A case of confusion in a patient

A home visit request for a confused elderly patient comes during a busy surgery. How should you proceed?

The dilemma
On a busy day recently I was the duty doctor for the practice. I was in the middle of the Friday-afternoon surgery and I was already running 30 minutes late, when the receptionists informed me that the carer of one of my patients, a 75-year-old man, had rung in to say that he has become confused over the past few days. What should I do?

A GP’s view
Dr Vasa Gnanapragasam, a GP in Sutton, Surrey

There are many short straws in life: Friday-afternoon duty doctor is one of them.

I would speak to the patient to determine if he really is confused in the medical sense.

It is not unusual for elderly people to appear confused when they wake up. Side-effects of prescribed or OTC medications may cause confusion, especially after accidental overdose, which may go undetected for a while.

Losing glasses or hearing aids can confuse the patient. If personal items are moved during cleaning or tidying this can also lead to confusion. Elderly patients can become confused if woken up during an afternoon nap.

Vascular and metabolic causes of confusion may require admission. Patients with multiple co-morbidities are likely to require admission.

A patient with mild depression is likely to become more confused when admitted to a hospital or moved to a nursing home.

Patients with Parkinson’s disease may become confused when the medication is not given to them at regular intervals. I would have to determine whether I can deal with this over the phone, visit at the end of the surgery or if things are stable enough to arrange a visit the following day.

If someone were able to bring him to surgery, I would fit him in as an extra and see him that day.

A discussion with the district nurse and any family may be useful. You should always remember the issues about confidentiality, capacity and consent when talking to them. If I decided not to admit him I would pass his details to the on-call doctor so that they were aware of the situation.

A medico-legal opinion
Dr Bryony Hooper, medico-legal adviser, Medical Protection Society

This is a situation familiar to most GPs, with conflicting demands being made on your time.

Not only do you have a surgery to get through, you also have an elderly patient who may require urgent attention.

GMC guidance states that you should give priority to patients on the basis of clinical need. At present you do not have enough information to do this, so you or a member of your team will need to speak to the elderly patient’s carer.

Is the patient able to come to the surgery? If so this is a more efficient way to assess him.

If not, it is likely that the patient will need a visit that day.

Providing an assessment of the patient’s condition and arranging appropriate investigation or care will take time in a confused 75-year-old patient, but you should not offer suboptimal care just because he became unwell at an inconvenient time. You are responsible for providing good clinical care to your patients.

Consider how your practice is organised — as Friday afternoons are likely to be busy should you be doing a booked surgery as well as being on call for emergencies?

Could you be using resources more efficiently within the practice, for instance by using a nurse to triage calls?

You have a duty to make the best use of resources available to you, and if you have concerns that patient care is compromised by inadequate resources or systems, you should be doing your best to improve the situation.

A patient’s view
Ailsa Donnelly, Patient Partnership Group

Establish the urgency of the situation so that priorities can be assessed.

The first step should be to phone the carer both to give reassurance and establish the facts. If there is any possibility that the confusion is due to a physical illness then appropriate treatment must be given.

The carer may not be able to bring the patient to the surgery so may need a home visit.

If in the doctor’s judgment the situation is not urgent and the carer is reassured about this, then an appointment should be booked for Monday and the carer given clear instructions for action to be taken in case of deterioration.

The doctor could find out if the patient has any other sources of support such as family or neighbours. If the situation requires leaving patients in the waiting room, an explanation about the delay would help.

If there is another doctor available then patients could be given the option of seeing him/her instead. In the longer term, the practice should consider ways to avoid such problems in future, perhaps with fewer appointments for duty doctor surgeries and warning patients when they book that delays may be possible.

If the problem of over-running is specific to this particular GP then they could obtain help with time management.

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