Dr S was called out to visit his patient Mr T, who had been suffering from acute abdominal pain. It transpired that two days previously he had been admitted to the A&E department of a local hospital with the same complaint.
Mr T had lost his discharge slips, but told Dr S that he had had an ECG, blood tests and an x-ray. He had been discharged with buscopan and coproxamol.
Dr S telephoned the hospital but found that no-one was able to give him any information about his patient at that time. Nor was he able to glean anything from the work colleagues of Mr T who had taken him to A&E.
An examination revealed a silent, distended and tense abdomen, and Dr S noted that Mr T’s peripheral circulation was rather blotchy, although he was not septicaemic. His diagnosis was that Mr T was suffering from peritonitis, and he advised him that he should be admitted to hospital immediately. This suggestion was met with a flat refusal, according to Dr S’s notes.
Despite repeating this advice to the patient and his wife, it became clear that Mr T would simply not countenance being admitted to hospital that evening. Dr S prescribed pethidine for pain relief and made a note in the records to contact the hospital the next day and to visit Mr T again once he had received the information.
In the event, Mr T did not survive the night. The post mortem revealed a 2cm anterior perforation of the duodenum. A writ was served on Dr S, alleging a failure to refer him back to hospital.
In preparing a defence against these allegations, we were greatly helped by the quality of the medical notes kept by Dr S. These allowed us to reconstruct what took place during the consultation, as they not only documented the clinical picture and the investigations carried out, but also his patient’s response to the suggestion that he be admitted to hospital.
In the words of an expert we asked to review the case: ‘It is clear from the note… that (Dr S) has spent an inordinate length of time in trying to obtain information both from the hospital and from the patient’s friends who had taken him to hospital.’
Our expert felt that there was nothing else that Dr S could have done at that time. ‘He has attended the patient, taken appropriate history, attempted to carry out a proper examination and has advised the patient appropriately on more than one occasion as to what is the correct method of dealing with his abdominal pain. The patient has made the choice not to accept his advice…’
The overwhelming feeling was that this was an entirely defensible case. We were not alone in this belief, since the claim was discontinued by Mr T’s representatives before reaching court.
Competent adults have the right to refuse any medical treatment, even if it results in their death. However, these situations are not easy for the medical practitioner. These patients are often difficult to deal with – they are rejecting professional advice, perhaps as the result of a loss of trust or respect, and can raise the hackles of the clinician. This may also lead them to complain or make a claim, should something subsequently go wrong.
The key, as in this case, is to do your best for them, regardless of any emotion generated, and record fully what you have done. Ensure that patients have sufficient, accurate information about the condition, the proposed treatment, any significant risks and side effects, the probability of recovery, any alternative treatments available and the consequences of not receiving treatment.