Caring for a woman with intellectual disabilities who refuses clinical diagnostic investigations

A 56 year old woman with moderate intellectual disabilities who lived in a residential care home presented to her general practitioner with iron deficiency anaemia, weight loss, and dyspepsia. She had severe osteoarthritis of one hip as a consequence of untreated Perthes’ disease, which necessitated her using a wheelchair. Her vision was severely impaired and her speech was unclear. She was able to make day to day decisions about her choice of food and clothing but required a full assessment of her capacity to make more complex decisions. Her behaviour was described as “difficult” at times, and she had severe anxiety about medical consultations and interventions.

A “fast track” referral was made for an endoscopy, but she refused to attend. Two months later her haemoglobin had dropped to 68 g/L and faecal occult blood testing at that time was positive. She was referred for an ultrasound scan of her abdomen but again refused to attend.