Change in medication

Complaint

The complainant complained about the treatment her late husband, the consumer, received from the provider, a General Practitioner. The complaint is that:

• In late November 1996 the provider stopped the consumer's medication, Adalat Oros tablets, without explaining why he advised this.
• The provider agreed to the consumer being admitted to hospital so that this change could be monitored. This did not take place for three days and the provider did not see the consumer during this time.
• When the consumer was admitted to Hospital three days after the consultation the provider did not advise the Hospital that there had been a change in medication. The consumer died that evening.

Investigation

The complaint was received by the Commissioner on 15 August 1997 and an investigation was undertaken.

Information was obtained from the following:

• The Complainant
• The Provider
• The Acting Medical Adviser, Crown Health Enterprise

The Commissioner obtained peer review advice from a general practitioner.

The consumer's clinical notes were obtained and viewed.

Outcome of Investigation

The consumer was a 78 year old man who had a number of past and current health problems, including hypertension for which he had previously been prescribed Adalat Oros tablets since September 1996. The provider had been his GP since February 1995 and had overseen his health problems, including the change to his medication in September 1996.

One day in late November 1996, the provider diagnosed that the consumer was having hypotensive attacks. The consumer's blood pressure had been 140-150/80 for some time but on this day was 110/60-70. The provider discussed with both the consumer and his wife the reason for stopping taking Adalat Oros tablets. The consumer stopped taking this medication.

The consumer's daughter, a nurse, contacted the provider the next day and asked that her father be monitored in hospital. No beds were available until three days after the consultation. In the meantime, the consumer's wife was in daily contact with the provider's surgery.

The consumer was admitted to Hospital three days after the consultation. The admission referral does refer to his having had medication stopped, but does not set out what these medications were and when they were stopped. The history taken at Hospital also confirmed that all medication had been stopped. No medication was commenced by the Hospital. On admission the consumer's blood pressure was 160/90 lying dropping to 120/60 standing. After admission the consumer's blood pressure rose to 220/120, increasing to 270/150. The consumer died later that evening.

The complainant said that during a meeting in July 1997, a physician at the Crown Health Enterprise stated that the consumer's medication should not have been stopped in the manner it was. This physician clarified that he is not in the habit of saying "a doctor should not have done this or that", the most he would have said would be:

"If anti-hypertensive medicine is to be reduced it would be prudent to reduce it gradually."

The manufacturer of Adalat Oros (Bayer Australia Ltd) advised the provider that:

"Extensive experience with (Adalat Oros) leads this group to the conclusion that there is no justification for suspecting a rebound hypertension by a sudden discontinuation of (Adalat Oros)."

The consumer was on the smallest dose of Adalat Oros that is available, 30mg. The dose of Adalat Oros normally used for hypertension varies between 30mg and 120mg. My advisor commented:

"Hypotension in the elderly can be a cause of considerable morbidity, especially falls and subsequent fractures?If he was having symptoms of hypotension then I think it is very reasonable to stop the drug as soon as possible. I do not believe it is necessary to admit a patient to hospital to withdraw such a small dose of anti-hypertensive medication."

The consumer was admitted to hospital more for investigation of his hypotensive episodes rather than as a precaution for monitoring his blood pressure after stopping his anti-hypertensive medication. The provider had been in contact with the consumer's wife over the time between the stopping of this medication and the consumer's admission to hospital. Over those few days no specific clinical symptoms had arisen that required a consultation with the provider. On admission to hospital the consumer's blood pressure was normal.

Code of Health and Disability Services Consumers?Rights

Opinion: No Breach

In my opinion the provider has not breached the Code of Health and Disability Services Consumers' Rights.

The provider's decision to stop the consumer's Adalat Oros tablets was justified. It was a small dose that could not be tailed off any more gradually. There was no reason to suspect any adverse effects from stopping the medication, as noted in the company drug information.

The advisor commented: "I do not believe that hospitalisation is required to conduct such a withdrawal. Blood pressure monitoring does need to be maintained but not at such a frequency and intensity that needs hospitalisation.

Although the consumer's hypertensive crisis was coincidental with the stopping of his medication I do not believe that it has been firmly established that this was the inevitable cause."

In my opinion the provider provided the consumer with medical services of a standard expected of a general practitioner in this situation.

Other Comments

Prior to receiving this complaint, attempts were made by both parties to resolve this issue. Following a meeting in July 1997 the matter appeared to be resolved but the complaint was made for two reasons:

• The information sheet regarding Adalat Oros stated this medicine should be decreased slowly under medical supervision and should never be stopped abruptly.
• The complainant's interpretation of a statement made by the Hospital physician regarding the manner in which medication of this type should be reduced.

In my opinion this matter could have been resolved had the parties, including the Hospital physician, discussed all the issues. When a family's loved one dies it is important that issues are discussed together and not in isolation from the facts. For this reason, a copy of this opinion has been forwarded to the Hospital phsyician for his information.