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Seriously ill geriatric who refuses to go to hospital

Case history

Mrs Gladys Smith, aged 91, has had recurrent cellulitis of the legs, which normally improves with oral antibiotics. This time, however, she has not responded and her renal function is deteriorating. She does not seem confused, but she is refusing hospital admission, and seems unable to care for herself adequately. Dr Steve Brown discusses.

How should I react? I need to explore the reasons for her refusal. Has she had a bad experience of hospital? Does she simply want to die at home? Is she truly able to make an informed decision? What family support is there? I need to build a good relationship with her because I can sense some difficult decisions ahead.

What initial assessment is needed?

I need to re-evaluate my clinical diagnosis, while remembering to make detailed and accurate medical notes. Am I sure she has cellulitis? Could she have a DVT, or a ruptured Baker's cyst, or a more rare condition such as erythema nodosum? I need to check her compliance with the antibiotics I have prescribed, and consider adding another antibiotic or changing my original prescription. I might contact the microbiologist for advice. An MSU could give clues to her deteriorating renal function.

Who else could help me in this difficult situation?

I need to ensure she is mentally stable. I would do a formal mental state examination, and even if she scores full marks on a mini mental test score it would be useful baseline information. If I were not sure, an opinion of a psychiatrist or an elderly medicine consultant would be sought, via a home visit. The latter would also be able to advise me on medical management – for instance how frequently to monitor her renal function.

Can I persuade her to be admitted?

It is not helpful to get into an argument. I would try to explain simply that she will probably deteriorate at home and being admitted may give her the best chance of improving. It would be helpful for any relatives and also the consultants to back me up. Mrs Smith may agree to go to hospital to see the on-call medical registrar, without agreeing to be admitted initially. I need to show respect for her decisions and not show hostility or frustration if Mrs Smith disagrees with what I think is the best course of action.

Can I compulsorily admit Mrs Smith?

It appears she would not fulfil the criteria of the 1983 Mental Health Act, as she does not seem to have a mental illness that could risk her health or safety or the safety of others. The 1948 National Assistance Act can lead to 'securing the necessary care and attention' for persons who are unable to care for themselves, or who are not receiving good care from others, or who are living in unsanitary conditions.

It is a rarely used Act, which the Government is currently thinking of redrafting; the Director of Public Health would have to apply for a magistrate's order to remove the patient from their home. In theory this Act could be used to admit Mrs Smith.

The Human Rights Act 1988 respects a person's autonomy in their own decision-making and seems to run contrary to the National Assistance Act. However, as yet I don't think there has been a legal challenge of the two Acts. The GMC requires a doctor to make the care of the patient their first concern.

The outcome

After discussion with the patient, their relatives and social services, it was decided to care for Mrs Smith at home. Her cellulitis improved slowly with a change of antibiotics, but she became bed-bound, her renal function deteriorated and she faded peacefully away two weeks later. I put renal failure as the main cause of death and cellulitis as a contributory factor. Before issuing the certificate I spoke to the coroner to ensure he was happy there was no need for a postmortem.

Key points

lFor cases with potentially significant legal consequences get a second medical opinion early

lConsult your medical defence company

lKeep detailed accurate records

lInvolve family members if appropriate

lBe aware of the coroner's role

Useful websites

•Mental health act www.rethink.org/information/legal

•Duties of a doctor

www.gmc-uk.org/standards

•MDU www.the-mdu.com

• MPS www.mps.org.uk

•National Assistance Act www.adss.org.uk/publications/

consresp/2003/accommodation.shtml

Steve Brown is GP trainer and partner in Beaconsfield, Buckinghamshire

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