Advice on what locum optometrists should do when they encounter a patient who refuses a referral has been highlighted by the AOP’s head of clinical and regulatory, Henry Leonard.
Speaking at the AOP’s Locum Clinical Skills Conference, held in Birmingham in March, Leonard’s Help! I’m a locum and… workshop explored a range of common clinical, ethical and regulatory scenarios that are encountered by locum optometrists, and how to manage them effectively in practice.
Leonard shared a range of examples that could result in a referral refusal, emphasising the steps that practitioners are advised to take.
One example detailed the case of an elderly gentleman who had raised pressures and was asked to wait for a visual fields test. However, when the practitioner went back to check on them, the optical assistant informed them that the patient had left because they did not want to be referred
Leonard advised that in the above scenario, he would encourage practitioners to write to the patient, setting out their findings, their advice and, importantly, what the potential consequences might be if the patient does not follow that advice.
“The patient may not realise that if they don’t have this test done, there is a risk that an eye condition goes untreated or undiagnosed, and there’s a risk of a permanent loss of vision,” Leonard said.
“If you put that in writing to the patient, they can’t turn around and say, ‘well I didn’t know’,” he emphasised.
On what to include in a written letter, the optometrist said that it “needs to provide enough information that the patient can reach an informed decision in their own time.”
He told delegates that in this scenario it could be useful to telephone the patient, but having something in writing that is ideally sent by recorded delivery provides the optometrist with both a record that they provided the advice and that the patient received it.
Another example, which explored capacity, detailed a patient with dementia.
Discussing if the practitioner could refer the patient, Leonard advised delegates to treat each patient on a case-by-case basis, and contact the AOP if needed.
“If you’ve got a concern about their mental capacity, you may need to provide the information in a different way, you may need to find out whether someone else has power of attorney,” he said.
Leonard highlighted that “optometrists are not expected to be experts in mental health or mental health conditions, but we are expected and allowed to exercise our own judgement in deciding whether a patient has the capacity to make a particular decision at a particular time.”
Leonard acknowledged that it can be tricky to establish what capacity a patient has in order to make a decision at a particular time.
“Capacity can change day-to-day, and even throughout the examination and depending on what you’re asking them to consent to.”
“You’re balancing your duty of confidentiality against your wider duty to the public interest, which is not always easy to do,” he added.
Leonard noted that the assumption is always that a patient does have capacity, until you realise that they may not.
The optometrist emphasised that in most situations practitioners cannot refer a patient without their permission, “even if you disagree with their decision.”
“It’s up to them if they’ve got the mental capacity to reach that decision, and you have to respect that,” he said.
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