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Is the customer always right? Gerry - a challenge!

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
Lincoln

Ifind it difficult to "connect" with Gerry,(1) despite having known him for about 14 years. He tends to banter and make comments such as "I know what you nurses are like" and "Women are all the same". I used to think this was because of embarrassment, but now I doubt it. He is 62, and since his diabetes was diagnosed 13 years ago his weight has steadily increased, and his body mass index is now 38.43. He tells me he has no intention of making any changes to his diet, and last time I saw him he had eaten sugary cereals, a bag of crisps and a banana for breakfast. His blood glucose was 22.7mmol/l and his blood ketones were 0.1.
I see him in the waiting room, and in view of his long overdue diabetic clinic appointment I invite him in for a routine blood test and to check his foot pulses. He says he doesn't come very often because I nag him. He does attend the hospital clinic at least annually, and the consultant has for some time been suggesting insulin therapy for him, but he will not hear of this. Instead, he is treated with metformin, glibenclamide and pioglitazone. The metformin has been reduced to 500mg twice daily for some time, because of deteriorating renal function, and recent hospital letters have questioned the safety of continuing this for much longer. His glomerular filtration rate (GFR) has hovered at 32ml/min for the past six months (it was 35ml/min before that), translating to CKD3 (moderate chronic kidney disease), and his urinary PCR (protein/creatinine ratio) is 177.
Gerry shows his usual bravado when I broach the link between his breakfast choice and hyperglycaemia.  He says that he manages his blood glucose by varying the metformin according to whether there are any family parties (of which there are many), but usually takes it three times daily. I try to advise him that this could seriously damage his already reduced kidney function, but little impact is made. He complains that I never tell him anything positive. I reply that he is positively going to kill himself at this rate.
Gerry has always taken a doctor's advice much more seriously than that of a nurse, so I ask if I could take some blood tests and make an appointment for him to see a doctor with the results. He agrees. His usual GP is on holiday for a fortnight, so I arrange for him to see the locum the next day, recording my concerns.
Gerry leaves the doctor's room as I am at my door with another patient, and he makes a show of pointing at me and laughing and dancing on his way past. It transpires that the doctor has told him it is up to him what he does, and has increased the metformin  prescription to three times daily. The blood tests I had taken still showed a GFR of 32, urea of 11.8 (normal range 2.5-6.5) and creatinine 199 (normal range 55-120).
I have real fears about the safety of his metformin as it carries the risk of uraemia. Metformin may provoke lactic acidosis, which is most likely to occur in patients with renal impairment; it should not be used in patients with even mild renal impairment (see www.bnf.org). It was being used because of his refusal of insulin therapy, and the related safety concerns were well documented in his case notes.
I advised Gerry to see the doctor as a way of trying to influence him by "remote control" - deviously trying to make my point via a clinician who he would be more likely to listen to. Instead he got medical endorsement. I owe Gerry a "Duty of Care",(2) as does the practice. I consider that he is not in sufficient knowledge of the risks to make a decision on a prescription-only medicine, though appreciated the doctor was. In my opinion, because he is feeling well he has underestimated the risks involved. I am frightened by the legal implications of knowing that he is being prescribed medication that I know is harmful, and feel I have to protest …
The locum doctor laughs. Gerry has obviously found his ideal GP. Well, he might not want me as advocate, but he got me, like it or not. I speak to the practice manager, who feels it is the doctor's responsibility. My GP mentor suggests that I continue to be devious and try again when his usual GP returns. I get the administrator to write, ostensibly from his GP, to invite him for a review on his return. It works. Gerry complains that I had "read him the riot act" but his metformin is reduced back to twice daily and he is referred to the nephrologist.
Something tells me it won't end there.

References

  1. Neighbour R. The inner consulation. Lancaster: MTP Press Limited; 1987.
  2. Davis M. Medical law. London: Blackstone Press Limited; 1996.

Resources
British National Formulary
W:www.bnf.org
The Renal Association
W:www.renal.org