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Stuck in the Middle

Antiretroviral Rounds |
July 27, 2009

Stuck in the Middle

A clinician sustains a needlestick from a patient who refuses HIV testing. An HIV physician, an attorney, and an ethicist weigh provide weigh in on how best to manage.

A 36-year-old man was admitted to the intensive care unit after being found confused and febrile on the street. Admission evaluation revealed evidence of multiple trauma, waxing and waning mental status, and leukocytosis; a urine toxicology screen was positive for opiates and cocaine.

While placing a central line in this patient, the intensivist stuck himself with the hollow-bore needle being used for the procedure. He experienced slight bleeding but did not recall any visible blood on the device. According to state law where the case occurred, written informed consent is required for HIV testing in the source patient. However, the patient refused to sign the consent form and became angry because he felt the healthcare team was threatening him. During the next 24 hours, he became increasingly obtunded and required intubation for airway control. The only person visiting him in the hospital was his girlfriend; no healthcare proxy or family member was available.

How would you manage the intensivist who sustained the injury? Would you give postexposure prophylaxis (PEP)? If so, what specifically would you give, and for how long? How would you determine whether the source patient is HIV-infected? Would you perform surrogate testing (for example, obtain a CD4-cell count) to assess this? Would you consider testing him without written informed consent? Would you ask his girlfriend to provide consent for him? If he is tested, would you give him the results after he recovers if the test is negative? If the test is positive?

Addendum: When we originally published this case, we asked readers what they would do (see responses below). Now, we have updated the case to provide the opinions of three experts.

Response 1

  1. Raphael J. Landovitz, MD

According to CDC surveillance data, the average risk for HIV infection following percutaneous exposure to HIV-infected blood is approximately 0.3% (Am J Med 1997; 102:9). An exacerbating factor in this case is the involvement of a hollow-bore needle that (presumably) had been intravascular in the source patient; thus, blood might have been present in the lumen of the needle, even if it was not visible on the needle's exterior. Most guidelines and many experts would recommend PEP for such an exposure, based on a single case-control study suggesting that it leads to a >80% reduction in the likelihood of HIV infection following a needlestick injury (N Engl J Med 1997; 337:1485).

In an ideal situation, the source individual would agree to HIV testing, and the results would determine the need for PEP. For example, if rapid testing for HIV antibodies was available and the results were negative, PEP could be deferred, assuming the source was not at risk for being in the acute “window period” of HIV infection (when viremia levels are extremely high, but antibodies are not yet present). If rapid testing was not available, PEP could be initiated while the source patient was tested conventionally (ELISA with confirmation from a Western blot or an immunofluorescent assay) — and then if a negative result was obtained, the PEP could be discontinued (again, with the same caveats regarding acute infection risk).

Laws around HIV testing and consent are evolving. CDC guidelines published in 2006 recommended dropping the requirement for written consent, to destigmatize and facilitate such testing. Although state laws are increasingly coming into concordance with CDC recommendations, such laws differ widely from state to state (Ann Intern Med 2009; 150:263). Even in states that have adopted “opt-out” HIV testing policies and dropped the requirement for written consent, the situation remains extremely complicated and relatively untested against legal challenge: If the source patient is unwilling to be tested, there are no ethical options to get around the refusal. Surrogate testing (of CD4-cell counts, viral loads, or p24 antigenemia) violates the spirit of informed consent for HIV testing and is not considered acceptable. The source patient's girlfriend cannot provide informed consent unless she has been specifically designated as his healthcare proxy.

The clinician then is left to balance the likelihood of HIV acquisition in this case against the potential toxicities of PEP. In the current HIV treatment era, the toxicity of a 28-day course of PEP is significantly less than it was in the not-too-recent past, and therefore the risk–benefit ratio for PEP is improving. Given the lack of data showing that a three-drug regimen for PEP is superior to a two-drug one, I would provide the intensivist with a 28-day course of tenofovir/FTC (Truvada) to be started as quickly as possible after the exposure, with baseline and follow-up ELISA testing at 4 to 6 weeks, 12 weeks, and 24 weeks.

