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Big Question

CASE HISTORY

It is nearly 6pm on a Friday and you are about to finish surgery when a result is phoned through.

It is an HIV result requested by the community midwife, and it is positive.

The lab first tried to contact the midwife's office but no one answered the phone. It then tried the labour ward and was advised to contact you.

You check the midwife's records on your computer and find she did indeed request an HIV test. She has included a note saying she is going on holiday and the patient can ring in for the results when she returns.

From the records it looks like the patient is going on a foreign holiday herself the next day – for two weeks.

There is no phone number on your records and there are no obvious risk factors for HIV from the patient's history. What do you do?

Three GPs share their approach to a practice problem

1. Dr Mabel Aghadiuno

‘A house call might just plunge her into a state of panic'

I doubt a house call would be in her best interests on the eve of her holiday, though it would give me peace of mind. Telling her about her diagnosis is just going to plunge her into a state of panic and leave her in the position of being abroad without the benefit of the post-test counselling that she so desperately needs.

Who would be there to help her overcome her feelings of fear, despair, anxiety, guilt and anger; also any misconceptions she might have about HIV?

So although she could infect others while abroad, waiting until she comes back to give her the result seems the lesser of two evils.

As soon as I could, I would make the community midwife aware of the patient's result and see what plan she had in place for post-HIV testing. If she did not have a suitable strategy in place, my course of action would be to contact the hospital obstetric team to make arrangements for the patient to see an HIV counsellor on her return.

I would also write a letter to the patient asking her to come to the practice: she might prefer to hear the result from me initially rather than from a stranger.

Finally, I would discuss with the midwife the type of protocols we should have in place for HIV testing, and the importance of pre- and post-test counselling, highlighting why HIV results should be given in person.

Mabel Aghadiuno is a part-time sessional GP employed by Croydon PCT

2. Dr Robin Fox

‘I have no idea as to her risk of infecting anyone'

It's like a parrot saying ‘The GP will sort it, the GP will sort it'. But that is our virtue – we are always available.

First, I would want to double check that this is the right result for the right patient. I would speak to the laboratory confirming the patient's name, date of birth, address and NHS number. I would ask the lab to fax me a copy of the result immediately, deleting the patient's name and address but retaining her DOB and NHS number in accordance with Caldicott principles.

I have no idea at present how she has contracted HIV and so have no idea as to her risk of infecting anyone.

If I knew for a fact that she would not infect anyone else, then I would definitely delay informing her until her return. And it has to be said the risk she poses to others while on holiday is pretty low. But how low is acceptable?

Ultimately my feelings of moral responsibility mean I would go round to her house tonight and tell her the news. If she has already left for her holiday and I have missed her, this would probably be the best outcome.

I will bring this up at our next multidisciplinary primary health care meeting as a significant event. We will all learn from this and with luck can put a better system in place.

Robin Fox is a GP in Bicester, Oxfordshire

3.Richard Stockell

‘I would contact the midwifery team about the pathway'

The combination of a late call with the result, the impending holiday and lack of availability of the appropriate team is a bit of a nightmare. This is a screening programme in which GPs are not normally involved and there is a designated care pathway, which I would hope to access on behalf of the patient as soon as possible.

My first option is to contact the midwifery team myself via the labour ward. I would ask them about the pathway for abnormal HIV test results and see if a district midwife would be able to help prior to the patient's holiday.

I would point out that the duty to follow up the result rests with them, and that the high-risk pregnancy team will become responsible for this woman's management.

If this proves unsuccessful I have two choices – either to wait until after the patient's holiday and allow her to find out about the result through the normal pathways or visit the patient this evening.

Delaying the information would risk the patient passing the infection on to a sexual contact while on holiday and might make termination a more difficult option for her. Because of these fears I would probably elect to visit the patient at home.

Having been involved at such an early stage, I would be better placed to offer help with the social and psychological fall-out.

Richard Stockell is a GP in Birkenhead – he is also a GP trainer and course organiser

what does this incident teach us?

Learning checklist

Dealing with abnormal test results

• What systems are in place for logging tests, and checking they come back?

• How are tests performed by third parties handled? Does the practice still have a duty of care?

• What procedures are in place to deal with abnormal results in-hours?

• How are urgent abnormal results dealt with out-of-hours?

• How does the practice ensure patients who have been told to ring in for results actually do so? What if they don't?

• Should patients be given significantly abnormal results on the telephone?

Record-keeping

• Are full contact details (including mobile number) requested and available on computer for all patients?

• Are these contact details entered on all pathology request forms?

HIV testing in pregnancy

• Does the local trust meet the standards set for the UK antenatal screening programme, in particular: ‘All women have confirmed positive test results explained to them in person. (A positive result is not normally given on a Friday or immediately before a public holiday.) Women are offered specialist counselling and support which is available for their partners and family if requested. Such counselling takes account of any relevant cultural issues. Arrangements for delivery of positive results and for confirmatory testing of a follow-up (second) specimen are prioritised.'

Informing the patient tonight

• What is your duty of care?

• It might be kinder to let her enjoy her holiday first. What ethical principles should govern your decision?

• Do you have prior knowledge of the patient that would help you make a decision?

• How can you maintain confidentiality if you call at her house?

• Will you need an interpreter?

• Will the patient fully understand the implications of the news?

• How long will you need to spend with her, will you be able to answer all her questions?

• Who will be available for urgent follow-up if she reacts badly (ie normally!) to the news – at home or on holiday?

• Is it ethical or practical to inform her simply that she should not travel and give her an appointment to discuss matters on Monday?

Not informing the patient tonight

• How pregnant is she? Delay may compromise the benefits of treatment for an affected baby or preclude possible termination?

• Is she likely to infect anyone else while abroad, either sexually or by sharing needles? What if she needs emergency health care while away?

• Will her holiday insurance be nullified

if she was not informed and had complications while abroad?

Melanie Wynne-Jones is a GP in Marple, Cheshire

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