Case study: Patient buying medication online

BACKGROUND

Mr G has a history of serious trauma and mental illness and has been receiving psychiatric care for a number of years. The 34 year old was previously taking a high daily dose of an antidepressant but was successfully weaned off.

Mr G attends an appointment with his consultant psychiatrist Dr A and asks if he can go back to taking the antidepressant, saying he is struggling without it. He says he has tried to get prescriptions from other doctors and thinks it’s unfair he is being forced to cope without it. He adds that he has had “no choice” but to buy antidepressant pills off the internet.

Dr A warns Mr G of the dangers of buying medication online and assures him that it would not be clinically indicated to revert to high-dose antidepressant use. Previously, Mr G had been taking almost twice the BNF’s recommended limit. Dr A explains that at present the best approach would be to focus on psychological interventions.

Mr G disagrees and insists that he “needs” his medication and walks out of the consultation.

Dr A contacts MDDUS for advice on how best to proceed.

ANALYSIS/OUTCOME

An MDDUS medico-legal adviser (MLA) speaks to Dr A and highlights key elements of the General Medical Council’s guidance, Good practice in prescribing and managing medicines and devices. It states (at paragraph 98): “You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate.”

It also provides advice (at paragraph 51) on handling patient requests for medicine you don’t think will benefit them. In these situations, the GMC says doctors should explore the reasons for the patient’s request, their understanding of what it would involve and their expectations about the likely outcome.

The guidance is clear that, if after discussion a doctor still thinks the treatment or care would not serve the patient’s needs, they should not provide it. The doctor should explain their reasons to the patient and explore other options that might be available, including the patient’s right to seek a second opinion.

The MLA advises Dr A that she should not let Mr G coerce her into prescribing a dose of medication that she does not believe is appropriate or serves his needs.

Given that Mr G walked out of the consultation, Dr A may feel there has been little chance to adequately discuss with him the reasoning behind her decision not to prescribe further antidepressants, and also to discuss other interventions or medications that might benefit him.

Dr A is advised to invite Mr G back for a further appointment. Should he refuse to attend then the salient points can be set out for him in writing, including his right to seek a second opinion.

With regard to concerns over Mr G buying medication online, Dr A should be satisfied that she has fully explained the health risks of doing so and that he understands her reasoning. This discussion should be clearly documented in the patient record. Assuming Mr G has capacity, it is ultimately his decision.

KEY POINTS

• Doctors are responsible for any prescription they sign and must be sure any treatment is safe and appropriate.
• If a patient disagrees with a treatment decision, discuss the matter with them and do your best to help them understand your reasoning.
• The GMC is clear that (following discussion with the patient) doctors should not provide treatment or care if they believe it would not serve the patient’s needs.