Thursday, 11 October 2007

Up the nose

I saw a woman the other day who complained of painful blisters in her ears, around her mouth and up her nose. After listening to her story I moved forward in my chair in order to examine her, and entered her personal space. “I don't want you to look up my nose”, she said. I raised an eyebrow and she continued “I have a thing about blowing my nose in public”. We talked for a little longer and I gave out non-verbal cues that said “it's only little old me, you don't really mind do you?” But she did. It was very tempting, as I got close to her to examine her ears and mouth, to bend down and have a quick peek. But just as gentlemen do not look up ladies' skirts, so they also ought not to look up their noses without permission.

I thought that she was suffering from cold sores, and so it wasn't essential for me to examine inside her nose. But it made me think about the nature of consent. I quite often do simple examinations without explicitly asking consent. I might come up close to look at a skin lesion, or take the patient's pulse as I talk to them. Sometimes I forget to ask permission to take the blood pressure, and find myself wrapping the cuff around the patient's arm as we continue to talk. In these situations moving from talking to examination seems to flow naturally, and the patient indicates their consent by not objecting. Presumably the patient was aware that doctors often do this sort of thing, which was why she felt it necessary to give me advance warning that she did not consent. I wondered whether sneaking a peek up her nose would constitute an assault, and I preferred not to risk it.


The Shrink said...

. . . the patient indicates their consent by not objecting/

Implied consent.

Which in UK law as you know is valid.

Do we sign consent forms for blood tests? No, a patient offering their arm and letting someone faff about with needles rightly presumes the patient is consenting to this.

For non-invasive, minor, routine undertakings it's acceptable. For example, the patient might not consent to you noting how icteric they look, or how excoriated their skin is, or their antalgic gait, but you'd notice those despite there being no consent for such an "examination" of their body.

Pitching up is an obvious declaration of intent to collaboratively work with a GP to improve the health problems they're generating. So to my mind there's implied consent for minor relevant undertakings related to that consultation.

A. said...

I would find it very hard to voice an objection of that sort to a doctor, even if I really didn't want to consent. I would assume the doctor felt it was necessary and so I'd endure whatever it was. I can only too well imagine how some horrible situations might arise.

Anonymous said...

Interesting issue around consent.

I fail to understand this patient's problem with having her nose examined but I guess she must have had her reasons. Hopefully, the fact that you respected her wishes will have helped her to gain more trust in you for future consultations.

I've had so many people look up my nose over the years that it feels a bit like the Channel tunnel. Come to think of it a specialist did remark once "sure, you could drive a bus through there!".

Dr Andrew Brown said...

It did seem bizarre that she wouldn't allow me to look, but I didn't want to push my luck.