Treating unvaccinated patients

Posted by NZMPI at December 24, 2021 11:09 am Blog, DIAGNOSIS, PATIENT CARE, PROFESSIONALISM, Video
Treating unvaccinated patients

Vaccination offers the best protection against COVID-19 both for individuals and those they interact with. However, some New Zealanders do not qualify for vaccination while others have chosen not to be vaccinated. The following video and article will provide an overview of the delivery of medical care to patients not vaccinated against COVID-19.

 

 

Treating Unvaccinated Patients – A Presentation by Law Clerk Georgia Bowker

 

Starting point

The starting point is the clear expectation set out by the Ministry of Health and the Medical Council of New Zealand that doctors will not refuse to treat unvaccinated patients.

Health services need to provide services in accordance with the Code of Health and Disability Services Consumers’ Rights. Under the Code patients have the right to freedom from discrimination, to be treated with respect, and the right to services of an appropriate standard.

Doctors should also bear in mind the principles and values of good medical practice, that a doctor must not refuse or delay treatment because he or she believes that a patient’s actions have contributed to their condition. Nor should they unfairly discriminate against patients by allowing personal views to affect the doctor-patient relationship. Further, unvaccinated patients should not receive a lower standard of treatment or care than they would have received if vaccinated.

 

Covid-19 Public Health Response (Protection Framework) Order 2021

In addition, certain health services premises defined as “designated premises” under the Covid-19 Public Health Response (Protection Framework) Order 2021, must not deny access to a patient on the grounds that they are unvaccinated (clause 31).

Designated premises are defined in the Order to include premises of health services that are partly or wholly funded by—

  • the Ministry of Health:
  • Oranga Tamariki:
  • the Ministry of Social Development:
  • the Department of Corrections:
  • a district health board:
  • Veterans’ Affairs New Zealand: or
  • ACC

This applies then to hospitals, secondary health services, urgent care services and GP practices, as well as private health care providers who see patients funded by ACC.

Safety of health care workers

However, the right of unvaccinated patients to have access to healthcare services is not absolute. It must be balanced against the right of health care workers to be safe in their workplace.

 

If a patient is unvaccinated (or refuses to say) then a risk assessment should be undertaken. The patient’s doctor will need to assess the risk to their own safety, the safety of other patients and staff, and the safety of the unvaccinated patient seeking care. If possible, they should put in place appropriate and reasonable, evidence-based measures that are proportionate to the risk and designed to minimise it.

 

The Ministry of Health has provided general guidance that in most cases, with vaccinated staff and other precautions in place, the risks are unlikely to be sufficiently high to deny access to an unvaccinated patient.

 

Appropriate precautions have been identified by the Royal New Zealand College of General Practitioners to include:

 

  • Offering the unvaccinated patient a teleconsult in the first instance to manage their medical problems remotely.

 

  • If a face-to-face consultation is considered clinically necessary, then treating the patient as a ‘red stream’ patient according to practice procedures, which may include:

 

  • Separation from others in the waiting room or having the patient wait outside the practice. Note however the advice of the College that it is not acceptable to put an asymptomatic unvaccinated patient into the same area as ‘red stream’ symptomatic patients; and

 

  • The use of appropriate PPE by clinical staff interacting with the patient.

 

Where a patient refuses to wear a mask, whether vaccinated or not, the first step is to assess the patient outside if possible, or alternatively offer a telehealth consult. Failing that, the patient should be treated as a ‘red stream’ patient utilising the separation strategy and use of PPE mentioned above.

 

Pre-consultation testing

The issue of whether unvaccinated patients should be required to provide a negative COVID-19 test prior to a non-urgent face-to-face consultation has been addressed by the Ministry of Health in its Position Statement of 25 November 2021.

 

The statement is not particularly user-friendly; however the following key principles can be taken away:

 

  1. Symptomatic patients, whether vaccinated or not, are by definition “high risk” and should be treated as such. Therefore, pre-consultation testing for this group would be unnecessary.

 

  1. At least at present – and things might change as Omicron takes hold – it would not be appropriate to adopt a blanket rule that all unvaccinated asymptomatic patients must be pre-tested.

 

  1. However, it may be entirely appropriate to require pre-testing of specific patients or cohorts of asymptomatic patients depending on an assessment of relevant risk factors. So for example, if an asymptomatic patient is immunosuppressed and unvaccinated, and other precautions are considered insufficient to adequately control the risk, then a requirement for pre-consultation testing may be reasonable.

 

  1. Where pre-testing is indicated, the statement provides no guidance about the timing of the test before the consultation. However the Ministry has advised separately that for an unvaccinated person to travel within New Zealand a negative COVID-19 test must be produced no more than 72 hours before departure. In our view, it would be reasonable to apply the same yardstick where a pre-consultation test is indicated, that is to say 72 hours prior to the consult.

 

  1. One situation in which the Ministry statement indicates that a pre-consultation test may be appropriate, is the asymptomatic patient who refuses to comply with protocols, such as observing distancing requirements or refusing to wear a mask. In such circumstances, if care can be safely deferred, it may be reasonable to reschedule the consultation and require the patient provide a negative test result.