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Practical steps towards better asthma care

Patient who won't be admitted to hospital

For whatever reason, some patients simply refuse to be admitted ­

Dr Melanie Wynne-Jones offers advice

It's easy to assume that patients who seek our help will take our advice, especially a warning that they need hospital admission. But patients who refuse admission may be:

·Unconvinced that admission is really necessary. This may be based on correct/incorrect

knowledge and beliefs, or because we have not made a convincing case.

·Scared of hospitals, including MRSA (an increasingly expressed concern).

·Worried about the welfare of relatives or pets left at home, especially if the patient is a carer.

·Distressed by unhappy memories if a loved one died in hospital (particularly the same hospital).

·Distressed at loss of autonomy/privacy, or worried about not being able to smoke/drink.

·Scared that they will die in hospital, and say they'd rather die at home.

·Influenced by relatives who are worried about any of the above.

If someone refuses admission, mentally run through a checklist:

·Why do I really want to admit this patient?

·Have I considered all the alternatives?

·What are the risks to the patient (or others) of not going into hospital?

·Does the patient understand and accept these?

·Does the patient have capacity to consent/refuse?

Doctors admit patients for a variety of reasons; the acid test is whether admission offers unique advantages over other solutions. For example, hospital may be the only way to access investigations, monitoring/observation and treatment that cannot be instantly provided in primary care.

In some situations, best management is obvious ­ the crushing central chest pain or gastrointestinal bleed. In others, the diagnosis may not be clear, but the risks of missing a serious diagnosis may be significant (for example after an episode of unconsciousness).

But it's important to be aware when our own uncertainties/fears could be affecting our decision-making; this may reflect a personal learning need which should not adversely affect patient care.

GPs often have to problem-solve situations rather than simple medical conditions. For example, where deterioration in an ill child or elderly person will not be noticed and acted upon, or where support services cannot be promptly marshalled, admission may also be the safest option.

Alternatives may be to review the patient after a period of time, perhaps by telephone if this is appropriate. This may be done best by the person who saw the patient initially, but takes time, requires adequate safety-netting and relies on untrained patients/relatives to report significant change. This may not be a good use of practice resources if it simply postpones the decision and creates work later in the day. Changes in out-of-hours provision have also made it less practicable.

Another alternative, particularly where the problem is more one of nursing or safe care/supervision, may be to enlist urgent help from relatives, district nurses or social services. Emergency admission to a residential or nursing home may also be possible.

Many areas have a hospital-based rapid-response team that can provide prompt assessment, nursing, equipment and other home services in a crisis where hospital admission is not strictly indicated.

You may decide what you really need is authoritative medical advice. Consultant domiciliary visits are now less frequent, but an urgent outpatient appointment may suffice.

You could also telephone the specialty consultant or SpR on call. This has several advantages ­ they may reassure you, suggest an alternative or 'holding' management plan, or reinforce your decision that admission is desirable, which will strengthen your advice to the patient.

If a patient still refuses admission after you have clearly communicated the reasons why you believe it is in their best interests, you need to check whether they have capacity to consent/refuse.

This is usually easy, but if the patient is at risk, and you have reasonable cause for doubt, suspecting that the patient's judgment may be clouded by illness or that there are elderly/ child protection issues, you may have a duty to act without their consent. You will probably need to discuss this with your trainer, the specialty consultant and/or your defence society first.

If you are certain that the patient has capacity, then ethically they have a right to autonomy, and to reject your advice. But under Duties of a Doctor you must still do what you can. You may be able to negotiate a compromise solution.

If not, make sure the patient truly understands the issues, and tell them

they have the right to seek help again without prejudice if they change their mind (this often happens). Document this in full, and communicate it to other practice members who may subsequently become involved.

Melanie Wynne Jones is a GP in Marple, Cheshire

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