From drunken revellers staggering around British town centres to more sombre images of jaundiced alcoholic patients lying in hospital beds, the social and health problems caused by alcohol are a regular feature of news and documentaries.
Sensationalist as much of this coverage may appear, there seems little doubt that alcohol-related problems are a growing burden on the health service. According to the latest statistics from the NHS Information Centre, there were more than one million alcohol-related admissions to hospital in 2009/10, an increase of 12% on the previous year.
Alcohol-related deaths in England in 2009 did fall by 3% to 6584 but this was still up by a fifth on the 2001 figure and other alcohol addiction charities estimate the number of alcohol-related deaths to be much higher.
Given the number of health problems associated with alcohol misuse - alcoholic liver disease, malignancies, etc - and the disinhibiting effect of alcohol on behaviour, drunken patients present particular challenges for doctors. In the two-and-a-half years between January 2009 and June 2011, the MDU opened 189 files in response to requests for help from members concerned about an aspect of treating an alcoholic patient, an average of six such cases each month
The primary reason for members to seek our assistance in each case was as follows:
- Coroners’ inquiries 70
- Complaints 44
- Disclosing information 34
- Consent and capacity issues 12
- Other 29
The large proportion of cases relating to coroners’ reports and inquests highlights just how difficult it is to successfully treat alcoholism. For example, it is often difficult to persuade patients to even accept they have a problem, still less ensure their cooperation with treatment. Tragically, at least 13 coroners’ investigations looked into suspected suicides while others followed an overdose, drowning or a fall.
In addition, some conditions can be difficult to diagnose in alcoholic patients because the symptoms can be confused with the effects of heavy drinking. For example, in a handful of cases we reviewed, patients had died from an undiagnosed subdural haemorrhage, a condition for which alcoholism is a risk factor but where many of the symptoms such as headaches, nausea and speech problems are also associated with heavy drinking.
The MDU’s study also revealed:
· The number of files opened over the period was consistent: 79 in 2009, 78 in 2010 and 32 in the first six months of 2011.
· 64% of cases concerned a GP, while 24 related to psychiatrists and nine were doctors in Accident and Emergency Departments.
· Over half of the complaints (24) were made by a third party, usually the patient’s family. This compares with a previous MDU study of complaints received in the year to April 2010 in which 84% of complaints were made by the patient.
· In the 34 cases in which doctors sought advice about disclosing information about a patient’s condition, nine involved reports to social services (usually where a child was at potential risk), eight were reports to the Driver and Vehicle Licensing Agency and four involved reports to the police.
· In seven cases, doctors had been asked to assess the capacity of an alcoholic or drunken patient to consent to treatment, make an advance decision, or make a will.
The following advice, drawn from the MDU’s analysis may help doctors avoid the pitfalls of treating alcoholic patients:
· Ensure appropriate steps are taken to exclude other possible diagnoses within a reasonable time. Include your differential diagnosis and management plan and relevant findings on examination in the patient’s notes.
· It may be that the patient’s alcohol problems means they are unable to complain themselves or that they have died but if you receive a complaint from a third party, check that that person has the necessary authority or is an appropriate person to act on the patient’s behalf. Respect the patient’s expressed wishes concerning the disclosure of information.
· Be aware of and consider the latest authoritative guidance on treating alcoholism such as the national clinical guidelines published by NICE in July 20112.
· Other than when required by law (such as a court order), it is only acceptable to disclose information about a patient without their consent in exceptional situations in the public interest where failure to disclose may expose others to a risk of death or serious harm, such as the risk to a child. You should still seek the patient’s consent unless this is not practicable and any disclosure should be the minimum needed for the purpose.
· The patient’s capacity is likely to fluctuate and may depend on the complexity of the decision they are being asked to make. In each case, you will need to assess their ability to understand and retain the relevant information, use it to make a decision and communicate that decision. Keep a record of the name and contact details of anyone with power of attorney or a court appointed deputy who you can contact if the patient lacks capacity.
Tags: Alcohol
