Scenario

A patient with non-insulin treated diabetes mellitus has repeatedly refused to attend the practice for diabetic checks or to attend for retinopathy screening. The last HBA1C from over a year ago showed poor control.

The GP has sent appointments to the patient to discuss the issues but the patient has not attended, and the GP is concerned about continuing to prescribe medication without monitoring.

Doctors not infrequently face circumstances where patients are reluctant to engage with treatment or monitoring. The question most asked by MDU members is whether or not they should continue to prescribe in this scenario.

That decision must inevitably be based on the individual circumstances, but the key consideration for any clinician facing this type of situation is simply that they can justify the decision they make.

Can a patient refuse treatment that might put their life at risk?

The Mental Capacity Act 2005 makes very clear that a person with capacity has an absolute right to refuse treatment. The fact that the patient makes an ill-advised decision does not, on its own, allow you to conclude that a person lacks capacity.

The law makes this clear, but if things go wrong as a result of the patient not engaging with treatment or monitoring, questions might later be asked about whether the patient had the requisite capacity to refuse treatment and what information was given to allow them to make a decision about treatment.

This might be particularly relevant where the patient is considered vulnerable or has mental or physical health problems which might impair their ability to engage with treatment.

In circumstances where a patient is not engaging with their medical care, the assessment of capacity and the exchange of information would ideally take place face to face. Often members turn to the MDU for advice after having made extensive attempts to encourage a patient to attend for review.

Should I attempt to visit a patient not attending invitations for review?

Clearly it would be impracticable for doctors to visit all patients who do not respond to invitations for routine review, but it might be appropriate in circumstances like the one outlined above.

A visit might provide information about the patient's social circumstances and allow you to consider other ways of improving the patient's engagement. Of course, it's sensible to give the patient advance notice of your visit.

What if the patient won't even answer the door? Is it enough to just write to them to explain that they are putting their life at risk?

Where a patient doesn't respond to you at all, then you should make a clear written record of your attempts to encourage them to engage with treatment.

When writing a letter, it might help to consider things from a patient's perspective. For example, does the patient know that they might be increasing their risk of cardiovascular disease through poorly controlled diabetes, even though they feel fine at the moment?

Details like this, as well as the potential risk to their life, may encourage the patient to engage but it's also helpful in showing the doctor's attempts to explain the issues in simple terms. If stopping prescribing might be one outcome of the patient's failure to engage, then make that clear in your communication with them at an early stage.

Sending your letter by recorded delivery will often confirm that it's been received. As well has writing to the patient, it is also important to keep records of all the attempts you have made to contact or engage the patient - including those which haven't been successful.

So should I prescribe or not?

In 'Good practice in prescribing and managing medicines and devices' (2013), the GMC says that you should prescribe medicines only if you have adequate knowledge of the patient's health and you are satisfied they serve the patient's needs.

The difficulty in such circumstances is that the doctor might know that the patient has an underlying condition, which in normal circumstances would mean that the ongoing prescription of treatment would clearly be needed to meet the patient's needs.

However, it may also be that the doctor can't say for certain that they have adequate knowledge of the patient's health to be comfortable that the treatment is safe.

This means that there is no black and white answer to the central question of whether it's appropriate to prescribe. It will depend on a risk assessment based on the drug in question and the patient's condition.

For some patients, stopping prescribing the drug might be fatal. For example, it might be very difficult to justify withdrawing a prescription for insulin from a patient with type 1 diabetes. In others the drug might be a preventive treatment intended to reduce the risk of a particular disease and might itself come with a risk of complications if not monitored, and so the balance may well be to stop the treatment.

It can help to seek specialist advice and to clearly document the thought process which has led to the decision rather than simply referring to the failure to attend for review alone.