MDU measures difficulties of treating alcoholic and drunken patients

22 November 2011

As debate rages over the merits of minimum alcohol pricing to reduce problem drinking, the Medical Defence Union (MDU) today reveals the range of challenges faced by the UK's doctors when treating patients who are alcoholic or under the influence of alcohol[1].

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 main reasons were:

Coroners' inquiries 70
Complaints 44
Disclosing information 34
Consent and capacity issues 12
Other (eg adverse incidents, GMC investigations) 29

Dr Yvonne McCombie, the MDU medico-legal adviser who carried out the analysis said: “The number of health problems associated with heavy drinking and the effects of alcohol on a patient's behaviour, mean that drunken and alcoholic patients present particular challenges for doctors. It is often difficult to persuade patients to even accept they have a problem, still less ensure their cooperation with treatment. The large proportion of cases in this study relating to coroners' reports and inquests highlights just how difficult it is to successfully treat alcoholism. 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 (brain) 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 DVLA) 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 study, published on the MDU's website, includes advice for doctors to help them 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.

Remember that 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.

Further information

1 Under the influence – a study of MDU cases involving alcoholic and intoxicated patients, Dr Yvonne McCombie, November 2011. The study is available to MDU members on the MDU website and to journalists on request.

2 Alcohol use disorders: the NICE guideline of diagnosis, assessment and management of harmful drinking and alcohol dependence, NICE, 29 July 2011

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