Theme: The doctor–patient relationship

1. 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

2. 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.

3. • 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.

4. • 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.

5. • 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.

7. Rights of homeless people, detainees and asylum seekersNHS 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.

8. Example:Case example – failure to discussAn 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

9. Reporting errors: FroggattA 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

10. Case example – personal relationshipsIn 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.

11. Questions between doctors-patients

12. • 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?

13. • 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?

14. • 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?

15. Responsibilities for patients and the duty of care

16. 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

17. 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

18. 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

19. 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.

20. 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

21. Intimate examinations

22. 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.

23. 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

24. 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.

25. 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.

26. 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 clarified with them that your assistance is required.

27. 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.

28. 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.

29. 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).

30. Thank you for attention.