Case study - Concerned loved one

BACKGROUND

A 95-year-old patient – Mr T – attends A&E complaining of palpitations and is accompanied by his son, David. He has had similar episodes in the past. An ECG shows a supraventricular tachycardia (SVT) and he is given treatment, following which he returns to a normal rhythm. He is admitted overnight for observation and started on verapamil.

Three days later Mr T is transferred to a general ward, having developed a fever and confusion. He is assessed by Dr L, an ST, and found to have a chest infection. Dr L prescribes antibiotics. Over the next few days Mr T’s infection improves, but he remains confused and is increasingly listless with nausea, poor appetite and poor sleep. Dr L diagnoses depression and prescribes sertraline.

Mr T’s son requests a meeting with Dr L. David is concerned to hear that his father has been prescribed sertraline in addition to his other medications. He has also searched online about the potential side-effects of verapamil and feels that this may be causing his father’s symptoms, rather than depression. Dr L explains that the antibiotics, which are due to finish the following day, are likely to be causing some of his symptoms. He tells David that the antidepressant has been prescribed because Mr T’s lethargy, sleeplessness and lack of appetite could be symptoms of low mood at having been confined to a hospital bed.

David then produces documentation showing that he has been granted power of attorney for health and welfare in respect of Mr T. He reiterates that he believes the verapamil and sertraline are doing more harm than good and he would like them stopped. Dr L tells David that as his father is too confused to consent to treatment, he is being treated in his best interests. He reassures David that a consultant cardiologist has recommended his father remain on the verapamil to prevent further arrhythmias but that he will ask a psychiatrist to review his father with regard to his mood.

A few days later, Mr T is transferred to a rehabilitation unit at another hospital. Unfortunately, he subsequently develops heart failure whilst in the unit, deteriorates and dies.

Two months later David lodges a complaint against Dr L with the GMC. In the letter he alleges that his concerns over the use of verapamil and other medications used to treat his father were ignored and the build-up of verapamil in his father's system precipitated later heart failure. He says Dr L disregarded his welfare power of attorney in regard to treatment decisions in the care of his father.

The GMC obtains an expert opinion on the standard of care provided and frames formal allegations, to which Dr L is invited to respond.

ANALYSIS/OUTCOME

MDDUS assists Dr L in drawing up his written response to the allegations. All relevant documentation is forwarded to the GMC for consideration by case examiners. Two months later the regulator responds with its decision on the matter.

On the allegation of an inappropriate drug regimen the case examiners find that the use and dosage of verapamil was clinically indicated in Mr T’s treatment given his frequent attacks of SVT, and that any side-effects had been adequately monitored. They also note that Mr T had previously been treated with sertraline for depression and its further prescription was not inappropriate.

But the case examiners do find fault with the manner in which Dr L responded to concerns from the patient’s lasting power of attorney with regard to treatment decisions. They cite relevant legislation with regard to decision-making for patients who lack capacity and find that Dr L should have been aware of how to act, or sought further advice, when Mr T's son objected to decisions made. The case examiners acknowledge that Dr L was only acting in what he believed was the patient’s best interests but they find that he was unaware of the relevant legislation that applied to this situation.

Despite this criticism the case examiners judge that this does not call into question Dr L’s fitness to practise or merit any action on his registration. The doctor is directed to the relevant GMC guidance in Good Medical Practice:

“You must keep up to date with, and follow, the law, our guidance and other regulations relevant to your work.”

KEY POINTS

• Be aware of the relevant legal frameworks for assessing capacity and making decisions for patients who lack capacity in the country where you work (Assessing capacity).
• All decisions for patients who lack capacity must be made in their best interests.
• Any legally appointed proxy decision maker (for example a lasting power of attorney or welfare attorney) should be consulted when determining a patient’s best interests. If a decision regarding an intervention is within the scope of their decision-making powers, where reasonable and practicable, their consent should be sought for the intervention.
• Be aware of the steps to be taken to resolve disagreements regarding a patient’s best interests, in line with the law and any local policy.