Ending the doctor patient relationship; easier said than done?
The more I read HDC reports the more I see the need for fundamental questions to be discussed and answered.
A recent report by the HDC tells a sad tale of a 66-year-old woman who died in hospital on day five of an admission for septicaemia as a consequence of cellulitis brought on by chronic skin lesions. The patient had type 2 diabetes, COPD and chronic skin diseases aggravated by obesity.
This is a story that probably plays out in New Zealand too regularly. So why did the Deputy HDC Commissioner write a 45-page report on the case?
In the two years before her death, the patient had two admissions to hospital where upon discharge she was referred to the district nursing service who then re-referred her to a home management service (Access Health Care) where her care needs were ultimately escalated to twice daily visits.
In 2017 her caregiver became concerned about her skin deterioration and asked on a number of occasions for a clinical review; however the requests were not escalated or acted on.
The HDC was correctly very critical of this communication breakdown; but it begs the question of ‘who should be in clinical charge of these services?’ These patients are partly in the public system and partly in general practice. But the DHB pays for the ‘hospital service’ only.
A three-monthly (at least) clinical report should have gone to the provider, but who was the ultimate provider? My view is that the person who pays for the service should have to be responsible for the safety of that service.
So, what about the GP? He had known the patient since 2009. The patient was reluctant and despite repeated attempts, did not attend the practice and sent her husband for repeat prescriptions.
The husband was repeatedly advised that his wife must come in for a face-to-face consultation, however he pleaded for repeats and promised that he’d get her to come in “next time”.
The GP said they may end the professional relationship but didn’t. The GP didn’t see the patient in person for two years.
In the GPs own words from the report:
“Requests from [Mr A] for prescriptions caused much anguish and I told him on 5–6 occasions that I would not care for her any longer as the relationship between doctor and patient had dissolved to dangerous levels and was unsafe. She refused to see me. I asked him to find another doctor to care for her. He refused. I should have ended my contact with her then with a recommendation to another doctor. Every other time he appeared I would refuse his request, but he would beg for my help and foolishly I would capitulate.”
The Commissioner was critical of the GP for repeating the scripts and for not ending the relationship and asked him to write an essay reflecting on the MCNZ’s ending a doctor-patient relationship statement.
I do wonder how many of us have found ourselves in the same predicament and if we have, how likely such a person would be accepted by another practice.
Towards the end, the patient finally agreed to a home visit where the GP recognised the seriousness of the situation, but the patient refused to be admitted to hospital. He left her a prescription and asked the husband to call the ambulance when she agreed to admission.
She finally agreed to be admitted by a district nurse 11 days later but died of septicaemia five days later.
The Commissioner was critical of the GP for not having done more to convince her.
For me, there are four key lessons:
- There needs to be clear accountability for the management of patients who are being managed at home by nursing services, and if it is the GP practice, this needs to be properly funded.
- Patients have a right to their own opinion even if it’s wrong. They may sometimes behave in a way that is out of our control.
- In theory, it’s easy to end a professional relationship, but often not so easy in practice. Under these circumstances, is sub-optimal care justified?
- If you find yourself in this situation DO seek peer advice AND record it in your notes.