In addition, I would consider the possibility that the intensivist was exposed to hepatitis B or C virus (HBV and HCV, respectively) from the needlestick. If the intensivist has somehow escaped HBV vaccination, a first dose of vaccine should be given immediately; if the source patient has evidence of circulating HBV surface antigen, hepatitis B immune globulin, too, could be considered for the intensivist. HCV testing of the source should be performed, and baseline and serial EIA testing of the intensivist should be considered to assess for acute HCV seroconversion, which would warrant early treatment with pegylated interferon. Notably, hepatitis testing in the source patient would not be considered a surrogate for HIV testing in the same way that testing for viral load, CD4-cell count, or p24 antigenemia would be.

Response 2

  1. Catherine Hanssens, Esq.

Any version of involuntary testing in this scenario is inappropriate — medically, legally, and ethically. Individual privacy rights do not operate in isolation from medical and public health needs, but a provider's desire to know a piece of information is very different from the need for, or even usefulness of, that information — in this case, the HIV status of the patient.

The patient did not, and does not, have the legal capacity to consent to an HIV test, and without a medical power of attorney, the girlfriend has no legal authority to consent on his behalf. Equally important, however, is that the testing under consideration would not provide information sufficiently conclusive to alter the recommended course of prophylaxis.

None of the tests suggested could rule out HIV infection or the possibility of exposure. A negative antibody test does not rule out recent infection. A CD4-cell count is useless, because it reveals immunocompetence or suppression, not the cause, and many HIV-positive individuals retain healthy immune systems for at least a short period following infection. Even a negative viral-load test is not conclusive in ruling out the presence of HIV.

The risk for infection from the needlestick accident described is extremely low, even if the exposure involved HIV-infected blood. That said, a 4-week course of tenofovir/FTC (Truvada), with its relatively tolerable side effects, would generally be worthwhile to diminish the remote risk for infection. Although the scenario makes no reference to the HIV status or testing of the intensivist, he himself should receive initial and repeat HIV testing.

This recommendation for PEP should be considered in the context of current HIV therapy trends, in which growing numbers of doctors are calling for lifelong antiretroviral therapy (ART) soon, or even immediately, after an individual is infected with HIV. If physicians and researchers thought a short course of treatment was too toxic or risky to endure without proof of HIV exposure, would they be recommending earlier initiation of ART to their patients in advance of clear clinical need and conclusive evidence that it improves long-term health and survival?

Finally, if the patient were tested, not revealing that fact would be unethical, regardless of the test result. However, the question is irrelevant because involuntary testing itself would be unethical under the circumstances described.

Response 3

  1. Lisa Lehmann, MD, PhD, MSc

The ethics of testing patients for HIV without their consent must be distinguished from the legal question of whether the law requires informed consent. From an ethical perspective, even in states with no requirement for written informed consent, we would still almost always need to obtain verbal consent from patients before testing them for HIV.

Consent may be waived if not knowing a patient's HIV status would cause serious harm to another person. In the present case, however, not knowing the patient's HIV status does not pose a threat of serious harm to the intensivist. The intensivist can prevent infection by taking PEP without knowing the patient's HIV status. In doing so, the intensivist may incur unnecessary toxicity and adverse effects from the medications. This potential harm must be balanced against the harm to the patient of testing without consent.

In this case, I see no compelling reason to test the patient without his consent. Testing the patient would not be for diagnostic purposes, to provide him with appropriate medical care, but rather for the intensivist's benefit. Furthermore, testing is not absolutely necessary to protect the health of the physician and has the potential to harm the patient. If the intensivist is concerned about his risk for HIV infection, he can begin PEP immediately, and when the patient regains his capacity to provide consent, he can be asked again about testing. However, even if the patient were tested after the needlestick, he could be in a window period during which he could transmit the virus without testing positive. Thus, a negative HIV test for the patient would not guarantee that the intensivist has no risk for HIV infection. If the patient never regains the capacity to consent because he dies, postmortem testing would be reasonable even without consent because concerns about potential harm to him would have disappeared.

