27 Oct Laws and corresponding hospital policies inform a decision on whether potential surrogate decision makers

1. Which laws and corresponding hospital policies inform a decision on whether potential surrogate decision makers may be contacted and informed of protected health information, including information pertaining to HIV status? What are the ethical underpinnings of these laws and policies?

2. Are there additional pieces of information or input from others that you want to have before you feel confident that you understand the intent of Mr. Lott’s remarks prior to intubation? If so, what information or input do you need?

Case 6. Privacy and Confidentiality This case accompanies the discussion of privacy and confidentiality, Topic 6 in Core Ethical Issues Involving Adult Patients, in Improving Competencies, second edition. We provide self- assessment questions throughout the case, as it unfolds. Answers are provided at the end of the case. Ethics Consultation Request Dr. Grant, a critical care physician, calls for an ethics consultation regarding a patient (Mr. Lott) currently lacking decision-making capacity, who previously expressed a desire for the clinical team to refrain from contacting his family or discussing his medical condition, including his HIV-positive status. Dr. Grant wants to know how to engage in conver- sations about goals of care with surrogate decision makers, given Mr. Lott’s previously expressed preferences. The Case The background of this case is based on what the electronic medical record showed and what the ethics consultant learned in talking with healthcare professionals. The ethics consultation service is not consulted until fairly late into the case, a point noted in the case presentation below. Mr. Lott is a 59-year-old man who was transported by ambulance to the hospital emergency department (ED) from the office of his primary physician (Dr. Fox) because he was experiencing respiratory distress. Dr. Walman, the ED physician assigned to assess Mr. Lott upon arrival, noted very early on that Mr. Lott was in serious condition with worsening respiratory distress. Anticipating that Mr. Lott would likely soon require intubation for ventilatory support and then be unable to communicate, Dr. Walman noted in the chart that he had explained the situation to Mr. Lott and asked if there were any family members or friends that hospital staff could call to let someone know about his situation. Dr. Walman further noted that Mr. Lott had explicitly declined to name any family or friend, clearly stat- ing that he did "not want anybody to know his medical information." Mr. Lott was soon thereafter sedated and intubated. Despite active assessment and support, his condition rapidly deteriorated. He suffered a cardiac arrest and received 17 minutes of cardiopul- monary resuscitation (CPR) before a pulse was restored. It was only after these events that Dr. Fox called the ED to check on Mr. Lott and was given a clinical update by the resident, Dr. Levi. During this conversation, Dr. Fox informed Dr. Levi that Mr. Lott is HIV positive. Mr. Lott was subsequently transferred to the medical intensive care unit (MICU) for ongoing critical care. In the week that followed, the MICU team continued to assess and treat him for now-resolving pneumonia and septic shock. Mr. Lott remains intubated and has not awakened, despite discontinuation of sedative medications. Dr. Grant, one of the MICU critical care physicians, talks with Ms. Alexia, the MICU social worker, about attempting to identify and locate family members so that decisions can be made about goals of care. Dr. Grant and Ms. Alexia decide together to seek ethics consultation to clar- ify whether the family should be contacted and given medical information in light of the statements Mr. Lott is known to have made about not doing so, before he was intubated. It is at this point that Dr. Grant calls for an ethics consultation, asking: "Do we call family members and disclose the patient’s HIV-positive status, given that Mr. Lott told us not to? We have to make some decisions here."