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When a patient's lifestyle affects their treatment

The question of the effect of patients' lifestyles on their treatment is something on which GPs sometimes seek the advice of the MDU, says Dr Paul Colbrook

The question of the effect of patients' lifestyles on their treatment is something on which GPs sometimes seek the advice of the MDU, says Dr Paul Colbrook

Drinking, smoking and other lifestyle factors may contribute to, or exacerbate, many of the conditions GPs see every day. However, while this may be a frustration, a patient's lifestyle should not influence his or her access to treatment.

GPs are ethically obliged to provide investigations or treatment on the basis of patients' clinical needs and the likely effectiveness of the treatment. The GMC's ethical advice for doctors on access to medical care states: 'You must not allow your views about patients' prejudice the treatment you provide or arrange. You must not refuse or delay treatment because you believe that patients' actions have contributed to their condition.

This advice is reflected in a recent report from NICE that is intended as guidance for those who formulate NICE guidelines, rather than as guidance for clinicians. The report states that 'NICE and its advisory bodies should avoid denying care to patients with conditions that are, or may be, self-inflicted (in part or in whole). If, how-ever, self-inflicted cause(s) of the condition influence the clinical or cost-effectiveness of the use of an intervention, it may be appropriate to take this into account.'

GPs are obliged to provide sufficient information to patients in order that they can make informed decisions. If you believe the success of a patient's treatment may be influenced by their lifestyle, it's important to discuss this with them when obtaining consent. The GMC says that for each treatment option you should give 'explanations of the likely benefits and the probabilities of success; and discussion of any serious or frequently occurring risks, and of any lifestyle changes which may be caused by, or necessitated by, treatment'

Clinical decisions

There may be occasions when a patient's behaviour diminishes the likelihood of a successful outcome or increases the risk of harm to such a degree that you believe a particular treatment option would not be in the patient's best interests.

Such a situation might arise, for example, where a 35-year-old overweight woman who smokes insists you prescribe the combined contraceptive pill as she has unacceptable spotting on the mini-pill, refuses to try an IUCD or injection, and her boyfriend refuses to use condoms. In such cases, you must make the care of the patient your first concern and explain the position clearly to them.

The GMC is clear that GPs should not recommend any treatment they know is not in their patients' best interests ­ meaning patients cannot compel a doctor to carry out a treatment that is not clinically indicated. If a patient requests such a treatment, explain that you have an ethical duty not to provide it and discuss alternative treatments with them. In such cases it may be helpful to arrange for a second clinical opinion.

Patients occasionally offer to sign a 'disclaimer' relieving you of responsibility for the consequences of a treatment. However, you are responsible, legally and ethically, for treatments you prescribe or provide, and must be able to justify your actions; a disclaimer will not change those obligations. If the patient suffers harm as a result of what you do or recommend (or fail to do or recommend) you may face a complaint or claim for damages. GPs in charge of a patient's care are ultimately responsible for making decis-ions about whether to provide a particular treatment. But GPs are advised to contact their medical defence organisation to discuss individual cases.

The case mentioned below is fictitious, but based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

Case history

A GP carried out a routine visit on an elderly man with severe chronic lung problems.

Following a recent hospital admission, he had stopped smoking and been provided with home oxygen. When the GP arrived at the home, the patient was sitting in his armchair with the mask on his forehead, smoking. After turning off the oxygen supply, the GP warned him of the grave dangers of continuing to smoke when using oxygen. The patient explained that he had tried and failed to give up his habit, and would probably die a smoker. He was unable to give any reassurances about not smoking around the oxygen tank. The GP felt he could not continue to prescribe oxygen in these circumstances and asked the MDU if he could refuse to do so.

MDU advice

After careful consideration, which may include a discussion with the patient's consultant, if you feel you can no longer justify prescribing oxygen on clinical grounds, then you should explain this to the patient.

While the GMC says you must not allow your views about patients' lifestyle to prejudice treatment, it also says that you must not give or recommend to patients any treatment which you know is not in their best interests2. It seems that the decision not to continue to prescribe oxygen is a clinical one, rather than based on your views about the patient's lifestyle, and on these grounds may be justifiable.

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