You took a telephone call from the carer of a 72-year-old diabetic man in sheltered accommodation. The carer is concerned that the man has not been performing his blood tests and his blood glucose is now 18mmol/l. When you spoke to the patient he said he was feeling very unwell and just wanted a bit of a lie down, but he flatly refused to be admitted to hospital. What would you do?
Dr Raj Thakkar's view
Complaints and mishaps often relate to failure to examine or visit. Given this patient's complicated history, a careful review of the notes would be helpful before he is visited.
What type of diabetes does he have? Does he have diabetic complications? What drugs does he take and have there been any changes lately?
Assess whether he truly does have a high blood glucose level, what has caused his blood glucose to be elevated and how unwell he is. Also consider how he can be managed.
Has he taken his medication as prescribed? Does he have an infection and is he septic? Are there more sinister causes such as an acute coronary syndrome? Is he ketotic? Is he confused and what are his vital signs? It may be that he can be managed at home. How involved is his carer? Can he/she give him his medication and call on him later on, or can a district nurse or out-of-hours doctor call on him?
If you feel he should be in hospital, can you persuade him to go in? If not, what are his fears and can you address these? If he doesn't want to go to hospital, careful safety netting and follow-up is required. The case should be documented in the notes, so any doctor can understand your management plan.
Dr Thakkar is a GP in Wooburn Green, Buckinghamshire. He qualified as a GP in 2004
Dr Azm Khan's view
I would find out the exact concerns of the carer. As the patient lives in sheltered accommodation it is worth finding out how often the carer comes to help him and how long he or she has known the status of the patient.
Ask how the patient has been recently. Any factors that might affect glucose level such as infections - most commonly chest or urinary infections - should be ruled out.
I would have a look at his records to find out how well his diabetic control is usually. Is he up to date with his diabetic review? I would offer him an appointment at the surgery or visit him if necessary for an overall check up.
The patient mentioned he wanted to lie down and is feeling unwell, which needs further evaluation. Is he depressed or fed up with his current treatment regimen?
I would encourage him to see a diabetic team because this will help him to control his diabetes better. If there is any sign of diabetic ketoacidosis I would normally refer him to secondary care. Obviously, if the patient flatly refuses to be admitted, I would like to find out why he is reluctant to go to hospital.
Has he had a bad experience in hospital or he is giving up? Try to explain the implications of not going to hospital if it is an emergency. Try to involve the carer and family members, if possible, in the decision process.
If the patient is stable and there are no acute problems then this is an opportunity for some health education regarding his diabetic control and to discuss the implications of persistent high blood glucose.
If the patient is insulin dependent then a regular blood glucose check is important. Or if he is a non-insulin diabetic, the carer and patient could be informed that daily blood glucose testing may not be necessary.
Dr Khan is a salaried GP in Newcastle-under-Lyme. He qualified as a GP in 2007
Dr Anna Cumisky's view
This case highlights the difficulty in telephone consultations. The man clearly needs assessing in person.
This patient requires a home visit. It would be wise to collect some background information before leaving by checking past notes and talking to the doctor and nurse who regularly look after the patient. Relatives may also be appropriate, although confidentiality issues arise.
An important aspect of the home visit is to assess whether the patient has the capacity to refuse hospital admission.
Should he be septic, for instance, he may be confused and not capable of making an informed decision. In this case, if admission is a priority, then it can be against his will. If the man has capacity then highlighting potential immediate risks and complications is important. Discovering why this man's blood glucose has leapt out of control is the first step. Is there concurrent illness or does he not take his antidiabetic regimen correctly? A urine dipstick for ketones would identify the magnitude of the problem.
An examination looking for signs of infection is vital. All examinations should be clearly noted for good medical practice as routine, but this is even more important when a patient disregards their doctor's advice.
If the man is competently refusing admission, it is important to make him and his warden aware of this and the potential risks involved. It is also important to tell him that should he change his mind, he need only call and will not be judged.
An appropriate management strategy should be instigated. This may involve acute treatment with hydration and antibiotics and simplifying the antidiabetic regimen. On-call telephone numbers should be left with the patient and warden and follow-up ensured by telephone the same day. Reasons for refusing admission should be explored so any misconceptions can be discussed.
Above all, a good doctor-patient relationship should be preserved, respecting the competent patient's autonomy and allowing him to make his own informed decision.
Dr Cumisky is a GP locum in Bath, Somerset. She qualified as a GP in 2008
- This topic falls under section 9 of the GP curriculum 'Care of Older Adults' and section 1 'Being a GP', www.RCGP-curriculum.org.uk
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