Doctor please do not mention history of alcohol intake in my medical records
HOPE CLINICS
Doctor please do not mention alcohol use in my medical records ?
Recently in a whatsapp group of gastroenterologists there was a discussion on what to do when asked by patients getting hospitalized ask us not to declare their alcohol use, or past history of Ischaemic heart disease or of pre existent diabetes in their medical records. All of us get special requests from patients and their relatives like please deliver my child at exactly 8.43 AM on Tuesday. Some relatives request us not to declare the diagnosis of cancer to the patient. Others want no mention of their opium addiction in their records. Often in drug overdose or cases of organophosphorus poisoning we used to be implored not to make a Medico Legal Case. Even in cases of domestic violence or of incest the victims often plead doctors not to make a medico legal case. At times the special demands are based on religious beliefs and customs like cleaning of room with cow urine. Even a advance Directive is a kind of special request where a person in his senses decides not to be treated beyond a certain point. Does the doctor have a choice in these matters ?
Why do patients not want their alcohol use or other addictions mentioned in their case papers. Mostly the reason is that insurers may refuse to pay for their hospitalization expenses or they do not wish their employer who pays for their treatment to come to know. Similarly Insurers would definitely refuse to pay if insurance was taken without declaration of pre existent disease like IHD / NIDDM. These requests usually are made in elective cases and not in life and death situations and doctors specially in private sector are perpetually afraid of losing patients more so in corporate hospitals where their “conversion rate” is a subject of their appraisals. However it would be problematic to explain death of a cirrhotic patient from ACLF following routine cholecystectomy specially if you have omitted mention of alcohol abuse in case records or of septicaemia / renal failure if previous history of NIDDM is not mentioned in records.
Even during a caesarean section it is difficult to time the exact moment of delivery of child, maybe the anaesthetist is late, maybe OT is not free or the spinal took a bit more time maybe the paediatrician was not ready, or maybe the cautery adjustment took time. Those who want baby delivered at particular auspicious time, though admitted with the understanding that it will be done so, are frequently cheated by a few minutes. Though some doctors may actually document the actual time of delivery to the annoyance of the patient / relatives , others modify the time of delivery to suit the “reasonable” demand.
Those who do not wish the diagnosis of cancer to be declared to their patient have their own reasons in that they feel they are protecting the patient. The doctor is faced with a dilemma every time such special requests are made by patients or relatives which go against normal medical practice. On one side as per law it is only the patient’s right to know his diagnosis and give consent for treatment while on the other sometimes specially in cases where the elderly are physically dependent on others one is left wondering whether or not to listen to the care giver who obviously knows more about the psychological and mental coping mechanisms of the patient.
Sometimes patients may ask to hide their diagnosis for different reasons and request doctors to do the same. Please do not mention history of epilepsy in past for patient admitted for delivery so that the In laws do not come to know. Others get health insurance and then 6 months to one year later get cholecystectomy done claiming first episode of pain during period of insurance. We recently had a case where patient had threatened and sued a radiologist for making a false diagnosis of cholelithiasis when a different U/S done by patient on her own in a charitable hospital showed no Gall Bladder stone. Six months later following another episode of pain and repeat ultrasound laproscopic cholecystectomy was done by us and though she asked us to hide the previous history we informed the radiologist who was still fighting the case in court of the cholecystectomy so that he could get relief.
Always remember that whatever doctors do, they are answerable for their actions. Even if an earthquake coming at the 8.43 AM on Tuesday causes the OT light to fall on patient and kill her, it is the doctor who will be asked why the elective caesarean could not have been done before (the earthquake) since patient was already admitted for past 1 day. Similarly a seizure during second stage would put things in a different zone if past history of seizures has not been mentioned.
We agree to special requests only because we are afraid we will lose the patient otherwise. Consequences of treatment within boundaries of the “special requests” carry their own risk. Once Rahul Mahajan and Bibek Moitra Secretary of Sh Pramod Mahajan were brought to emergency in Apollo Hospital in unconscious state after a party with cocaine and alcohol. The doctors at Apollo were pressurized not to make a medicolegal case. They admitted both in ICU and gave certain drugs to mask the effects of cocaine / alcohol however unfortunately 3 hours later Bibek Moitra expired. Now there was no way MLC could be avoided but in meanwhile in ML Register other patients had been admitted so there was some cutting and alteration in medical records. High Court refused to quash FIR against doctors of Apollo Hospital who were charged with tampering of evidence. As doctors we need to understand that we can comply to special requests only to the extent which will not get us into trouble.
Basically no special request being made should be considered without a written request being submitted by patient / authorized representative. When we ask for written request, half of those demanding special favours drop out realizing that what they are asking for may have consequences. Those who do give written request should be asked to get the request endorsed by one more legal heir. Document very clearly the extent you are willing to go in complying with the special request on the same paper. Getting insurance claim passed is not your job and those working in insurance or with links in insurance companies are usually the ones making such request, so verbally it should be made clear to them that you will omit to write ethanol abuse in discharge summary and in the papers sent to insurers but the indoor records would contain all this information. Similarly for all other special demands insist on written request , and then oblige only to the extent where you feel comfortable. In the whatsapp group discussion issue of what to do if a person comes in delirium / alcohol intoxication in emergency. Not mentioning alcohol use in this situation would be foolhardy.
In certain communities informing the police regarding incest , domestic violence would probably be the reason the victim may actually be killed. One needs to be very careful in these situations because law demands that you inform the police under certain situations and not doing so carries a punishment in law. If one encounters these cases in private clinics best solution is to refer to higher preferably government centers. Requests like not to get post mortem done also should not stop you from informing the police. Whether or not to get the post mortem done then is the decision of the police and not your. Acceding to no post mortem request initially is later followed by wild accusations hence one needs to be careful.
In case of alcohol / opium , the best solution is to document every detail in your indoor papers with a written request stating that a particular addiction not be mentioned in discharge summary. Always remember that we are acceding to special requests only so that we do not lose the patient to our professional rivals. The financial aspect of such special requests should always be considered in light with the consequences before acceding to the same. Do not outrightly reject a request, listen attentively , acknowledge the concern, assess the feasibility of the request, communicate clearly about limitations
Bibliography
1) Shiny Varghese & Prs vs State (Govt of NCT of Delhi) decided on 15th Feb 2008, Delhi High Court