Last weekend, whilst I was doing my Saturday surgery, I was asked to deal with a troublesome patient. Mrs X had come to the waiting room demanding to be seen so that a dressing could be changed. Mrs X is an alcoholic, probably has an element of dementia and has significant mental health problems. I am not even sure what insight she has into her condition or her behaviour. The reception staff explained that this could not be done on a Saturday and suggested alternative arrangements. Mrs X became abusive, spat at the receptionist and refused to leave. The receptions staff were really upset and eventually me and colleague managed to get her to leave. There have been several incidents like this in the past and we were asked to consider removing her from the list. It was suggested that earlier requests for her to be removed from the list had been denied because we as doctors never had to face her abuse and her unacceptable behaviour. It was put to us that if she had abused a doctor in this way, then she would have been removed from the list without any hesitation. I know that if she had used racist comments then I would have found her behaviour unacceptable and would have argued for her to be removed from the list.
I tried to argue that we had to understand the context of her behaviour. She was very vulnerable, did not have any insight and whilst her behaviour was unacceptable we had a duty of care to her. We are generally known as a very accommodating practice and on the whole we tend to register patients with difficult problems. What would we achieve by removing her from our list? Would another practice be able to offer her better care? – her behaviour certainly wouldn’t change and she would almost certainly be removed from someone elses list eventually. In effect she would not receive healthcare because she was always so disruptive.
What should one do in such circumstances? Is it true that she can’t take responsibility for her actions? Despite many attempts to get her to understand and work with us (when she was sober), she constantly abused our goodwill. Is being drunk sufficient excuse for this kind of behaviour? Are we as doctors more lenient with patients like this because we never have to deal with the consequences directly?
Ultimately, I lost the argument and in a meeting of the practice, it was decided that she be removed from the list.
Is there a right answer? How do we balance our duty of care against the responsibility of the patient to behave in a non-abusive manner?