1 April 2022

Where does a GP’s duty begin and end?

Aged Care General practice

There’s a fine balance between caring and interfering.

I had always loved Helen’s visits. She was always positive and took such pride in her appearance, despite being in her mid-80s.

She’d say that when she dressed up to go out she “looked like a million dollars”.

I didn’t see her all that often. A bit of arthritis. A tricky blood pressure and a bout of gout. I did know she lived alone in a unit and had no immediate family having never married.

Helen was always a little scatty and said she had to write things down to remember them, but she was fiercely independent and was adamant she was on top of things. Well, about a year ago unbeknownst to me, Helen went to hospital, where she stayed for about a month!

I had no idea until about six months later – I just thought I hadn’t seen Helen in ages. I looked up the file and found the hospital discharge summary, which told me she’d had a heart attack and hence the long stay. She hadn’t been to our practice since.

Anyway, I rang her. She sounded genuinely pleased to hear from me but also seemed vaguer than before. She wasn’t going out because of the pandemic, but yes, she’d happily come down the next day to the surgery. She didn’t turn up. I rang again – she apologised profusely about missing the previous appointment and said she’d turn up later the next day. She didn’t.

Now what would you do from here? How hard should I push? Where does my responsibility start and stop? Should I just respect her decision not to attend? There was no next of kin on her file so there was nobody else I could check with.

Fortunately a couple of weeks later she appeared in my rooms accompanied by her niece (who lives interstate and whom she rarely sees). Helen hadn’t seen a doctor since hospital discharge, she wasn’t taking any medications (BP 160/100), and she denied any problems except for a bit of a poor memory. And I’ve got to say her short-term memory seemed woeful, much worse than when I’d previously seen her.

After a general check and a rambling history from her, I restarted her antihypertensives and asked her to get some bloods and return the next week. That was a month ago.

I don’t know if it’s just me or the demographic where I practise, but I seem to be acquiring a fair few of these elderly patients who are all alone and who I feel are really unable to manage at home but are determined to do so. It’s really tricky. Of course, we’ve organised the ACAT assessment and I’ve tried to mobilise a whole range of services, but often they will just reject the help. Their paranoia tends to get worse along with the dementia.

And covid hasn’t helped. So many of these patients pre-covid had their week determined by various social commitments and face-to-face medical appointments. They lost all that in the pandemic and it’s not coming back any time soon for a number of them.

Aside from what the isolation did to them mentally, it also robbed them of the regular opportunity to be seen by others – those momentary touchpoints where someone could check they were doing OK. Now, like Helen, they get groceries delivered, they haven’t visited the club for two years and they have lost the cognitive ability to organise the regular catch-ups with people they use to see.

They live in the confines of their house believing they are managing and blissfully unaware of how much help they really need. They are just one fall away from becoming a headline “woman found dead in flat after a week”.

What’s going to happen to these people? And how much should I do? How much can I do?

It is always so much more manageable when the elderly patient has a caring son or daughter. Not that it is necessarily easier for the caring relative of course, but at least someone is watching over these people day to day, someone will know if they fall or feel unwell.

The Helens of this world have no one – isn’t that just tragic? ABS data show almost 95% of older Australians live in a house or flat (as opposed to nursing homes or aged care places). What’s more, over a quarter live alone!

It’s a problem without an obvious solution.

Am I advocating all elderly, frail people living alone move into aged care – of course not! But someone needs to help these people and where does my duty of care start and stop?

Maybe I should set up a regular recall system so I automatically check on these patients. But that’s a bit presumptuous isn’t it? There’s a fine balance between caring and interfering. What do you do?

As it turns out, I just got Helen’s blood results back and they’re perfect. Much better than when she was on multiple meds a couple of years ago. Maybe I should just mind my own business …

Jeremy Knibbs is on leave

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3 Comments on "Where does a GP’s duty begin and end?"

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Dr J N Parikh
4 months 11 days ago

I think the best is to leave them alone .I have seen many refusing treatment and we have to respect their right I know a colleague who died within 4 weeks of diagnosis of liver cancer presumably he has seen enough suffering I know many who do not do what we advise. Let us be realistic .How many of us can stick to diet indefinitely

Dr Ray
Dr Ray
4 months 11 days ago
Linda, well said. These elderly, failing vulnerable are everyone’s responsibility and then sometimes, sadly no-ones. The choice to be there for them, whether it be professional, friend or filial has no black and white answer. It’s not a yes/no, right or wrong problem, but one with many shades of human grey. One should do what feels right, what would pass the “it’s my child/parent/patient” test at that moment in time. It’s the skill that years of life and experience has hopefully given us all. Let’s use it wisely and show our younger cohort how it is done, for we ourselves… Read more »
Brian Sullivan
4 months 12 days ago

Hi Linder,
I read and understand you dilema completely. I am the CEO of MEDrefer, focusing on quality referrals by GPs. I am also involved with a group of other vendors looking to service aged care. One of our group is very involved with remote clinical management and monitoring eg hospital in the home.
There is some very exciting technology available for Helen and I suggest you look them up on visionflex.com.au or phone Mike Harmer 02 8914 4000.
Duty of Care is becoming a very grey area in Health and I commend you for caring.
Regards, Brian Sullivan