This case-study looks at what you should do if a patient confides in you that they have been a victim of domestic violence.
The scenario can be viewed as an interactive story on the GMC website here - or you can read it in full below.
Narrator: Sylvia has come to see Dr Peters for a routine check-up about the management of a chronic condition which can affect her mobility during particularly bad episodes. Sylvia has previously confided in Dr Peters about her partner, Therese, who is an alcoholic and has been violent towards her on several occasions. Sylvia was recently hospitalised after one such attack and spent several days in a women's refuge but she returned home to Therese a few days ago.
Conversation between Sylvia and Dr Peters
Dr Peters: I think we'll up the dose again and bring you in for a further test in about two weeks' time if that's okay with you. But Sylvia I'm worried about you going back home so soon. Are you sure you're going to be okay?
Sylvia: Oh Therese isn't that bad really… it's only when she drinks and I can usually keep out of her way.
Dr Peters: But you're still at risk, especially if you're in the middle of a bad episode. You were injured quite badly last time when you were in good shape, fitness-wise. What if Therese is violent in the next few weeks when you're feeling weaker?
Sylvia: I can handle myself okay, Dr Peters. I was feeling pretty rough yesterday but still managed to defend myself – I guess the adrenalin kicks in doesn't it? "Fight or flight" and that.
Dr Peters: You mean she attacked you again yesterday? Did you call the police? Sylvia you've only just got home again! I thought Therese promised to stop drinking – that's the only reason you agreed to go back isn't it?
Sylvia: She will, I'm sure. But it's not going to happen overnight. It's fine Dr Peters, really. You don't have to worry about me. And there's really no need to tell the police – I'm sure they've got much more important things to worry about.
Should the doctor…
a. Call the police or social services to tell them that a serious assault has been committed?
b. Insist that Sylvia agrees to tell the police before providing treatment for her?
c. Do nothing, drop the subject and treat Sylvia as it's her choice if she wants to place herself at risk?
a. This would not be in line with GMC guidance. Although Sylvia is vulnerable she still has capacity and Dr Peters should abide by her decision not to disclose, even if it places her at risk of serious harm (and provided no one else is at risk).
b. This would not be in line with GMC guidance. All patients are entitled to care and treatment to meet their clinical needs, and doctors should not withhold treatment from patients who need it, whatever the circumstances. Doctors should usually abide by a competent adult patient's refusal to consent to disclosure, even if their decision leaves them, but nobody else, at risk of serious harm.
c. This might be in line with GMC guidance. However, doctors can encourage patients to consent to disclosures they consider necessary for their protection. Dr Peters should do his best to support Sylvia to make a decision in her own interest, for example by arranging contact with support agencies.
What the doctor did
Narrator: Despite his best efforts, Dr Peters was not able to persuade Sylvia to allow him to disclose details of the further attack to the police, or social services. He warned her of the risks of refusing to consent, but he could not override her decision because Sylvia is a competent adult and, because Sylvia lives alone with Therese, nobody else is obviously at risk.
Before Sylvia leaves, Dr Peters makes sure she has information about support services in the area, including the refuge and a domestic violence support group as well as the local police's domestic violence team.
Disclosures to protect the patient, Confidentiality, Good Medical Practice, paragraphs 51-52
51. It may be appropriate to encourage patients to consent to disclosures you consider necessary for their protection, and to warn them of the risks of refusing to consent; but you should usually abide by a competent adult patient's refusal to consent to disclosure, even if their decision leaves them, but nobody else, at risk of serious harm.22 You should do your best to provide patients with the information and support they need to make decisions in their own interests, for example, by arranging contact with agencies to support victims of domestic violence.
52. Disclosure without consent may be justified if it is not practicable to seek a patient's consent. See paragraph 38 for examples, and paragraph 63 for guidance on disclosures to protect a patient who lacks capacity to consent.
This case-study is from the Good Medical Practice in Action section of the GMC websitePatient confidentiality: Domestic violence