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Litiginous family constantly cry wolf

Three GPs discuss a tricky problem

Case history

Your patient Donna Woodsley has lived alone since her family moved 20 miles away. She has a degree of learning disability, asthma and type 2 diabetes and calls the surgery twice a day, often to request visits because of chest pain and shortness of breath.

When visited she is often miraculously better and simply wants help to retrieve her inhaler from behind the sofa. Her family ring each evening demanding a visit and threatening litigation if the doctor does not go and anything happens to Donna.

Your practice is rural, and realistically there is no other practice Donna could register with. The PCT is not very supportive and has confined itself to making soothing noises about anxiety management and patient expectations.

Dr Jane Bowskill

'If I keep getting threatened she'll be removed from list'

A knee-jerk response is to consider removing Donna from the list and telling the PCT they can sort it out. The fact there is no other local practice is not really my problem. However, I only have experience of working in towns, where patients have a choice of GPs ­ it must be more difficult in rural areas.

Practically, the thing to do would be to arrange to visit Donna and discuss the problem with her. Are her learning difficulties assessed and recorded? Does she have any insight into the problem, or can she not understand ?

She should have a key worker who has responsibility for her. I would arrange to talk to them as well, emphasising the practice cannot be expected to act as her minder, and her demands are an abuse of expensive medical resources (social services are very concerned about costs).

It is interesting someone felt Donna could

manage on her own when her family moved away, as the unreasonable visit requests seem to suggest otherwise.

I would not be afraid to tell her that if her family continue to threaten me she may need to look for another GP ­ I would wait and see if things improve.

If things did not improve, I would send a letter to the family, telling them their requests and threats are becoming unacceptable and offering to meet them, or at least talk to them on the telephone about how to go forward.

However, if, as is probably likely, this is met with abuse and further threats, the only option is to remove Donna from my list.

I would record everything carefully, talk to my defence body or the LMC secretary and ensure the partners all agree on the plan of action.

Dr Chris Hall

'Failure to act will inevitably lead to a relationship breakdown'

Refusal to visit, although sometimes perfectly justified, is one of the most common reasons for a complaint. Complaints are distressing and time-consuming, but failure to alter Donna's behaviour, or rather that of her family, will inevitably act to reinforce the problem. Ultimately, it is the

doctor's decision when and where a consultation takes place, and this has to be pointed out.

With the patient's permission I would invite them, in writing, to attend the surgery to discuss management issues and concerns. Donna should, of course, attend with her medication. It would be prudent to have a GP partner present.

This will give the opportunity for all three 'parties' to meet together and explore each others' agendas, and may give valuable insight into Donna's relationship with her family. Does she know they ring demanding home visits? If she does, are they a cry for help? What is their level of insight into out-of-hours arrangements? On what possible grounds are they threatening litigation? Does guilt lie behind many of their threats? Do they understand the majority of out-of-hours contacts are now dealt with by phone advice alone or with patients attending the out-of-hours centre?

A strategy would be to emphasise that some degree of family input is necessary, and if Donna is unprepared or unable to take responsibility for her own health, then either the family must play some part or some input from social services may be necessary. This could include a suitability assessment of Donna's accommodation and her ability to self-care. Her apparent lack of compliance with and understanding of her medication should be explored.

This meeting would give me the opportunity to emphasise the frequency and nature of her out-of-hours calls are wholly inappropriate, and that the doctor-patient relationship carries responsibilities for both parties.

I would make it quite clear failure to act upon this will inevitably lead to a relationship breakdown, and possible removal from the list. The threat of this may be sufficient impetus to behaviour change.

On the other hand, offering regular review in the surgery and the services of a dietitian, diabetologist and possibly a psychologist demonstrates the practice is being firm, but fair.

It may still be possible to salvage this deteriorating situation to the satisfaction of all concerned.

Dr Prashini Naidoo

'If we decide to go to war there will be casualties'

Donna and her family are heartsinks. They waste practice time and are causing stress to the clinical and administration staff. Donna is calling constantly either out of genuine fear or loneliness. Her family find it easier to harass me than to deal with her. The PCT finds it easier to ignore me rather than be lumbered with a difficult problem. I am feeling trapped between my duty of care to this patient and the helplessness and anger she creates by childishly 'crying wolf'. I resent being pushed around.

The practice and I can continue to play this game but change our attitudes so it bothers us less. Donna probably will need one named doctor who will visit and deal with the family. The division of the rest of the practice workload needs to be fair. This united approach will reduce the emotional burden and 'contain' the situation.

Alternatively, the practice and I could decide to challenge this unacceptable behaviour and go to war. Unfortunately, there will be casualties. Donna's calls will escalate in the short-term; her family will become more abusive; the receptionists will be in the frontline; some people within the practice will lose their nerve before others and there will be in-fighting. We need to speak to our defence body and obtain advice about worst-case outcomes.

We also need to commit to a strategy: all phone calls need to be directed to the practice manager; all clinical information needs to be assessed by a doctor. We need to speak to our allies: the ambulance service, social services, the deputising services, the PCT and our patient group committee.

The practice will need to decide whether challenging Donna's behaviour is worth the effort or whether it may be better to pursue the path of saintly tolerance.

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