Transcript Theme: The doctor–patient relationship

Theme: The doctor–patient
relationship
•Responsibilities for patients and the duty of
care
•Independent assessors
•Rights of homeless people, detainees and
asylum seekers
•Patients’ rights
•Treating oneself, friends and family
10 things you need to know about . . .
the doctor–patient relationship
• The onus is on the doctor to make the doctor–
patient relationship work.
• A doctor ’s duty of care for a patient can begin
even before the patient is seen.
• Patients have many legal rights requiring
respect, but most of these are not absolute
rights.
• Health professionals should be frank and
truthful, including when patients’ prognosis is
poor or when it is unlikely they could afford a
treatment option which is only available
privately.
• The onus is on doctors to recognise when a
conflict of interests, or what may be perceived
by others to be one, is looming for them and
to deal with it openly and appropriately.
• NHS employees are prohibited from accepting
gifts from patients or their
relatives. Practitioners who are not NHS
employees can accept gifts. If likely to benefit
from a patient ’s will they should not be
involved in assessing the patient ’s capacity
when the will is made.
• It is unlawful to administer medication
covertly to patients who have mental capacity
even if they are behaving badly and they need
the drugs to prevent their condition getting
worse.
• Doctors have responsibility for ensuring that
professional boundaries are maintained.
• If agreeing to witness patients ’ legal documents,
doctors need to be aware that it may be assumed
that they have also checked the patient ’s mental
capacity to make the decision in question.
• Doctors have legal rights to conscientiously object to
participating in some procedures, but these are
very narrowly defined in law. A conscientious
objection cannot justify unfair discrimination.
Rights of homeless people, detainees and asylum seekers
NHS GPs have an obligation to provide care on an equitable
basis according to their capacity to take on new patients.
They cannot exclude people whose condition requires a lot
of time or resources (so-called ‘uneconomic patients’), or
patients who have multiple conditions. They must take into
considerationthe GMC ’ s advice as well as the Equality Act ’ s
ban on discrimination.
Example:Case example – failure to discuss
An 85-year-old patient fell after being discharged from hospital for cancer
surgery. He was admitted to Cheltenham General Hospital, moved briefly to a
different hospital for palliative care before being readmitted to Cheltenham
General with pneumonia. Two Do Not Attempt Resuscitation (DNAR) orders were
made while he was there, apparently without discussion with either the patient
or his family. When he died, the family referred his case to the Health Service
Ombudsman. The relatives complained that they had been told that the patient ’s
condition was not immediately life-threatening, although the death certifi cate
showed that he was known to have terminal bladder cancer.
In her analysis of the case, the Ombudsman said it highlighted the importance of
good communication. The patient should have been told about the severity of his
condition and asked if he wanted his family to be updated, rather than being kept
ignorant of his deteriorating health. Following the case, the trust drew up plans
for communication training for its medical and nursing staff. 12
Reporting errors: Froggatt
A patient ’s breast biopsy was confused with someone else ’s sample by the
histopathologist, with the result that a healthy patient had a mastectomy and
suffered distress, believing herself at risk of premature death. The mistake was
suspected by a consultant oncologist who contacted the histopathologist and
asked him to review the slides. This revealed normal tissue without evidence of
malignancy. The patient ’s GP was informed and it was agreed that the situation
should be explained to the patient at the hospital by the surgeon who had
operated on her, with two nurses to provide support. Telling patients that they
have undergone unwarranted distress and surgery is clearly diffi cult. The patient
said it was easier to accept the mastectomy when she thought she had cancer,
but she felt worse knowing that it had been unnecessary. She became depressed
and thought constantly about the operation. The patient developed a serious
psychiatric disorder which seemed unlikely to improve. In court, the patient was
awarded Ј350,000 damages and lesser sums were awarded to her family for the
trauma they had undergone. 18
Case example – personal relationships
In several cases raised with the BMA, GPs had struck up personal
relationships with people undergoing a crisis. Acting as volunteers in
charitable church groups or community support organisations, they had
played a mentoring role for troubled teenagers or helped asylum seekers
draft their appeals. This personal relationship subsequently became
problematic when the person being helped needed them to write an
‘independent’ doctor ’s report for some state benefi t. Another doctor
who had rebuilt his career after alcoholism joined a network offering
support to others struggling with simila problems. This was
unproblematic when the relationship was entirely separate from the
doctor ’s working life but not when the individuals needing befriending
were his patients. Keeping a clear boundary between their professional
and private life became impossible.
Questions between
doctors-patients
• When precisely does my duty of care for
patients begin and end? What exactly does it
entail?
• Who is ultimately responsible (and potentially
legally liable) if something goes wrong when
tasks are shared in teams or are delegated?
• What should I tell patients, without defaming
colleagues, when things not my fault have
gone wrong? Do I have to disclose mistakes
when nobody was really hurt but telling
patients means they may try to sue anyway?
