A patient with disseminated malignancy has asked for referral to a hospital for integrated care with a view to homeopathy. I don’t believe homeopathy is an effective treatment or in her best interest. How should I respond?
Dr Simon Parton: Agree if the patient fully understands their condition
My first priority would be to establish the patient’s understanding of the diagnosis. What information has she received about conventional management options, prognosis and potential side-effects?
I would discuss my concerns with the patient about the risk of deviation from recognised and evidenced therapy while maintaining a relationship of trust and support. I would offer to share with her any published NICE guidance for her cancer, and review any literature she has on her proposed homeopathic treatment. I would offer to meet again in a few days to allow further discussion.
I would also direct her to charities such as Macmillan Support, Cancer Research UK and Breast Cancer Care who have information about supportive and complementary therapies that are safe and appropriate.
Having established that she fully understands her condition and her request is based on choice rather than a lack of understanding or capacity I would agree to her request and maintain regular reviews of progress. I would also suggest consultation with conventional oncology services so that there is an opportunity to discuss standard therapies with specialists and maintain an ongoing dialogue with conventional therapy teams so she could consider treatment at a later date. Because of the likely palliative nature of any therapy for disseminated disease, early information and referral to community palliative care services might be appropriate.
Whether she is reviewed in a traditional oncology service or an integrated homeopathic service she will need the ongoing support of her GP and it’s essential to maintain that relationship, especially when she approaches the end of life.
Dr Simon Parton is a GP in Lewisham and chair of Lewisham LMC
Dr Pipin Singh: Make sure the patient knows the lack of evidence
It will be important to have a full understanding of the patient’s condition and prognosis. A curable metastatic condition may alter the advice that you give.
Establish what the patient already understands about her condition and prognosis. If she has capacity to make a decision, you have to respect her wishes. If she doesn’t understand her condition and you feel she lacks capacity, you may wish to offer further discussion with her next of kin or close relative. If there is no one else to discuss with, you may wish to consider a patient advocate.
Knowledge of homeopathy will vary from doctor to doctor, however as GPs it is important we respect patients’ health beliefs. Explore why the patient is requesting homeopathy. Does she have a fear of conventional treatments? Find out what the patient already knows about homeopathy. Is this something she or a family member or friend has used before with good outcome?
You should explain that homeopathy is not recommended by NICE or the NHS and does not have a robust evidence base. It is not routinely available on the NHS although a few doctors do offer homeopathic options for certain conditions. There is also no regulation of homeopathic practitioners.
Agreeing to a referral is acceptable as long as the patient has capacity and is fully informed of the pros and cons.
Dr Pipin Singh is a GP in Wallsend, Tyne and Wear
Dr Zaid al-Najjar: You needn’t refer but you must explore why she has asked
Whether you believe homeopathy is effective or not, it has a significant following and many GPs encounter situations like this.
In the first instance, it would be helpful to discuss your concerns with the patient, exploring why she feels conventional treatment might not satisfy her needs.
You do not have to make a referral if you do not believe it would be of clinical benefit or in the patient’s best interests, but it is important to consider Section 5d of the GMC’s consent guidance on patient treatment:
‘The doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient they do not have to provide it. But they should explain any other options that are available, including the option to seek a second opinion.’
Together, you may like to explore the possibility for mainstream therapies to be carried out alongside homeopathy, subject to the availability of funding and willingness of the specialists involved.
Ensure you record all discussions you have with the patient.
If you have concerns about the patient’s capacity to make an informed decision about her care, given the disseminated malignancy, you should contact your defence organisation.
Dr Zaid al-Najjar is a medicolegal adviser at the Medical Protection Society and a sessional GP in London