Surrogate testing for HIV is ethically unjustified in that it represents a duplicitous attempt to circumvent both the patient's autonomy and state law. It is also clinically problematic because a CD4-cell count is unreliable in critically ill patients and therefore should not be used to guide clinical decisions.

The patient's girlfriend in this case is not an appropriate surrogate to provide informed consent for testing. Some states that require written informed consent mandate that the consent be from the patient, not from a surrogate. Even if the girlfriend could legally provide consent, disregarding her own motivations for wanting the patient tested might be difficult for her.

The intensivist's preferences with regard to PEP should guide the decision about how to proceed. The risk for HIV transmission from needlestick injuries should be explained, as well as the increased risk associated with a needlestick involving a large-bore needle that was in a vein.

Tell us what you would do

How would you manage this patient? Submit your comments below.

Reader Comments (50)

James H Avruch

I'm not an intensivist and i have not had a needlestick from a high- risk patient. Some have argued that testing for HIV is no different from syphilis or TB; some have argued that consent in this instance could be implied. What about human autonomy? Perhaps if the patient had not explicitly refused HIV testing, then after he was obtunded consent could be implied, but he did specifically say that he did not want to be tested. Who knows why, and who is to say that his reasons were insufficient? True, most high-risk patients who refuse testing probably do so out of a legitimate fear that they will test positive. Which i think is the most telling point here- if you sign up to be an intensivist, then this type of situation goes with the territory, and you should be prepared at some point during your career to take an unnecessary course or two of truvada, as horrible as PEP may be. Because HIV is different than syphilis or TB, and that's the way that our society works, whether that makes strict medical sense or not. So intensivists, suck it up and deal, b/c this fellow who probably has HIV is YOUR patient and has no less autonomy than someone without a host of HIV risk factors. If you don't like it, try derm or ophthamology (both very lucrative, i'm told), because this is exactly the guy who you signed up to care for, exactly the guy who needs you the most, and just because you stuck yourself with a needle doesn't mean this individual loses his right to refuse testing. In other words, just because the patient will not take up a degree of personal responsibility does not mean that the intensivist may relinquish his personal responsibility for his actions, firstly choosing such noble and demanding work as intensive care, and secondly choosing to place a central line on a man with unknown HIV status. We always have choices, and so must this pitiable man as well.

Testing after the fact will not take the blood out of the needle. One could make cogent arguments that knowing the patient's HIV status is integral to his acute-level care and is thus a necessary test with implied consent like any other emergency procedure. All that is true, but the man specifically declined HIV testing verbally. At that point, for me, it's game over. Dutifully take your truvada and believe that karma will reward you.

Competing interests: None declared

Emily Mawdsley

Wouldn't we adjust the PEP regimen based on the source patient's results? For example, if the pt tests positive for HIV, I would recommend a 3-drug regimen for PEP initially (per guidelines). Additionally, most experts would give therapy targeted to the results of a genotype if the source patient was indeed positive (or the patient's most recent regimen). This negates the argument that knowing the results would not change therapy.

Additionally, the importance of knowing HIV status in caring for a critically ill patient cannot be overlooked. In this situation, the patient is undergoing many tests and therapies for which he has not explicitly consented. Why is knowing about HIV any less important or necessary to his care than knowing about diabetes, drug use, or syphilis? All of these diagnoses can cause personal distress as well but no special precautions are taken when testing for them. The physicians responsible for this patient should request emergency testing of HIV, first and foremost , because it is needed to care for the patient.

