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Dr Rachel Birch, Medico-legal Consultant at Medical Protection, addresses the issue of patients with Covid anxiety and
offers practical advice for GP practices and hospital outpatient settings
There is no doubt that the Covid-19 pandemic has caused concern to many, if not all of us. However, as the pandemic continues, and more waves of infection are likely, some patients may be genuinely scared to attend healthcare settings for fear of catching Covid-19, despite having received their primary and booster vaccinations.
Consider the scenario below
A 65-year-old female patient has rheumatoid arthritis and has been on disease-modifying anti-rheumatic drugs (DMARDs) for two years. She refuses to attend the hospital outpatient clinic at all. Furthermore, she has not attended her GP practice for blood tests for over six months.
She had a telephone conversation with her GP last week and has requested that all her care is undertaken remotely. She has been unable to get through to the outpatient clinic on the telephone and has simply not attended any appointment that she has been sent.
She has a long history of anxiety and this has worsened considerably over the course of the Covid-19 pandemic. She is reluctant to attend any appointments in person as she is concerned that she might catch Covid-19. She has received two Covid-19 vaccinations.
What steps might the GP and consultant rheumatologist take at this stage?
This scenario is not uncommon at present, although the clinical presentation and the details are likely to vary between patients. 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.
What steps has she taken to manage her anxiety and is this something that the GP can help with?
During this telephone call it would be helpful for the GP to also make a clinical assessment of the patient’s rheumatoid arthritis, as best as they can. An alternative might be to arrange a video consultation with her. The GP should find out how bad her arthritis is, how it is affecting her, and whether this is also contributing to her reason for not wanting to attend the practice or hospital clinics.
It may be that the patient is in significant pain and it is this that is preventing her from travelling. Next, the GP should ask if she is currently taking her DMARD medication and whether she is 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 greatly overdue on 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 DMARDs are medications 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 her DMARD medication without having her regular blood tests. In order for her to make the decision not to attend the practice or hospital clinic, 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 while there are still Covid-19 cases. 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, it would be important for them to contact the patient’s rheumatologist to seek advice. It would be helpful to explain the patient’s current desire not to attend the hospital. The rheumatologist may have noticed that the patient has not attended recent appointments, but there is a chance that they have not been made aware of this.
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. If so, there may be a possibility that the rheumatologist could use video consulting to review the patient, assess her current state and provide advice on her treatment. Failing that, it is worth exploring whether the rheumatology department has a community specialist nurse, physiotherapist or occupational therapist that could go out and review the patient at home.
Medical Council advice
The Medical Council1 advises 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 DMARD medication.
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 her current medication regime. There is a significant risk to her health when she continues taking her medication without blood monitoring; and there is also the risk of severe pain if the medication is not prescribed. In this circumstance, it is important that the GP and rheumatologist work together and discuss any alternatives between themselves as well as with the patient.
It is important for the GP to document all discussions with the patient, as well as details of any advice received from the rheumatologist. The consultant rheumatologist should also document, in the patient’s hospital records, any discussion they have with the patient or the GP.
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, or your medical defence organisation for specific advice.
1. Medical Council. Guide to professional conduct and ethics for registered medical professionals. 8th edition (amended). 2019 www.medicalcouncil.ie/news-andpublications/reports/guide-to-professionalconduct-ethics-8th-edition.html