Dr Rachel Birch, Medical Protection medicolegal adviser, presents two case scenarios, illustrating what locum GPs can do to support patients while minimising any potential risks.
Case study – We want some sunshine!
Mr G, a 68 year old patient, came with his wife to see Dr A in the middle of a busy on-call surgery. He said he needed her to complete a form stating that he was fit to fly.
He told Dr A that he had been recently diagnosed with inoperable lung cancer. His wife was keen to take him to Spain for some sunshine before his health deteriorated. The couple had been told by a Macmillan nurse that people with cancer may require medical travel clearance from their doctors before being allowed to board an aircraft.
Dr A had not met Mr G before, as she had just started covering maternity leave for his usual GP. She explained that she didn’t feel she had the knowledge of him or the expertise to comment on Mr G’s fitness to fly. However, she arranged to contact the couple the following day, and sought Mr G’s consent to discuss his health with the respiratory consultant in the meantime.
If asked to comment on fitness to fly, avoid stating a patient is “fit to fly” since this could be perceived as a guarantee of a patient’s fitness.
That afternoon Dr A reviewed guidance from the Aviation Health Unit (AHU) of the Civil Aviation Authority (CAA), where she read that at cabin altitude there can be a slight reduction in oxygen levels, which might present problems to patients with respiratory disease or who are anaemic.
She contacted Dr M, the respiratory consultant, who agreed to review the patient in his clinic. Dr M ultimately agreed to complete the form for Mr G, as although the cancer was inoperable, Mr G did not currently have symptoms of breathlessness.
The GMC advises, in paragraph 14 of Good Medical Practice, that doctors “must recognise and work within the limits of your competence”. Dr A was correct not to provide a certificate for Mr G when she felt this was beyond her expertise as a GP.
It was appropriate to ask the respiratory consultant for advice on travel, since the difference in oxygen levels at altitude may compromise some patients with respiratory disease.
Patients should be advised to check with their travel insurance companies if there are any doubts about their fitness to travel.
Cancer Research UK and Macmillan Cancer Support both publish information on travel advice for patients with cancer.
Case study – A trip of a lifetime
Dr K was doing a one month locum post covering Dr M’s sabbatical leave. Mrs H had insulin dependent diabetes and came to see Dr K in a routine diabetic clinic appointment. She was planning a holiday in Australia and had read that people with diabetes may require medical travel clearance from their doctors.
Dr K undertook a routine diabetic review with Mrs H. They discussed her medication regime, and she denied any hypoglycaemic symptoms. He looked at her recent blood results and conducted a physical examination. It appeared that her diabetic control was good and her condition was stable.
They discussed what she would need to carry with her on the flight. She would require needles, insulin, a blood sugar testing kit and medications for diabetic emergencies. Dr K arranged for Mrs H to see the diabetic specialist nurse at the local hospital to discuss the insulin regime she would require for the flight.
All of this meant that Dr K could state he knew of no reason why Mrs H couldn’t fly, and clarified in writing what equipment and medication Mrs H would be carrying in her hand luggage and why. He also advised Mrs H to contact the airline in advance to discuss her equipment and medication, and her dietary requirements.
Airlines may ask patients to provide letters or medical certificates confirming that a person’s medical condition is currently stable and the patient is “fit to fly”.
GPs should consider the wording of statements for airlines carefully, and where possible offer factual information about a patient’s condition, the stability of it and presence or absence of recent deterioration.
If asked to comment on fitness to fly, avoid stating a patient is “fit to fly” as the latter could be perceived as a guarantee of a patient’s fitness.
Try to word statements carefully, using phrases such as “this patient’s condition appears to be stable” or “I know of no reason why this patient shouldn’t be fit to fly”.
Diabetes UK offers advice on diabetes and travel. Before flying patients should consider consulting a specialist doctor or nurse regarding their insulin regime, especially if the flight is long. Passengers should be able to administer their own medication without difficulty. It is important that they are aware of problems caused by time zone changes and follow the specialist advice.
Patients may not always consider that air travel is risky and consider that it is a routine matter for a GP to sign a fitness to fly statement.
Doctors may wish to consider discussing with the patient whether air travel could adversely affect a pre-existing medical condition. The guidance outlined by the Aviation Health Unit of the CAA is a useful resource as it outlines factors to consider including the effect of decreased air pressure in the cabin, immobility, timings of medication, the mental and physical effect of navigating through airports and the need for health insurance.
Fitness to fly can be an emotive area. Patients may have special reasons for wanting to travel and doctors may feel pressure to complete forms and declarations of fitness to fly. However, it is important that GPs act in their patients’ best interests and only make statements that are truthful and honest and not misleading.