I am surprised that the lawyer and ethicist did not consider these points in their responses. I agree that the law is king, but every effort should be made to do what is right for both the patient and the exposed employee. In this case, that means testing as early as possible. Legal counsel for the hospital should be helpful in achieving these goals in a lawful way.

Competing interests: None declared

Charles E Walsh

Charge: attempted murder, of intensivist by patient. Subpeona HIV status. Treat intensivist per results. Golf.

Competing interests: None declared

Suleiman ibrahim Kuranga

From the history given, there is no need the intervist insist on the patient doing the test againt his will, but he should rather report the case to the managemet or the hospital authority and start the PEP therapy with truvada preferrably because of its less untoward side effects.

Dr Kuranga I Suleiman (FWACP), Ilorin, Nigeria.

Competing interests: None declared

Anne M. Pennisson,MD

Other tests could be used p24 antigen,cd4 counts but the pt should be tested for rapid HIV and vl. The physician at this point is a patient too. Offer PEP.

To not test this patient is another example of a "criminal" (the patient with illegal drugs in system" trumping the rights of the responsible citizen and patient (the physician.)

Competing interests: None declared

Peter T Comfort

If HIV +ve, the patient endangers medical staff, their families,their own future health and all those whom they may come in intimate contact with. Whether to HIV test this patient or not is not to be approached from an individual perspective when there is a serious possibility of community health risk.

I would test the patient immediately and without his consent, just as I would carry out the other emergency procedures without his consent. Regrettably,the intensivist will need to follow the usual needle stick protocols, on the assumption that the patient has the HIV/HBV/HBC viruses. If the patient tests +ve for any of these, then I would inform him of the results and of his obligation to protect others from himself, as well as strongly advising him to undergo appropriate treatment. As regards any illegality/unethical practice in my action, I would be happy to face any court, and any jury, knowing that my actions have saved more lives than 1 here, and that should I have failed to act as I had, the consequences would have been far more serious.Whatever the Court then does to me is unimportant.

Competing interests: None declared

Deborah May

So breaking the law whenever it is deemed to be in the best interest of the physician is an acceptable practice, according to many posts. Sorry, "common sense" and personal vulnerability do not trump the law.

Competing interests: None declared

Thabisa Sibanda MBchB, PG diploma in Clinical trials

Firstly it is unethical to test this patient. Surrogate markers are equally unethical and also unhelpful. Unfortunately this situation is critical for the intensivist as he has two options both of them very risky.

Option 1. Blindly take PEP and hope that there will be no adverse events. At the same time remain psychological traumatised when it is possible that there is no need to panic after all.

Option 2. Presume that either the patient is negative or that he (the intensivist) is one of the 99.7% lucky one who will not seroconvert. Check his status at 3,6,9,12 amidst a lot of panic attacks. This I will call TRUST in divine power.

If I was in the shoes of this guy i would do the following;

1. Draw blood from this patient and do a rapid test (from my on kit). Keep this information confidential from the patient, girlfriend and even my colleagues.

2. If the guy is positive, I would tell my colleague that I have opted for a blind course of PEP.

3. If the guy is negative I would tell my colleagues that I have opted to TRUST in divine power.

The long and short of it is that I will maintain ethics by keeping this information confidential.

Competing interests: None declared

A W P, MD JD

The Canons of legal ethics provide for an attorney who has not been paid by their client the leeway to "ethically" disclose to third parties confidential information that had theretofore been protected under attorney-client privilege—solely for purposes of leveraging the client into paying the owed attorney’s fee. Contrast this ethical pragmatism with the ethical standards to which some of the commenters in this thread hold healthcare providers….

