Dr Ellie Mein
Common phobias can present challenges for both patients and doctors, as Dr Ellie Mein explains.
With an estimated 10 million people in the UK suffering from a phobia, it's not surprising that doctors will be approached by patients seeking help for these conditions. Below are three common phobias that can impact upon healthcare.
Fear of flying (aerophobia) and requests for sedation
GPs can be faced with requests for benzodiazepines when patients have anxiety caused by flying. The decision to prescribe this medication is ultimately a clinical decision for the doctor, but the GMC is clear that doctors are responsible for the prescriptions they sign and should be prepared to justify their prescribing decisions.
They should also consider if they have adequate knowledge of the patient's health, if the requested drug meets the patient's needs, and consider the risks and benefits. They should also factor in whether there are other alternatives to tackle the anxiety, such as therapy.
The British National Formulary (BNF) and NICE guidance deals with benzodiazepine prescribing, and recommends caution when considering the use of these drugs. Essentially, it says that if you do prescribe, it should be with the smallest dose for the shortest period possible in appropriately selected patients.
The side effects of these medications should also be carefully considered, given they can 'cause drowsiness, impair judgement and increase reaction time'. Their effects can be potentiated by alcohol and the BNF also notes the potential for a 'paradoxical increase in hostility and aggression'.
Possible repercussions include the following points.
- The patient may not be able to react appropriately to save themselves if an emergency occurs.
- The patient presents a risk to others as a result of heightened aggression or slower reaction times in the event of an emergency.
- A sedated patient may move less during the flight, which could put them at increased risk of a venous thromboembolism.
- The passenger cabin of commercial aeroplanes are usually pressurised to the same atmospheric conditions found at an altitude of 10,000 feet. As such, the effective oxygen level is only 14.3% compared to the 20.9% found at ground level. This difference may well be significant in the context of medications – such as benzodiazepines – that can cause respiratory depression.
- The patient will also need to be aware of the rules around importing drugs into the country they're travelling to if they plan to take tablets with them for the flight home.
Claustrophobia and refusal to have MRI scans
It's estimated that every year, approximately two million MRI scans worldwide are not performed because of patients refusing to be scanned or terminating the scan early due to claustrophobia.
There are many resources online that can help prepare patients on what to expect during a scan including step by step explanations and videos of MRIs being performed.
In more severe cases, the NHS website suggests that mild sedatives are an option for people with severe MRI anxiety. However, the MDU would recommend members to carefully consider the 2018 Royal College of Radiologists' guidance, Sedation, analgesia and anaesthesia in the radiology department, which states that a 'trained and credentialed team should administer sedation and analgesia.' There is also an emphasis on thorough pre-procedure assessment, planning and monitoring.
When members contact us about cases relating to claustrophobia and MRI scans, it is usually because they've received a complaint that they were not sympathetic. Common themes are that the doctor has indicated that the patient is 'silly' for being scared of the scan, has wasted NHS money by stopping it, or that there was no discussion about the options available to help the patient prepare for the scan.
Needle phobia and ethical dilemmas
Up to 10% of the UK population suffer from a degree of needle phobia. Similarly to claustrophobia and MRI scans, we see members receiving complaints about their lack of empathy when consulting with patients with needle phobia.
More complex medico-legal queries arise when doctors are faced with patients who have severe needle phobia but refuse necessary investigations or treatment due to their fear. In those situations, doctors are advised to consider the following points.
- Try to identify needle phobia and its potential impact on a patient's care early on, in order to avoid last minute, rushed interventions.
- Use a multidisciplinary approach by including senior input from psychiatry as necessary, and from the anaesthetic team, who may be able to discuss treatment strategies with the patient.
- An early capacity assessment should be undertaken and clearly documented to help inform ongoing management.
- Involve the legal trust early as some cases do require court involvement.
- If the patient has capacity, the responsible clinician should consider whether an advance decision should be discussed and put in place for the likely scenarios that may occur later in care, at a time when the patient may lack capacity.
- If capacity is uncertain, obtain a second opinion.
- If the patient is identified as lacking capacity, plans should be put in place to hold a best interests meeting.
Dr Ellie Mein
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
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