1198
HIV TESTING
Parsa, Walsh • HIV TESTING
When obtaining informed consent from pa- the opposite side9 are physicians who recognize
tients, the emergency physician must consider the that emergency physicians are in many cases de
patient’s competence level. Certain patients may facto primary care providers.
be competent to make simple decisions, but not
competent to make decisions on more complex is-
R
ESOLVING THE PROBLEM
sues. At the time of decision the physician must
determine the patient’s level of competence for
each particular issue. Simple tests of competence
generally involve no more than the presentation of
facts, and then asking the patient to repeat back
the salient points.
In the case presented above, the physician is faced
with the obvious dilemma of what to do with this
patient’s positive HIV test result. Before we con-
sider the options available to us, we must consider
the context of the patient’s decisions while he was
in the ED. Our patient evidenced a sudden change
in temperament in requesting the test not be per-
formed. This suggests an emotionally laden, per-
haps uninformed decision. It is quite possible that
with further discussion the patient would better
understand the importance of knowing his HIV
status and be able to cope with the results appro-
priately. In addition, this is a test performed on his
body, and is a part of his medical record. Thus, one
could strongly argue that our first line of action
should be to attempt to contact the patient. By do-
ing this, patient confidentiality would be preserved
and the patient would be able to digest and divulge
the information as he deems necessary, thus main-
taining his autonomy.
Usually interventions requiring consent carry
some risk of adverse outcome, or involve end-of-life
issues. The risks of having an HIV test performed
are of a far different variety.2 There is essentially
no risk medically to the patient in obtaining the
blood sample to perform the test; and the objective
medical benefits of knowing one’s HIV status are
documented.4 The risks to the patient of a positive
HIV test are of a social and psychological nature.
A positive HIV test can lead to loss of support from
family or friends, depression, broken relationships,
and myriad other problems that could have a tre-
mendous impact on the patient’s personal life.
Cases have been documented of patients’ being at-
tacked and injured or killed when their illness was
revealed.5–7
Unfortunately, the above case was not so sim-
ple. We were unable to locate our patient and had
no idea of his whereabouts or current activities. We
did not have the luxury of time as it was possible
that he was currently placing others at risk of con-
tracting HIV. In this situation many physicians be-
lieve the principle of beneficence overrides patient
autonomy. The patient’s wife and child might be
infected, and further delay of potential HIV diag-
nosis and treatment increases their risk of compli-
cations.10,11 In this situation one would ordinarily
proceed to inform an at-risk third party. There is
legal basis that physicians have an obligation to
inform such parties.12,13
Our third option in this case is to ignore the test
results. If the physician orders had been properly
followed, this test never would have been per-
formed. Thus, a busy physician could rationalize
that the test results should be discarded as if they
were never obtained. Most physicians would prob-
ably disagree with this approach, realizing that it
is in the patient’s (as well as the family’s) best in-
terest to know this information regardless how it
was obtained.
For many years employment could be threat-
ened if a person was thought to have AIDS.2 As a
result, HIV tests have been given a special status
that is not afforded other basic medical tests in our
country. Over the last several years, the prejudices
previously associated with HIV have become far
less common. However, when asking a patient to
consent to an HIV test, any number of idiosyn-
cratic reasons to accept or to refuse may surface in
the patient’s mind. Possibly the patient has never
thought about the issue or perhaps is reminded of
a friend who committed suicide or otherwise suf-
fered discrimination after being diagnosed as hav-
ing AIDS. It is doubtful that we often know the
true reason for a patient’s refusal to accept an HIV
test.
With these thoughts in mind, the physician
must also face the question of doing the test in the
ED. The benefit of pre- and posttest counseling in
HIV is well known.8 Some physicians believe that
it is inappropriate to order HIV tests in the ED for
patients who will not be admitted due to the need
for this counseling, which may not be available in
the ED. Having an individual’s positive HIV test
results with incomplete patient tracking informa-
tion could make patient notification difficult or im-
possible. Hence, many physicians believe it is more
appropriate to refer individuals not needing ad-
mission to primary care clinics, to a public health
Finally, emergency physicians need to be up to
date with state and local reporting obligations for
various infections. Even if the physician has de-
cided not to attempt to contact the patient or his
family with the results, one would still be required
service, or to a local agency offering free, anony- to inform the proper health authority in most ju-
mous testing with counseling and follow-up. On risdictions.2
Henze
