T that the practice will carry out a Significant Event Analysis and look at how they might better deal with such situations in future. An offer of a meeting to further discuss the issue is ignored and the case is closed.

KEY POINTS

• Competent patients who persistently refuse advice or consent leave doctors few options when it comes to care.
• Patience and persuasion are all that a clinician can rely on in such cases.