A reluctant diabetic

The scene

A GP is concerned about a patient who does not engage in ongoing monitoring of his condition A 24-year old diabetic patient who was prescribed insulin by his GP repeatedly failed to attend diabetic clinics or the surgery for assistance in monitoring his condition.

The patient did not respond to letters, telephone calls from the surgery or notes attached to the insulin prescriptions asking him to attend for review. The GP was able only to review the patient on an ad hoc basis, when he made emergency appointments for advice on other conditions.

The GP called the MDU advice line for clarification of the medico-legal position on prescribing for patients who refuse to be monitored. His dilemma was that he was responsible for prescribing appropriately, and was concerned that there were risks to prescribing, but that the patient needed insulin to manage his diabetes.

MDU advice

Doctors should take all possible steps to engage with their patients in order to fulfil the relevant ethical guidance. The GMC’s Good Medical Practice (2006), and Good practice in prescribing medicines (2008) require doctors to have an adequate knowledge of the patient’s health, and work in partnership with the patient to ensure that they understand the nature of their condition and proposed treatment.

The doctor must take the relevant history, examine the patient and perform any necessary investigations. The patient must understand how to take the medicine prescribed, be able to do this, and be aware of any side effects.

The steps a doctor might take include inviting the patient for consultations, writing to them setting out the risks of declining to consult, seeking the advice and involvement of other practitioners involved in the patient’s care and, in the GP setting, perhaps visiting the patient if other attempts fail.

However, if patients with mental capacity decide not to engage, doctors must respect that decision, reviewing the position periodically, and documenting carefully the steps that they have taken to work in partnership with their patients.

It is advisable to consider the reasons why a patient may appear not to want to engage in monitoring their condition.

For example, they may have difficulty getting to the surgery during appointment hours because of work commitments, or have to rely on others for transport or child care.

For each patient, doctors need to carry out a risk assessment, balancing the benefits and risks of providing treatment unmonitored against the pros and cons of stopping the medication. The decision reached will differ depending on the particular condition and the treatment in question. In this case, the member decided that the patient’s need for insulin outweighed the risks associated with taking it unsupervised.

The patient had been trained in using blood glucose monitoring equipment, and had monitored his condition for many years. The patient also had warning symptoms if he was becoming hypoglycaemic, which he knew how to manage.

In addition, the doctor wrote to the patient regularly to invite him to the surgery for review, and to provide him with information about his diabetes. When the doctor was able to see the patient, he performed the relevant diabetic checks, emphasising that the condition was best managed on a planned, rather than ad hoc basis.

This page was correct at publication on 01/08/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.