Competing interests: None declared

Melissa Hawthorn

Is that lawyer high? Since when do the rights of one always trump the rights of another? By this I mean: since when do the rights of the medical community always come in as rock-bottom last? And to try the "ethically inappropriate" garbage? Trying to make your opponent feel guilty and unworthy is a defense of the last resort. A person's freedom and rights extend unrestricted only until they bump up against another's. So tell me, Ms. Esq. and the rest of you "ethical" experts, why does someone who, in all likelihood knows he is infected and that is why he refused testing in the first place, always "win"? A doctor can go to court and get the court to agree to a treatment to save a patient's life even if the patient resists... after all, that would be loss of mental capacity and gives the court the right to overrule the stated wishes of the patient But he can't go to court and get a blood test ordered from an obviously mentally-incapacitated patient who could conceivably endanger many others in the course of his irrational life? By all means, let us take all humanity out of the law.... and all reason as well. Has the human race actually devolved to this point? All that matters is the absolute literal words of the law? I doubt Thomas Jefferson, et al ever intended this when they set up the government.

Competing interests: None declared

Rabia Akbar Vali

both the patient and the treating doctor are important and both need to be taken care of and as the pt is not fully cognitive i would test him and at the same time start the pep and inform the patient re the result whatever reported and act accordingly once the pt is in full cognisance.

Competing interests: None declared

Doanh Lu

The responses from the experts clearly showed that they have never had a needle stick from a high-risk patient, nor taken a PEP regimen with its attendant constant nausea and fatigue, nor suffered through many months of uncertainty, over and over, as intensivists and surgeons are apt to stick themselves more than once. Until these experts have exposed themselves to such risks daily, their rather one-sided opinions border on being hypocritical. Doctors, who work hard to save these patients, have the right to protect themselves, as well. Furthermore, at least in developed countries, HIV disease has become a chronic disease and managed much like diabetes and CAD. It's not a fearsome disease it once was. Why all the hush-hush around testing for it? Why not considered HIV just another chronic disease? The time has come for ethicists and lawmakers to change their views on the requirement for HIV consent. In my opinion and experience as a HIV doctor, not knowing one's HIV status is more harmful than knowing it.

Competing interests: None declared

Rochelle Y. Odell

Being a former Critical Care Tech at a community hospital in Georgia, I received a needle stick. Fortunately, it was further up in the IV line because the RN had not secured the needle in the added IV Line and when turning the patient, it became loose and stuck me.There was no exchange of bodily fluids.

When working as an ICU Nurse Tech, we had a patient with full blown AIDS who's wife didn't believe he was dying from HIV-AIDS and no amount of showing her the test results as he had the disease for some time could convice her or her chldren. One of our ICU RN'a just hapened to be in our Urgent Care Office one evening when I came in for a pain flare up, as she had received a blood stick from this patient. I knew she was started on the drug cocktails given to medicaI professionals, but didn't see her after about a month and often wondered if she had developed HIV.

I believe all patients being treated in an Emergency Department setting or as an in Patient , should sign a form to be tested for HIV, so that the staff is protected. Particularly if the patient is scheduled for surgery, when the risk to the Surgical Team is at it's greatest.

I was working at a hospital in Las Vegas for three months as a Cardiac Monitor Tech waiting for an opening at USC, and all potential employees were not given the option of taking an HIV Test, it was a requirement for employment.

It makes no sense to me. Patients who have TB have to be reported to the CDC as well as any patients who develop STD's, yet a blood disease that kills the patient at some point in time, does not have to be reported. What's wrong wth this picture?

Competing interests: None declared

Rabia Akbar Vali

the patient is admitted in a confused state and preferably i will take the consent of his girl friend and if she refuses i will opt for post exposure prophylaxis with combivir and viramune for the intensivist after drawing blood on D0 and every 6wks thereon..

Competing interests: None declared

khaled hamad

after reviewing the hx and the circumstance of the injury and taking in consederation that the pat. was found in the street with positive toxicolody this places him in risk group for hiv. the other thing to cosider that the victem case used a hollow-bore needle increase the risk further. also the injury seems to be somehow deep which increase the risk further and this occured though the gloves which dcrease the risk since the pt. condition is deteriorating. it looks that his immune status is depressed and asuming that he is hiv posetive that means he has advance disease. and sice he is refusing hiv testing while he is awake this cant be done and his gairlfrind cant give consent on his behalf and cd4 count testing want be helpful in this situation it is not aconfermatory test for hiv.

putin all together i think this is high risk expusure so i will starte postexpusure prophylaxis after testing the victem for hiv HBsAg.

and follow him up and try to get more information about the sourse pat. or to get help for the low aouthority to take consent and if it is negative i ll stop the prophylaxis.

