Rugby player ignores GP's warning

PRACTICE DILEMMA 

A teenager ignores your advice and then suffers a splenectomy. His father is furious. Could you have prevented it?

THE DILEMMA

Roger, a 16-year-old, developed severe glandular fever. He was quite ill and had hepatic and splenic enlargement. He recovered remarkably quickly from his physical symptoms, but his spleen remained palpable. His rugby team were in a cup final and he came to see me, alone, to ask me if he could play. I explained to Roger that he should not play because of the risk of rupturing his spleen. He was disappointed, but seemed to accept my decision.

The next I heard of Roger was a letter from the hospital saying he had been admitted as an emergency and had had a splenectomy following a ruptured spleen from playing rugby.

His father came to see me the following day, threatening to complain because the hospital said his son should not have been playing. I had written my advice to Roger in the notes, and showed his father the entry on the screen. He was not satisfied, and said that if I had communicated Roger's risk to his parents, they would have made sure he did not play.

Should I have acted differently?

A GP'S VIEW - DR PETER ILVES, A GP IN SOUTH-WEST LONDON

The GMC provides guidance on the management of a situation like this.

It gives you a good grounding in practical terms, but it does not deal with the obvious emotional aspect of this rather tense situation.

The GMC states that we should assess a child's capacity to decide on any decision or management plan; a competent child will be able to understand the nature, purpose and possible consequences of a proposed investigation or treatment as well as the consequences of non-treatment. This would seem to similarly apply to a situation of outlining consequences of actions.

However, this is a 16-year-old and, as such, he comes under the category of an adult. Therefore the assessment of such competencies is not a factor, despite how the father sees it. If there is a complaint to be made, then in theory it should come directly from the boy.

The only issue that therefore remains is the handling of the original consultation. Did you counsel the boy effectively as to the consequences of his actions if he ignored you?

Much of this is about communicating risk well. We could be in a difficult position at court if a patient tries to establish that the situation was not fully explained in terms that they could understand, or that the true risk was not conveyed adequately. We have to face patients and their legal advisers as best we can with a good clinical record.

Another factor to consider is the disclosure of the son's notes to the father. It is understandable and only human that you would have done so.

However, this was a breach of the son's confidentiality.

Roger is over 16 years of age and as such has full rights, and an expectation of you, to protect the confidentiality of his medical records; you should have sought his consent. We have all been in a similar situation at some stage in our careers but a confrontation and breaches of confidentiality are not what you need at this stage.

A MEDICO-LEGAL OPINION - DR LYN GRIFFITHS, MEDICO-LEGAL ADVISER, MEDICAL PROTECTION SOCIETY

Without any information to the contrary, it can be assumed that as a 16-year-old Roger does have decision-making capacity and is entitled to expect his doctor to respect his right to privacy and adhere to his duty of confidentiality.

You seem to have fulfilled the obligation to provide Roger with all the relevant information required so that he was fully aware of the serious potential consequences of playing in this rugby match.

It is unclear if there is any association between you and the rugby club.

If there is, then I would have expected you to seek Roger's consent to you advising team management that, in your opinion, Roger was unfit to play and that he risked seriously harming himself should he do so.

With hindsight, it might have been helpful to have offered Roger the option of you informing the club of his condition so that no pressure to play would be brought upon him.

There is no indication in the scenario described that you had any suspicion whatsoever, that Roger would ignore medical advice and allow himself either to be coerced or voluntarily decide to play in this cup final.

If you had believed that Roger might choose to play and risk serious harm to his health, then at that juncture it might have been justifiable to breach confidence and advise an appropriate person, such as Roger's parent, of your concern. If you had made the decision to breach confidence in this manner you should, however, also inform Roger of your intended action and the reasons for that decision.

A PATIENT'S VIEW - TREVOR SEEMANN, A MEMBER OF THE PATIENT PARTNERSHIP GROUP.

I believe that you have acted with absolute probity. Your medical advice was above reproach and you dealt with Roger honestly and with apparent empathy.

Maybe you should have told his parents of his visit, its purpose and your advice. However this can be broken down into two areas - legal and moral. I do not claim to have any legal answers, but morally I cannot see why you ought to have contacted them - you certainly would not have done if it had been about his sexual health.

You clearly felt that Roger had the maturity to understand and act on the advice you gave him. At 16 he is old enough to take responsibility for his own actions. I cannot see any reason why you should reproach yourself.

If Roger and his father have failed to communicate they will not be the first father and son to do so.

Perhaps the time has come to wash away the grey legal area between ages 16 to 18 and make 16 the age of consent and the age to vote and so on.

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