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Problem patient wants you to sign adoption application

Case history

Melissa has been your patient for some years and is a frequent attender at your surgery with multiple, generally unexplained, symptoms. Though she has no definable illness, she has not worked for years, having fallen out with a series of local employers (who you know put up with most things).

She frustrated your long-suffering predecessor to the extent that he mentioned her especially in his retirement speech as one of the aspects of general practice he would not be missing. Now it is your turn, and you stoically shrug aside the receptionists' sympathetic glances when she comes in for her usual lengthy, hectoring consultation.

These are often spent complaining about imaginary slights at the hands of your colleagues, who later pass you in the corridor trying not to snigger. But this week she makes you sit up – she presents you with the form for a formal report for adoption purposes as she wishes to adopt a child. There is a fee of £71 and she states that she wishes to see your report.

You feel she is surely too neurotic to be suitable for adoption – but how can you express this to the adoption agency in a report you know she will read without her flying off the handle?

Dr Lucy Free

'I would make it clear to

her that her report will not be entirely favourable'

I fear this is a no-win situation and damage limitation may be a smart move from the outset. To start with, it is extremely important to read the wording of the request form very carefully.

Do I actually have to do this? Are there any let-out clauses or time constraints? To whom is the report to be sent, and what exactly does it ask for? Can I pass the buck? It may be that it is possible to avoid confrontation on some technicality before the water gets too deep.

The adoption process is long and tortuous and I should be heartened by the knowledge that the evidence I give will not be the only evidence requested.

The final decision is not mine, and I should not get myself bogged down in the philosophical elements of adoption, rejection and homing; leave the morass of children's rights to those who deal with it daily, they will be far more experienced than me, and will have had some exposure to her personality already.

Neither would I consider trying to talk her out of it, surely a waste of time at this juncture. I would just make it clear that owing to her past history (frequent attender with no real pathology) the report may not be entirely favourable. Medicine, especially these days, is based on evidence and I should be able to substantiate anything I write.

I would stick to facts and give examples; the less personal opinion I can put in, the better, if I want to maintain my relationship with her.

It may be worth trying to telephone the agency for an off-the-record chat but I am going to have to put something down on paper.

Some would argue that there are far worse mothers around, but that's not what I am being asked.

At the end of the day I have to do what I believe is the right thing, even if she does fly off the handle – evidence itself that my feelings are justified. I'll just make sure I put my bill in first!

Dr Andrew Wordsworth

'Her frequent presentations could have concealed a hidden agenda of childlessness'

Pressurised GPs rarely have the necessary time to deal satisfactorily with the deep-seated issues that in certain patients cause our hearts to sink. Nevertheless, the old adage 'once a heartsink, always a heartsink' is not necessarily true. A different face may introduce a fresh dynamic.

I am not convinced that she is too neurotic to be a fit adoptive parent. Children can be a positive life- changing experience for many people. Melissa's frequent presentations for multiple unexplained problems may have concealed the hidden agenda of childlessness. Her low opinion of my medical colleagues may be a perfectly rational reaction to their failure to help her unearth this problem. Then again, she could be a complete screwball!

In order to write a meaningful report I need to understand her better. I would ask why she wishes to adopt and why now. I would also want to know which of her qualities she considered would make her a good adoptive parent. I would happily share with her my own experience of the adoption process. The preparatory work undertaken by the Social Services Homefinder is incredibly intensive and should expose and root out significant psychosocial problems, including her chequered employment record.

My primary consideration here is the well-being of any child Melissa may adopt. I would explain to her that any report I was to write would represent my own considered opinion. I therefore need time to search through her notes thoroughly. I have a duty to report evidence of significant psychiatric or physical ill-health. After outlining Melissa's previous medical and psychiatric history, her attendance rate could be covered with the sentence 'Melissa has also consulted clinicians at this practice on X occasions in the last Y years for minor or self-limiting conditions'. Drugs history including nicotine, alcohol and substance misuse is essential. Any personal or family history of inclusion on the Child Protection Register should be reported, even though this information ought to be already known by Social Services.

Melissa is very welcome to read my report. Any objections can be noted and if appropriate acted upon. How she responds is up to her – and at the end of the day she can seek another opinion.

Dr Clare Pedder

'While I have my doubts, can I really be certain what kind of mother she'll be?'

One of life's ironies is the fact that the feckless fecund are free to produce children without interference, irrespective of how unsuitable they may be as parents. Those who are unable to have children or require assisted conception are subject to the sort of scrutiny that would make human rights lawyers throw their hands up in horror.

Requests for such reports highlight my uncomfortable dual role as patient advocate and moral judge for society. While I may have my own doubts, can I really be certain that I know what kind of mother Melissa would make?

If the answer is no, I need to tread the fine line between expressing my concern and damning any chance she may have to proceed. As far as my limited understanding goes, the prospective

adopter is subject to a probing inquisition by social workers before approval, and it is likely that Melissa's neurotic traits will become apparent during this process.

Melissa and I need to discuss this request before I put pen to paper. I would want to clarify what her understanding is of the process ahead of her and of what I was being asked, as well as obtaining her signed consent for this. Her records and current psychological state need reviewing to ensure there is no psychiatric illness that needs addressing, nor any previous history of abusive behaviour.

Why has she made such a life-changing decision now and what does she hope to gain from becoming a mother? Are her expectations realistic? Perhaps her childlessness has contributed to the unhappy, dissatisfied woman she has become and this may be the making of her (or not!).

Assuming no formal illness, my report would be a neutral one, neither damning nor praising but a statement of fact with regard to her past and present medical history, including her frequent attendance with medically unexplained symptoms.

Melissa can add her own comments to the report if she so wishes and the adoption agency is equally welcome to discuss matters further by phone.

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