Loading...
A couple of weeks ago, we posted an Antiretroviral Rounds case about a physician who sustains a needlestick while placing a central line in a patient with waxing and waning mental status and a positive toxicology screen for cocaine and opiates. State law requires written informed consent to perform an HIV test, but the patient refuses to sign, becomes obtunded, and has to be intubated. His only visitor is his girlfriend, and no family member or healthcare proxy is available.
Before providing our readers with the expert opinions that we solicited, we wanted to know what you would do. We asked several questions, but the key one was, Would you test the patient?
To date, we've received 35 “Reader Remarks”— one of the strongest responses that Journal Watch has received since we launched this feature 6 months ago.
Overwhelmingly, respondents favored testing the patient, regardless of what the law states. For example, SSZ noted, “Doctors have rights, too. The interventionist has an obligation to save this patient AND an obligation to his own health as well. Testing should be done while the patient is confused and the interventionist should receive appropriate treatment. The law is not correct for every situation, and . . . I hope sanity would prevail in this case.” And, according to MB, “Our beloved patient is having all kinds of things done without real ‘informed consent' to possibly save his life. We can add HIV testing to possibly save the doctor's life or make it easier. Then find a jury that would convict the doctor or the hospital.”
At least one respondent differed substantially from this view, with VS writing, “Follow post-exposure guidelines for unknown source. Do not test the patient against his will.”
Now we publish the responses of our three experts: an expert on postexposure prophylaxis; an expert on the intersection of HIV, law, and policy; and a bioethicist and practicing physician. And guess what? Although they answer the questions in subtly different ways, they all come out clearly against testing the patient.
For what it's worth, I'm with the readers on this one. To me it seems as if there are two undesirable actions that are in conflict:
Test the patient against his consent. No, it's never desirable to do anything against a patient's will, and literally illegal, but at least it can be justified as providing important information for the patient's own health.
Provide “empirical” postexposure prophylaxis (PEP) to the intensivist. This forces the clinician to take what is most likely unnecessary (and often poorly tolerated) treatment for 4 weeks, then to go through the 6 months of anxiety waiting to hear whether he is one of the unlucky few who acquires HIV on the job.
Sorry, in my book there's no contest: The second of these choices (no test, empirical PEP) is far worse than the first, and I'm pretty sure OSHA would agree with me. Workers have rights, too. (This is not to say that our experts are wrong — just that I disagree with them!)
Read it all here. It's not too late to weigh in. Just follow the link and scroll to the bottom of the page to leave a remark.