Competing interests: None declared

E Kunka

I would start PEP for the Doctor and then go ahead to collect blood for an HIV testing from the patient. I feel that since there is another persons life at stake, his right to health should not be undermined. I would give him 2 NRTIs +1NNTI

Competing interests: None declared

Elsa J. Aguilera

1) After taking blood from the intensivist for HIV, HBsAg, HCV treat him on emergency basis

2) Ask the girlfriend for a blood test to r/o HIV, HBsAG and HCV as a way of knowing what is going on with the patient and herself. She is living with a drug addict and the possibility of being infected is significant

3) If the girlfriend does not consent to the above, GO ahead with testing the patient. After all, the intensivist 's life is changed for the worse

4) Give to the patient the blood results (negative or positive) for treatment and for the avoidance of virus/es transmission if results are positive (or education/advice if negative)

3) As soon as possible consult with both the Hospital Ethics committee and the hospital lawyer (Of course after 1 and 2 are done)

Competing interests: None declared

Jos� Manuel Ferreira

in portugal the patient would be testede because in our understanding the patient admited to hospital is in the ritgh for the best treatment and this only can be provided if all the test necessary can be done! legally the patient as the rigth to be informed but there is no history of no complaint of that subject in our country! The patients often are gratefull to the phisician who finally made the rigth diagnosis!

Competing interests: None declared

James S. Long

Start PEP on the intensivist, test for HIV, even without consent, and inform him of the results after he recovers.

Competing interests: None declared

NSKE NSKE

Without a doubt if it was me - obtain baseline test for HIV both HIV antibody and vL. Then immediately begin HAART. After a month repeat the baseline labs.

Competing interests: None declared

GB Howell

I would test and I would treat.

Competing interests: None declared

Mart�n G. Murman

Primum non nocere

Competing interests: None declared

Joalie Davie

I assume that the patient will not be available for a follow up HIV test as well so even if the patient is negative at the time that will have to be in consideration with the history and the true risk of recent exposure and possible infection of the patient with HIV.

One option is that the test be done and the patient will have to be informed that he doesn't have to be informed of the results of the tests and that the test will not reflect in his record but it will reflect in the physician records.

I would only recommend this option if the result of the HIV test done once will make difference in the management, then I would recommend to do the HIV test on the patient's blood but not inform the patient of the outcome of the test and inform the physician.

If the patient still refuses, then I would base prophylaxis on the past and current risk factors for this patient and blood tests other than HIV testing which might suggest a diagnosis of HIV/ AIDS. Of course I would let the physicain involved decide the ultimate course of treatment/prophylaxis.

Competing interests: None declared

Vickie L Becker

I would test the patient and give the intensivist PEP, according the most recent guidelines: Hep B- HBig + vaccinate; HIV- 2 or 3 HIV drugs (azt/3tc) +/- protease inhibitor

Competing interests: None declared

Herschel V. Murdaugh

My first responsibility is to the patient, then the physician stuck with the needle. Clinical experience suggests that the patient who refuses an HIV test believes he or she may have HIV. For the well being of the patient I would assume the diagnosis and do the first thing to guide therapy - get a viral load. I would treat both the patient and the physician as guided by the viral load.

Competing interests: None declared

Benjamin D. Gordon, M.D.

