Practice dilemma - A colleague's refusal to treat

The Dilemma - A 40-year-old woman complains after seeing your practice nurse. She has attended your surgery four times over the past six weeks complaining of cough and breathlessness. Despite stating she was very keen to stop smoking and having been referred to a smoking counsellor, she continues to smoke 20 cigarettes a day. She was coughing up green sputum and had evidence of a chest infection when she saw the nurse. The nurse refused to treat her on the basis she was continuing to smoke. How do you deal with the situation?

The patient's smoking is not grounds to refuse to treat her cough
The patient's smoking is not grounds to refuse to treat her cough

A GP's view - Dr Thomas Abraham is a GP in Hull
First, I would direct the practice manager to deal with the complaint applying the practice's complaints procedure.

Top priority will be to assess the patient myself. I would make a broad apology on behalf of the practice and reassure her that the complaint would be looked into. My main concern will be to examine the patient and make a clinical diagnosis.

Since it is fairly obvious that she has a respiratory infection, I would treat accordingly. Because she is a smoker and having repeated episodes of cough and breathlessness, I would consider a chest X-ray and spirometry.

The medical management will depend on the findings. Throughout I will emphasise the need to quit smoking and take appropriate steps in discussion with her.

I would discuss with the nurse the pros and cons of her action. I would explain that refusing to treat smokers is unethical and a dangerous precedent. In many cases, smoking is an addictive condition, which needs a sympathetic approach.

I would emphasise to the nurse that her attitude amounts to being professionally negligent and ethically unacceptable. She should be encouraged to apologise to the patient directly.

A patient's view - Dr Rosemary Humphreys is a lay member of the RCGP Patient Partnership Group
It must be very frustrating for health professionals when patients do not take their advice and return for further treatment with the same symptoms.

However, unless this patient has been violent or abusive to staff, she has the right to be treated for her condition.

As her relationship with the practice nurse appears to have broken down, the GP should assume responsibility for her, investigate her symptoms and initiate a course of treatment.

A follow-up appointment, when hopefully the symptoms are alleviated, is the time for a frank but sympathetic discussion about the effect that smoking is having on her health.

The GP could also explore with the patient why she has been unsuccessful in stopping smoking, despite expressing a wish to do so. This patient may have underlying work, family or personal problems that are making it even more difficult for her to relinquish this 'prop'.

A different smoking counsellor, access to a peer support group or an alternative form of nicotine replacement therapy might help. NHS Choices has an internet support site which might suit people who find attending a group difficult.

The GP will also need to discuss with the practice nurse her decision to withhold treatment in a supportive rather than critical way. Perhaps the whole team needs to talk about strategies for dealing with uncooperative patients.

A GP trainer's response - Dr Prashini Naidoo is a GP trainer in Oxford
The complaints manager, usually the practice manager, should deal with the complaint as per the practice protocol. If the patient complained informally, it would be useful to establish her expectations.

If the patient complained in writing, the complaints manager should acknowledge receipt of the complaint and outline the timescales for investigation.

The complaints manager needs to assess whether the nurse, deliberately or inadvertently, delayed appropriate patient care and the consequences to the patient. He or she also needs to check whether, as the patient alleges, the nurse deliberately chose not to treat a medical condition based on her personal values.

My job, if asked to give clinical advice, is to be impartial.

My role as a colleague to the nurse is to provide support but not false reassurance. My duty to the patient is to ensure patient safety is not compromised.

Perhaps a significant event audit to discuss the lessons learnt from the investigation will help the practice to develop. The report of this needs to be shared with the patient. If the patient is dissatisfied with the outcome, she should be advised to contact the Health Service Ombudsman.

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