Good practice demands that GPs work in partnership with patients. But how should you respond if that partnership breaks down and a competent patient refuses to accept your advice, even if you believe you are acting in their best interests?
1. A man with an inguinal hernia declines a referral
A competent patient has the right to decline a referral or treatment, even if you believe that decision is not in their best interests.
Your first option would usually be to explore the reasons for the patient’s reluctance. In this case, he might be anxious about what the treatment involves and you might be able to reassure him.
You could give the patient printed information to take away, because he might change his mind after discussion with his family or partner.
You could suggest he returns to discuss things with another GP for a second opinion, if he wishes.
You should advise him that without surgery, the hernia is likely to progress in size and symptoms, and you would be happy to discuss a referral at a later stage. If it is appropriate, you should discuss any non-surgical options to manage his symptoms.
If the patient still declines treatment, it is important to explain the need to seek further medical help if the lump increases in size or if he experiences abdominal pain. This discussion and the patient’s decision should be documented in the notes.
2. A woman in her late 20s misses a smear test
There may be many reasons for a woman to miss a smear test and the patient might be prompted to make an appointment if she receives a reminder about it.
If she still does not attend, you should refer to local arrangements for contacting and following up patients under the NHS Cervical Screening Programme. The practice should have procedures to follow up patients who do not attend.
GPs should ensure that patients have been given adequate information to enable them to make an informed decision.
Check if she would prefer to go to a well woman or family planning clinic. All steps taken to inform her
of the importance of screening should be documented.
3. A teenage boy refuses the presence of a chaperone
Some patients are so embarrassed about an intimate examination, they refuse to have anyone else present.
Is the chaperone’s gender the problem? He may prefer someone of the same sex. If a male is not available, you may need to rearrange the appointment, provided the examination is not urgent.
The patient has a right to refuse a chaperone. However, if you are unwilling to conduct an intimate examination without one, you should explain to the patient why you would prefer to have one present.
You may need to offer an alternative appointment, or an alternative GP, but only if the patient’s clinical needs allow this.
4. An elderly woman is not taking her warfarin
Bearing in mind the danger to the patient if she does not take her medication, you need to act quickly.
Talk to the patient about the risks and try to find out whether there are any underlying causes, such as side-effects or confusion about the dose.
If the problem cannot be resolved, consider whether continuing to prescribe the drug is in the patient’s best interests, bearing in mind her poor compliance, her history and personal circumstances.
An alternative may be more beneficial, so be prepared to discuss this with the patient and the initiating clinician. If necessary, obtain the patient’s consent to refer her to an anticoagulant specialist.
5. A single mother refuses to discuss her child’s welfare
It is advisable to seek advice from an experienced colleague, a named or designated doctor for child protection, or your medical defence body.
Depending on the nature of your concerns, consider asking a health visitor to visit the mother at home.
You have an ethical duty to act if you believe a child is at risk, but your duty of confidentiality means you should seek the mother’s authority to share information unless there is a compelling reason not to do so.
If you cannot obtain her authority, consider the child’s best interests against the risk that disclosing information will damage the mother’s trust in you.
If a child or young person is at risk or is experiencing abuse or neglect, the GMC says it will usually be in their best interests to share information with the appropriate agency.
If you share information without consent, the GMC expects you to explain to the mother what you have done and why, unless this would put the child or mother at greater risk.
You should also record your decision, any steps you have taken to try to obtain consent or your reasons for not doing so, and details of any advice you were given.
- Dr Old is a medico-legal adviser for the MDU