A patient whose mental status is "waxing and waning" and who has evidence of cocaine and opiate use is not in a competent mental state. His refusal cannot be considered with the same legitimacy as someone "alert, coherent and cooperative". To put the physician at significant risk in this situation belies common sense. The objective of having laws at all is an attempt to achieve "justice". Sometimes law does not achieve this and the use of judgement is required. When this patient was obtunded, HIV testing should be done. This does NOT harm the patient in any way and proper information can then guide appropriate management - of both patient and physician. If the patient is positive, when he has regained a rational mental state, he should be told and receive what is indicated. If he is negative, he does not need to be told. Bottom line: either way, NO HARM IS DONE.

Competing interests: None declared

ROBERT A MAXWELL

1. Ask him again, even though he is intubated, and inform him that the physician suffered needlestick, for permission. Also do STS, HepB&C 2. Ask his girlfriend for permission to test her for HIV 3. Ask her for permission to test him. 4. Save a sample of his blood in the frezzer. If he should die, then I would have it tested for HIV. 5. Test MD for HIV; repeat in 6 wks

Competing interests: None declared

Ruth H. Strauss MD

To be honest, I would ask the girlfriend, and if she said "no" I would probably either have 2 physicians sign it was an emergency or call the Risk Management Department or consult a lawyer, but at all costs, OBTAIN the result--the doctor is the one who is trying to perform life- saving treatment for the patient and there is no rational reason to deny him of his own life-saving information. I would imagine even in a court of law, that the decision to do this would be upheld.

Competing interests: None declared

carlos e. rojas

The same principle of law, that you may breech information about pt condition, in case of life threatening event involving either the patient or others, should apply and the HIV testing should be done. As far as PEP, I will treat him in standard fashion, considering a high risk patient.

Competing interests: None declared

Deepak Bhagwandas,MD.PT

Start antiretrovirals ppx

Competing interests: None declared

Dr, Cornelius Reinhard Weerts

Undergo an HIV Test twice -in different times - on your own cost.

Competing interests: None declared

Jean Yared

I would start by testing the intensivist for ELISA HIV at D0 (and every 6 weeks up to 6 months), if negative I will proceed to HIV RNA PCR. Anyway, I will also start him prophilactically on 2 NRTI's +/- 1 PI for up to 4 weeks.

Competing interests: None declared

Bettina Bernstein

postexposure prophylaxis if the intensivist was not allergic HIV test on the blood already drawn as the test result is important for management of the patient and the intensivist the results on basis of an urgent emergency need then get a court order if the test is positive to obtain informed consent to treat

Competing interests: None declared

Mariah Haley

Patients shouldn't be the ONLY people with rights in this situation!

Yes, they have the right to refuse to consent to have their blood tested -- fine, then test the blood and don't tell them the results if they don't want to know. BUT...the internist needs to know whether he/she has been infected with HIV b/c this will change the rest of his/her life!

Tell the patient -- you have the right to refuse consent, but your blood will be drawn & tested so that the other person (who also has rights) needs to know about his/her treatment options. If you don't want to know the results of the testing, that's fine, but if something comes back positive, we will have to do some further investigation in case other ppl are infected as well.

Healthcare workers put up with a lot of things and NOT getting to know whether you are possibly HIV positive is something that needs to be taken care of. Sorry the patient refused -- he has that right -- but I also have the right to know what I've possibly been infected with.

Competing interests: None declared

Maria Mohammed Satti

I will test the patient without his consent & will not give him the results either way they are. He either knows he is positive or does not want to know.

Competing interests: None declared

Ste..a J. Fitzgibbons

Hospitals all over the world have policies for this, what's the big puzzle? The patient's blood is sent for testing that includes HIV and sometimes other tests; the patient is not given the HIV result but the stickee is, and antiretroviral treatment started if appropriate. It would certainly be ethical to re-offer testing at some later time to the patient. You can't have a perfect solution, but you can prevent or slow the development of HIV in the intensivist. Again, what's so new about this situation??

Competing interests: None declared

Humberto Olivencia

In my hospital we have a consent that is firmed by most of the patients when they are hospitalize ( not firmed in emergencies) were the patient agree in testing in the above circumstances. Done to protect the physicians. The patient can decide if he wants to know ect.

