AMA Journal of Ethics^®

Case

Mr. Smith, 50, was HIV positive. Having given informed consent, he underwent cardiac catheterization following a positive stress test. He was found to have mild-to-moderate single vessel coronary artery disease. Mr. Smith did well during and immediately after the procedure and was discharged.

After discharge, however, he had complications and severe pain. He returned to the hospital the day after the catheterization and was found to have massive groin and scrotal swelling, diagnosed as scrotal hematoma. A vascular surgeon was consulted and reported that there was no need for surgical evacuation. Accordingly, Mr. Smith’s hematoma was managed conservatively by elevation of the scrotum, and he was given analgesia for his pain. On admission, his hemoglobin was 12.3g/dl and remained stable throughout his hospital stay. Mr. Smith also received occupational and physical therapy. His hematoma decreased in size only minimally over the course of his stay, and he continued to complain of pain.

By hospital day 5, the primary team decided that Mr. Smith was medically stable and could be discharged safely to the extended care facility (ECF). There, physical therapy and the conservative management of his hematoma would continue. Upon mention of the plan for his transfer, Mr. Smith became upset. He remarked that the complication was not his fault and that, since the hospital “did this to [him],” the least it could do was provide him a place to recuperate. “I will leave when I’m ready,” he stated.

The attending cardiologist had apologized to Mr. Smith for the complication when he was readmitted to the hospital. Now the cardiologist politely explained that, given his HIV status, an extended hospital stay was dangerous for him because of “the bad bugs that live here.” This made matters worse. One of the medical students on the team later discovered that the patient had misinterpreted the cardiologist’s statement to mean that his HIV status increased the risk of infection for others. All in all, Mr. Smith felt that he had not been treated well, stating he did not appreciate what he perceived to be the flippant way in which the attending cardiologist had announced his HIV status for others in the room, including the patient’s roommate, to hear. Further, he said, one morning when he had not felt well enough for physical therapy and asked the therapist to return in the afternoon, a nurse had said to him, “You can lie around at an ECF just as easily as you can lie around here.” Understandably, this offended Mr. Smith. He was discharged from the hospital after 14 days.

Commentary 2

The first commentator provides an illustrative account of ethical questions critical to a sound fiduciary physician-patient relationship. What is not adequately stated is that a thorough discussion of the risks and benefits of the cardiac catheterization as part of the informed consent process might have prevented some of Mr. Smith’s anger or at least prepared him for the possibility of complications such as those he experienced.

In our relatively limited clinical experience, students pass through the majority of clinical inpatient rotations. Within this environment, time, priority management, urgency, and economics drive only the briefest of patient interactions. In less-pressing circumstances, offering better information organizes the patient’s expectations for a workable treatment plan. This information would include a discussion of the patient’s potential increased risk of adverse outcomes and modified subsequent recovery in context of his HIV status. If the patient chose the procedure after understanding the properly explained risks, he then would have stepped into the realm of autonomous decision making with a feeling of ownership of the adverse outcome. Moreover, a simple question, “I sense you are concerned about leaving the hospital; can you tell me about this?” would show empathy and might succeed in alleviating Mr. Smith’s underlying apprehension.

Mr. Smith’s HIV status should not only influence the management of his expectations but should serve as the source for another vital aspect and discussion point in this case and in ethics— patient confidentiality. Understandably, it is difficult in crowded hospitals to maintain the highest standards of confidentiality. Asking the nurse to take Mr. Smith’s roommate for a walk, however, or asking the patient if he felt up to joining you on the couch or bench in a corner of an isolated hall, or simply making an effort to speak more softly to conserve his confidentiality might have instilled confidence that you value preserving his privacy—perhaps more so in the offering than in the actual event. The Council of Judicial and Ethical Affairs at the American Medical Association states, “Such respect for patient privacy is a fundamental expression of patient autonomy and is a prerequisite to building the trust that is at the core of the patient-physician relationship…. Physicians should be aware of and respect the special concerns of their patients regarding privacy” [1].

The nurse’s comment illustrates an important aspect of expectation management that is often overlooked. If the expectations of the entire team are not unified, discord can ensue. Rather than helping resolve Mr. Smith’s concerns, the nurse fed into his perception that the staff wished to be free from him by passing on his care to an ECF. Perhaps this perception engendered a fear of abandonment, or it might have suggested to Mr. Smith that being discharged to the ECF was a punishment. In either case, the comment fueled Mr. Smith’s sense that his autonomy was not being respected and that the physicians’ purported beneficence was really paternalism.

The pendulum of autonomy may swing toward the patient in many contemporary circumstances. A physician who fully understands, accepts, and exercises the professional rights of his position will teach the patient about the risks and benefits of procedures as related to their own health. He or she will explain the finite nature of medical resources with their accompanying financial obligations as well as alternatives, in a cooperative and confidential environment in conjunction with health-care staff. If these guidelines, and those suggested by the first case commentator, are heeded, greater understanding may pervade the healing halls of hospitals and clinics.