Dr Shivani Chirkut, medico-legal consultant, and Christine Groenewald, operational team lead at Medical Protection, discuss the importance of ensuring the patient’s voice remains heard when family and additional clinicians get involved in their care. This was the topic of their talk at Medical Protection’s annual Ethics for All conference this week.
They write:
Consider a fictional 70-year-old retired schoolteacher who has been under the care of his GP for 18 years.
He lives independently and can make his own decisions. He attends an appointment – with his daughter – for fatigue and unexplained weight loss.
The daughter asks to receive all test results for her father as she is assisting with his appointments and administration. Privately, the patient asks the GP to tell him first if anything serious is found because his daughter “worries a lot” and sometimes things happen too fast when she takes over.
Iron-deficiency anaemia prompts specialist referral. A bowel lesion is identified and surgery is recommended. The patient’s daughter asks the GP to persuade her father to agree to surgery, but the patient asks whether the surgery can rather wait. The GP knows her patient well, but she must recognise the different expectations behind these requests.
Family support without losing the patient
Being present, receiving information and making decisions are different roles. A patient who welcomes help has not necessarily authorised unrestricted disclosure or delegated decision-making authority. South Africa’s National Health Act recognises patients’ participation in decisions about their health and protects the confidentiality of their information.
With regards to the patient’s daughter receiving test results, it is important to clarify what the patient authorises, obtain written consent where applicable, and record any limits. The HPCSA confidentiality guidance in Booklet 5 reinforces explaining what will be disclosed, to whom and why.
The GP should ask the patient how he wants his daughter to be involved, if at all, and whether he prefers that some conversations are held privately. Neither age nor family support, by themselves, indicate an inability to decide.
Familiarity can encourage assumptions. Knowing a family for years does not mean its relationships remain unchanged. Revisiting the patient’s wishes shows that they still matter.
Trust and responsibility across the care team
The GP should help her patient understand the choices available to them without pressuring them to agree. Medical Protection and HPCSA consent guidance in Booklet 4 emphasise the importance of informed, voluntary decisions. Where specialist information is missing, the GP can acknowledge her limitations and obtain clarification, while working within her competence.
After further discussion, the patient agrees to surgery. His care then involves a surgeon, anaesthetist, ward nurses and a covering doctor. Thus, additional people are now introduced into the arc of care. At discharge, the patient and his daughter remain uncertain about medication changes, follow-ups and who to contact in the event of any complications. The GP has not received a discharge summary and therefore is unclear about the surgical findings and the expected next steps in terms of follow-up.
The expectation that “the GP will follow up” cannot be relied upon without clarification of the arrangements.
Effective communication requires verification that the relevant information has been conveyed to, received by, and understood by the appropriate healthcare practitioner.
Ethical rule 27A(f) in the HPCSA Booklet 2 requires effective communication with patients and other professionals. Clinicians must understand their roles and the patient needs to know how these connect.
When concerns change the relationship
The patient deteriorates and his daughter phones the surgeon’s rooms, she phones the ward, and messages the GP. Following readmission with a postoperative complication, she is now frustrated and requests copies of her father’s records and threatens to lodge a complaint. The clinicians end up questioning one another’s actions.
The case does not establish negligence or determine whether an earlier response would have changed the outcome. In any future claim, handover standards, WhatsApp boundaries, negligence analysis and complaint procedures may come under scrutiny, but none of this should eclipse the patient’s immediate care needs.
The daughter may want an acknowledgement of her efforts to obtain help and the patient may simply want an explanation and reassurance. The GP may understandably feel hurt at the threat of a complaint to the regulator after years of caring for the patient.
The best course of action is to listen, explain established facts clearly, and identify what remains uncertain. Medical Protection advises responding openly and honestly to patients’ and families’ concerns and seeking medico-legal support early. Colleagues should establish what happened without assigning blame prematurely.
Care continues during an investigation and preserving the doctor-patient relationship should never depend on a complaint being withdrawn, nor should a request for answers automatically be interpreted as rejection of the doctor.
Four points for everyday practice
1. Keep the patient’s voice central. Clarify how they want relatives involved and revisit their wishes as circumstances change.
2. Make responsibilities and next steps explicit. Agree who will act, who will follow up and where the patient can seek help.
3. Connect care through communication. Check that relevant information reaches the right people and that the plan is understood.
4. Protect the therapeutic relationship when concerns arise. Listen, establish the facts, avoid premature blame and maintain appropriate care.
The patient’s final words, in the above case, return us to his priorities: “I want to know what happened, but I don’t want to lose my GP.” A patient can want answers and accountability while still valuing the therapeutic relationship.
See more from MedicalBrief archives:
Court ruling clarifies doctor-patient relationship
Informed consent a moral and legal requirement