• If a senior colleague tells me to do something
for a patient beyond my competence, do I
have to attempt it?
• What responsibility do I have for patients who
are uncooperative, fail to follow advice,
discharge themselves prematurely or miss
appointments?
• Do I have to see people who are aggressive or
threatening or can I just call the police?
• Do patients have the right to queue jump by
switching between NHS and private care?
• If NHS patients say they want to see another
doctor instead of me, do they have that right?
• When so many of the formal boundaries that
used to exist have vanished from professional
relationships, what counts as inappropriate
friendliness with patients?
Responsibilities for patients and
the duty of care
Doctors have special responsibilities for ensuring
that their relationships with patients work well.
Although the public has many means of accessing
health information, patients are still seen as
having a power disadvantage in their relationship
with health professionals, who have more
knowledge, experience and influence. Ethics
guidance aims to balance this inherently
asymmetrical relationship by giving the more
knowledgeable party – the professional – a raft of
duties and responsibilities. These vary according
to the professional relationship
Delegation of tasks and referral of
patients
Delegation involves professionals asking other
staff to carry out procedures
or provide care. When specific tasks are
delegated, the professional arranging
the delegation still retains responsibility for the
patient ’ s overall management and must
ensure that tasks are delegated only to those
who are competent to carry them
Patient autonomy and choice
Managing patients ’ expectations
Listening to patients and respecting their autonomy
is emphasised in all ethical guidance. In the best
circumstances, this is straightforward and
appropriate treatment options can be matched
up with the patient ’ s preferences. When there is
a mismatch, dilemmas arise. Patients who have
mental capacity are entitled to decline treatment
for any reason, even if their choices appear
irrational, but doctors do not have to comply
when patients request a particular treatment
Conflicts when commissioning services
Any agency commissioning services needs
robust mechanisms for managing real and
perceived conflicts of interest. Choices that
are in the interests of the majority of local
people, the commissioning body and
taxpayers may not be good for patients
needing expensive care. Solutions are
required that not only save public money but
also ensure fairness and equity. A balance
needs to be achieved and the impact of
decisions should be proportionate.
Covert medication
Health professionals should never mislead people about
the purpose of their medication or withhold
information about it from people who have mental
capacity. The temptation to skip giving a proper
explanation of what the patient’s tablets are for seems
to occur most when staff are hard pressed for time and
looking after patients who are either elderly and
forgetful or people whose behavior is challenging.
Various reports have described how some patients are
routinely given medication without discussion of the
purpose of them or, in some cases, are over-medicated
to make their care easier to manage
Intimate
examinations
GMC guidance on chaperones
‘Wherever possible, you should offer
the patient the security of having an
impartial observer (a “chaperone”)
present during an intimate
examination. This applies whether or
not you are the same gender as the
patient.
A chaperone does not have to be medically
qualify ed but will ideally:
• be sensitive, and respectful of the patient ’s
dignity and confidentiality
• be prepared to raise concerns about a doctor
if misconduct occurs.
• be familiar with the procedures involved in a
routine intimate examination
• be prepared to reassure the patient if they
show signs of distress or discomfort
In some circumstances, a member of practice
staff, or a relative or friend of the patient may
be an acceptable chaperone.
If either you or the patient does not wish the
examination to proceed without a chaperone
present, or if either of you is uncomfortable
with the choice of chaperone, you may offer
to delay the examination to a later date when
a chaperone (or an alternative chaperone) will
be available, if this is compatible with the
patient ’s best interests.
You should record any discussion about
chaperones and its outcome. If a chaperone
is present, you should record that fact and
make a note of their identity. If the patient
does not want a chaperone, you should
record that the offer was made and declined.
• Recognising boundaries
• Managing personal relationships with patients
• In many of the cases raised with the BMA, boundaries
in the doctor–patient relationship have been crossed,
unintentionally. As many old taboos and social
distinctions within society have disappeared, doctors
and patients can find themselves naturally socialising
together or working closely with each other in
campaigns.
• • obtain the patient ’s permission before the
examination and record that permission has been
obtained
• • give the patient privacy to undress and dress and
keep the patient covered as much as possible to
maintain their dignity. Do not assist the patient in
removing clothing unless you have clarifi ed with them
that your assistance is required.
During the examination you should: explain
what you are going to do before you do it
and, if this differs from what you have
already outlined to the patient, explain why
and seek the patients permission; be
prepared to discontinue the examination if
the patient asks you to; keep discussion
relevant and do not make unnecessary
personal comments.
Intimate relationships
Some circumstances need to be particularly
carefully handled, such as when patients
consult a doctor for emotional difficulties
after a loss or bereavement. Any intimate or
close personal relationship which develops in
such circumstances is problematic and is
likely to be seen as cause for disciplinary
proceedings.
• Breakdown of the doctor–patient
relationship
• Relationships can break down for many
reasons and when this happens, patients
generally transfer to another doctor (either
to another GP or another consultant).
Thank you for attention.