Self-directed case with discussion prompts

Shane, a 38-year-old man, presents requesting prescriptions. He has attended the practice infrequently over the past 10 years. The last note in his file is that a medical summary was sent to the prison health service in response to a release of information request one year ago.

You note Shane has a previous history of a motor vehicle accident, low back pain and hepatitis C. In the last consultation on file, he had received a script for opioids, a referral to the local liver clinic and was noted to have moderately high blood pressure. 

He tells you that his current medications are mirtazapine and a ‘heart tablet’, and he also wants treatment for his back pain. After further history, he confirms he was released from prison 10 days ago and has run out of his medication. He is not sure if he was given any paperwork about his health.

1. What effects could stigma and previous life experiences have in building a relationship with Shane?

2. What communication and consultation approaches may promote a therapeutic relationship?

3. What factors may impact on continuity of care for people leaving or entering prison?

4. If Shane was an Aboriginal or Torres Strait Islander, what else would you need to consider?

5. What other information would you like to gather through history-taking and examination?

6. How would you gather further information about Shane’s healthcare in prison, without duplicating investigations that have already been done?

7. What are the key risks to health and wellbeing for Shane in the post-release period?

8. What priority social support needs would you ask about during this consultation?

9. What factors would you consider when addressing Shane’s request for treatment for his back pain?

10. What other healthcare providers and services could you draw on in the ongoing management of this patient?

11. If Shane was an Aboriginal or Torres Strait Islander, what specialised services or people could you include in your management plan?

12. What role might a GP play in giving support or care to the patient’s family?

13. What resources, including community-based services, may assist you in promoting Shane’s health?

14. How would your approach be affected if your practice was in a rural or semi-remote location?

15. What preventive care might you consider for Shane?

16. What are your reflections on biases, professional boundaries and therapeutic relationships when working with Shane?

17. What are the ethical considerations when providing healthcare for people in prison, including confidentiality and privacy?

18. What are the broader systemic issues regarding incarceration in Australia? What advocacy role may exist for GPs?

19. What would Shane have experienced during his incarceration? What healthcare would he have received? What are the barriers and facilitators to healthcare delivery in prison? How may this have affected Shane?

20. If Shane is reincarcerated three months after you have taken over his healthcare, what health information would you send to the prison health service on receiving the signed request for information?

21. What are the privacy, confidentiality and legal requirements when managing a patient who is incarcerated?

22. How would you access additional support or advice with regards to managing this presentation?

23. How is significant illness managed in the prison environment?

24. What if Shane advised you that he had had an overdose since leaving prison, and had already had to use the emergency rescue naltrexone he was issued on release? How would you manage this?