A bereaved patient becomes dependent - practice dilemma

A recently widowed patient's persistent desire to see a GP is causing problems in the practice.

The Dilemma

A female patient has become increasingly dependent on me after I was supportive and sympathetic when her husband died in an accident. She now makes appointments once or twice a week and refuses to see anyone else. If she cannot make an appointment within a few days, she makes a scene in reception, and inevitably I am called down and end up giving in just to placate her. This is causing stress for the staff and for me. I have tried reasoning with her and explaining that I cannot be available for her personally all of the time. She then appears contrite, but the process is soon repeated. How do I resolve this situation?

A GP'S RESPONSE - Dr Raj Thakkar is a GP in Buckinghamshire

The desired outcome in this case is obvious, but the process to achieve resolution to this problem must be handled appropriately.

In particular, it is critical to ensure the patient's psychological problems are managed for her own mental health, to eradicate her dependence on the GP and to avoid her reacting adversely.

In the first instance, it is important to assemble a team which includes the GP, one of the partners and the practice manager. It would be prudent to decide on a process, beginning with fact finding.

This should be carried out in a timely fashion. I would suggest looking at the patient's history to understand any background psychological morbidity, documenting the facts from the GP and taking statements from reception staff about her behaviour.

The patient should then be invited to a meeting, with the aim of agreeing the status quo is unacceptable, setting clear boundaries and outlining what the consequences will be if these are overstepped.

Explain that another GP will support her through her illness. The meeting should be documented and she may even be offered a copy of the minutes, so all parties are clear about the management plan.

Finally, the GP might be offered appropriate training, to avoid similar situations arising in the future.

A MEDICO-LEGAL VIEW - Dr Zaid Al-Najjar is a medico-legal adviser at MPS

You should first consider the real reason the patient is attending frequently and whether she has been able to grieve for her husband.

It may be appropriate to look for signs of underlying mental or physical illness, so she can be referred to a counsellor or other mental health worker.

If there is no underlying illness, consider her background and support network. She may not have anyone in her life who can help her through this difficult period.

Find out if your colleagues have had similar dealings with this patient and ask for their suggestions on how to deal with the situation. This may also provide insight into your own behaviour with her and give an objective view on the way forward.

Perhaps the patient is not aware of how often she is presenting at the surgery and of how unreasonable her behaviour has become, so consider gently telling her, without being accusatory or judgmental, and explain your concern that she may need external help.

This may open the door to allowing the patient to accept help from other healthcare professionals.

Unacceptable behaviour such as that displayed in the waiting room should be addressed and boundaries set, politely yet firmly, so that she knows what is and what is not acceptable in the practice.

You should also keep a record of any such warnings.

If the problem continues and you are considering ending your therapeutic relationship with the patient, you should contact your medical defence organisation or LMC for advice before doing so.

A PATIENT'S OPINION - Danny Daniels is an expert patient

The GP needs support from his partners and recognition that the problem is a practice matter. The increasing dependence on the GP is not healthy for the patient or the GP.

The patient's behaviour in reception also supports the view that the practice has to take responsibility in seeking a positive outcome for the patient and the GP.

At some point in the near future, a professional in bereavement counselling should become involved.

The practice needs to be honest with the patient, while remaining mindful of her current fragile state.

At any future meetings, it would be in the patient's best interests if she were accompanied by a friend or relative, someone in whom she has confidence.

For the wellbeing of the patient, it is of paramount importance that she does not feel threatened. The dialogue must emphasise the determination of the practice to resolve the situation to the benefit of all parties.

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