Practice dilemma - An interfering neighbour

A neighbour of an 88-year-old female patient with moderate dementia comes to see you to tell you she is worried about her friend because she has no family and nobody to look after her.

Explain to the concerned neighbour the importance of maintaining dementia patients in their own surroundings for as long as possible (Photograph: SPL)

Your surgery has an excellent psychogeriatric team which is supporting the patient and wishes to keep her independent for as long as possible. You explain to the neighbour that you cannot discuss the case, but she becomes angry and says her friend should be in a home. She says she is a local councillor, and if you do not do anything she will notify the authorities and write to the local paper saying your patient is being neglected. How should you manage this situation?

A GP's response
Dr Alison Glenesk is a GP in Aberdeen

The main issues here are confidentiality, mental capacity and the patient's best interest. There is nothing to stop you listening to the neighbour's concerns, although you need to assess whether she has her friend's interests at heart.

The psychogeriatric team may already be involved, but your patient may also need help with everyday activities and assisting with this will show the neighbour you are trying to help. You also need to stress the importance of maintaining patients in their own surroundings for as long as possible.

You cannot give detailed information about your patient's care without her permission, but the patient's moderate dementia means that she may not be able to give consent.

The GMC tends to take a common sense view on disclosure of confidential information about patients who lack mental capacity, saying 'you may need to share personal information with relatives, friends or carers to enable you to assess the patient's best interests'.

To avoid the matter reaching the local press, you might inform the neighbour that you are sure that she, as a councillor, will know that you cannot discuss the details of her friend's case, but help is already being offered. It is important to point out that she herself can assist by continued visiting and reporting any new concerns that she may have.

A medico-legal view
Dr Sarah Townley is an associate medico-legal adviser at the Medical Protection Society (MPS)

This is a difficult situation that needs defusing to avoid distress to the patient. You should explain to the neighbour that you need the patient's consent to discuss the matter with her and will need to ask the patient for her view.

When you meet the patient, you need to assess her capacity to make decisions regarding her care. Remember that capacity is decision-specific and the assessment of capacity should not be based on the patient's ability to make decisions in general. If she lacks the capacity to make such decisions, it would be reasonable to contact her 'independent mental capacity advocate' and other professionals involved in her care, to discuss whether disclosure is appropriate and in the patient's best interests.

It is important to balance the patient's right to privacy with what is in her best interests. In this case, some information about support arrangements may need to be disclosed. The key question is the best interests of the patient, not whether a story in the local paper might be uncomfortable for those involved. If you decide to share information with the neighbour, bear in mind it should only be relevant information, but remember there is no general right of access to the patient's records or previous healthcare information. If you decide to disclose information, be prepared to justify this decision.

You should discuss the matter with your colleagues and your medical defence organisation, and document all discussions.

A patient's opinion
Stella McPherson is an expert patient

The neighbour should be reminded about patient confidentiality. The doctor, realising that the neighbour was interfering, could try to defuse the situation by acknowledging how helpful she is in trying to support this patient.

Elaborate by saying how useful it is to have a good neighbour and commend her for setting time aside to support her friend. The doctor could ask the neighbour why she felt this patient should be in a home and whether she is aware of the different options available today to support people in their own home.

The doctor should take the time to explain the different services that are available to the patient, including the psychogeriatric service. It should be explained that it is accepted that most patients manage better in familiar surroundings, provided they are safe.

Once the neighbour becomes familiar with the range of services available, she may agree that moving to a home might not be the best option.

Should the neighbour not listen and the situation spiral out of control, the doctor should remind the neighbour about the services available to all of the patients in the practice and explain that in this situation, there is no proof of neglect.

The doctor should advise the psychogeriatric team and social services to make them aware of these difficulties.

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