Patient demanding diclofenac

BACKGROUND

Mr G is age 31 and has suffered from ankylosing spondylitis since his teens. He is seen regularly by Dr L at the GP surgery and insists that the only effective medication to control his persistent joint and back pain is diclofenac.

Dr L and the other partners at the practice are concerned over the frequency with which Mr G is requesting repeat prescriptions of diclofenac, due to cardiovascular and gastrointestinal bleeding risks associated with the prolonged use of non-steroidal anti-inflammatory medication. Dr L has explored these concerns with Mr G and offered alternative treatments to relieve his pain, such as exercise and physiotherapy – and the use of other non-steroidal medications.

Mr G believes that only diclofenac works and has stated that he accepts any risk involved in taking the medication.

Dr L contacts MDDUS for advice on how the practice should proceed. Could the practice record the patient’s understanding and acceptance of the risks involved by way of a signed disclaimer, or should they refuse to continue to prescribe diclofenac?

ANALYSIS/OUTCOME

An MDDUS adviser provides written advice to Dr L referring him to General Medical Council guidance on Good practice in prescribing and managing medicines and devices, which states that doctors should be satisfied that treatment or medication prescribed adequately serves an individual patient’s needs.

Given the patient is requesting specific medication, Dr L is also advised to consider whether there are any local or national guidelines (including appropriate analgesic pathways) to direct prescribing in this case, and to also consider obtaining the opinion of a specialist in pain management.

The adviser reminds Dr L that patients do not have the right to demand specific treatment, and the decision to prescribe must ultimately be a clinical decision made following a careful review of the patient and discussion with colleagues, where appropriate. This obligation is set out clearly in GMC guidance which states:

"If the patient asks for treatment or care that the doctor doesn’t think would be clinically appropriate, the doctor should explore their reasons for requesting it, their understanding of what it would involve, and their expectations about the likely outcome… If after discussion the doctor still considers that the treatment or care would not serve the patient’s needs, then they should not provide it. But the doctor should explain their reasons to the patient and explore other options that might be available, including their right to seek a second opinion."

In regard to a signed disclaimer, the adviser states that a patient’s signature on a disclaimer would unlikely be sufficient proof of their understanding of the risks posed by continuing the medication, and it would remain the responsibility of a GP to oversee all aspects of care related to the prescription.

Good medical practice requires that a doctor documents all relevant discussions and factors that resulted in a joint decision with the patient. The GMC recognises that medicine is not always black or white, and that doctors must use their professional judgement when applying the regulator’s principles to “grey” areas in everyday practice. Doctors must be able to explain and justify any decisions made or actions taken.