Dr Rachel Birch, Medicolegal Consultant at Medical Protection and Editor-in-Chief of Practice Matters, answers a query regarding a patient refusing to attend the practice due to fears for her safety.
"We have a 57-year-old patient who has a long history of anxiety, which has worsened considerably over the course of the COVID-19 pandemic. She has rheumatoid arthritis and is on methotrexate. She refuses to attend the hospital clinic and has not attended our practice for blood tests for over five months. She has booked two recent GP appointments, but cancelled them both on the day.
She has recently requested that all her care is undertaken remotely and has told us that she won’t attend the practice as she is concerned that she might catch COVID-19. She has received two COVID-19 vaccinations. She has been on methotrexate for several years and, until the pandemic, she had regular blood tests that were all satisfactory."
What should we do?
This scenario is not uncommon at present, although the clinical presentation and the details are likely to vary between patients. The ongoing COVID-19 pandemic has caused a lot of concern to some patients, such that they may be scared to attend practices for fear of catching COVID-19, despite having received the double vaccination. This particular patient may have good reason to be cautious, considering she may have an impaired immune system and therefore be at risk of severe illness.
The best initial step is for her usual GP to telephone her to discuss her request in more detail. She has a history of anxiety and it may be that this has become more significant, perhaps preventing her from accessing medical care. Has she developed depression? It is certainly possible, if she has been shielding herself from risk of infection at home for a long period of time. Does she feel the same about attending the hospital as she does the practice?
During this telephone call it would be helpful to also make a clinical assessment of the patient’s rheumatoid arthritis, as best they can. An alternative might be to arrange a video consultation with her. How bad is her arthritis and how is it affecting her? Is this also contributing to her reason for not wanting to attend the practice? It may be that the patient is in significant pain and it is this that is preventing her from travelling. Is she currently taking her methotrexate? Is she taking anything else in addition to this?
The GP should also review her prescriptions, to assess how often she has been requesting them, as well as her recent blood tests, to gain an idea of how stable her full blood count, renal function and liver function have been over the last few months before she stopped attending for blood tests. It would appear that she is overdue these blood tests, and it is important that these are monitored regularly, depending on local protocol and guidance from the rheumatologist.
Presuming that the patient has capacity, it is important that the GP provides the patient with sufficient information, in a way that she can understand, in order for her to make informed decisions about her care. In particular, it would be important to discuss with her that methotrexate is a medication with the potential for harm, explaining that she should therefore have regular blood monitoring to ensure that she is not at risk of harm and to detect any early changes. It is important that she is made aware of the serious risk to her health if she were to continue taking methotrexate without having her regular blood tests. In order for her to make the decision not to attend the practice, she needs to be fully informed of the risk of the medication, and balance it against the risk of contracting COVID-19. There is the possibility that, once this discussion is held, she makes the decision to attend the practice for blood tests.
The GP may wish to consider if there are alternatives to the patient attending the practice. For example, could one of the public health nurses or community nurses visit the patient to take her bloods? It is likely that they are visiting care homes and vulnerable patients in the community. In light of the patient’s concerns, they may be able to add the patient to their caseload. An alternative might be for the GP to visit the patient at home, to check her bloods and undertake a clinical assessment. The patient may have particular concerns about a busy waiting room – perhaps she could attend first thing in the morning or last thing in the afternoon, minimising her exposure to other patients.
Once the GP has had this first discussion with the patient, they may wish to consider contacting the patient’s rheumatologist to seek advice. It would be helpful to explain the patient’s current desire not to attend the hospital. Depending on the patient’s level of pain and clinical condition, it may be that there are treatment decisions that need to be made. Is it possible for the rheumatologist to consult with the patient virtually? Presumably there have been times, during the COVID-19 pandemic, that appointments were conducted remotely.
The Medical Council advises1 doctors that:
“As far as possible, you should make sure that any treatment, medication or therapy prescribed for a patient is safe, evidence-based and in the patient’s best interests.”
It goes on to state that the potential benefits should be weighed against the risks of adverse effects and interactions. Doctors are advised to seek independent, evidence-based sources of information on the benefits and risks associated with medicines before prescribing.
If the GP can persuade the patient to have blood monitoring, either at home or at the quietest time at the practice, then it may be that it can be arranged for the GP and rheumatologist to undertake remote consultations with the patient safely, with the GP continuing to prescribe the methotrexate. However, if the patient refuses to have her blood monitored at all, then the decision needs to be made on whether the patient can safely continue on methotrexate. There is a significant risk to her health taking this medication without blood monitoring; there is the risk of severe pain if the medication is not prescribed. In this circumstance, it would be important to seek rheumatology advice on any alternatives and discuss this with the patient too.
It is important for the GP to document all discussions with the patient, as well as details of any advice received from the rheumatologist. As COVID-19 cases fall and the pandemic subsides, perhaps the patient’s face-to-face care can be revisited with her at that stage.
In this current pandemic there may be patients who, for various reasons, are reluctant to attend the practice. If you have any concerns, please do not hesitate to contact Medical Protection for specific advice.
1Medical Council. Guide to Professional Conduct and Ethics for Registered Medical Professionals