Competing interests: None declared

Peter J. Waldman

I woud definitely treat the intensivist with PEP, would absolutely consider testing the source patient without consent, and I would also ask the girfriend for permission. In addition, once the patient is obtunded, hospital administration could provide implied consent, since the diagnosis of HIV would be crucial for the patient as well as the physician.

Competing interests: None declared

Lawrence E. Plaskett

In view of the circumstances under which he was admitted, I would evaluate his HIV status. Additionally, I would inform him of the results whether negative or positive. (However, since his condition had deteriorated significantly, the need for providing this information to him, could be delayed pending improvement in his general health including his 'mental status'.)

I would consider close followup (delayed treatment) of the physician until the patient's HIV status was determined.

Competing interests: None declared

Daniela G Nikolova

On all questions my answers are- yes. PEP will be 3-component therapy-for example- Combivir and Viramune or Kivexa and Kaletra I think it is good- the intesivist have to chek his HBsAg,anti HCV, as the same for patient, because as a drug ab/user may be he is with VBH or VCH

Competing interests: None declared

Mel Breite

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.

Competing interests: None declared

Paul H King

test the subject....period..no discussion required

Competing interests: None declared

V Sanders

Follow post-exposure guidelines for unknown source. Do not test the patient against his will. Provide postexposure prophylaxis. Intitial lab test for HIV, Hepatic Function Panel, Hep B, and HCV. Repeat labs in 6 wks, 12 wks, and 6 months. Hep B series if not already given. Counseling if needed.

Competing interests: None declared

Krispin Hajkowicz

I would perform a non-consented HIV test on the patient for his own wellbeing in an emergency. A positive or negative result would significantly change the management of the patient.

I would offer with a strong positive recommendation to the intensivist to take tenofivir/FTC as soon as possible, either for 30 days or until the result of HIV serology is negative on the patient. I would cease the PEP if the HIV test is negative.

I would give the patient results of a positive or negative test when he recovers.

Competing interests: None declared

howard zhang

I would prophylactically treat the physician, and test the patient for HIV even though he refused. I think the consent is not required in this situation. The patient will not be informed with the result because he does not seem to want to find it out.

Competing interests: None declared

Harvey A. Elder

I would have drawn the blood for the test before receiving the patient's permission. If refused, I would identify the intensivist as the one stuck by a needle from this person. That way, the patient's results are not available to the patient but the intensivist has the requisite info.

I would question the patient as to high risk drug and sex activities after I drew the blood. This would be part of my discussion with the patient.

Competing interests: None declared

KS Kahlon

At our institution, patients who are able or a legal surrogate sign a form at the time of hospital presentation consenting to necessary medical treatment: blood draws, radiography, IV fluids, antibiotics, etc. My understanding is that this includes consent for HIV, HBV, and HCV testing in the event of serious exposure involving hospital personnel. In this case, since the patient is already being given life-sustaining treatment in a hospital, consent for HIV, HBV, and HCV testing in this situation is implied.

Competing interests: None declared

Tania Acevedo

Treat the intensivist, with prophylaxis and test the patient. There 2 human lives that can be seriously affected by this result.

Competing interests: None declared

Samuel S Zagarella

Doctors have rights too. The intensivist has an obligation to save this patient AND an obligation to their own health as well. Testing should be done while the patient is confused and the intensivist receive appropriate treatment. The law is not correct for every situation and if tested , I hope sanity would prevail in this case.

Competing interests: None declared

SUDHIR REGMI

Certainly, the first step from my side would be post-exposure prophylaxis for the intensivist. In view of patient's toxicology screening,he falls into high risk group.So, better would be to take written consent from his girlfriend.If not possible, do HIV screening and donot provide reports to the patient concerned. Here, issue of testing for HBV and HCV also should be considered.

Competing interests: None declared

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