A 37-year-old previously healthy man comes to the emergency department due to worsening cough and dyspnea for the past several days. Evaluation shows tachycardia, tachypnea, labored breathing, and hypoxemia on room air. Chest x-ray reveals diffuse bilateral interstitial infiltrates. The patient states he has had unprotected sex with multiple partners. He is not married and does not have any children. Rapid HIV testing is positive. The diagnosis is discussed with the patient, and hospital admission for treatment of hypoxic respiratory failure due to suspected Pneumocystis pneumonia is recommended. The patient agrees but does not want any of his family members to know about the HIV diagnosis. Which of the following is the best course of action?

Question

A 37-year-old previously healthy man comes to the emergency department due to worsening cough and dyspnea for the past several days.  Evaluation shows tachycardia, tachypnea, labored breathing, and hypoxemia on room air.  Chest x-ray reveals diffuse bilateral interstitial infiltrates.  The patient states he has had unprotected sex with multiple partners.  He is not married and does not have any children.  Rapid HIV testing is positive.  The diagnosis is discussed with the patient, and hospital admission for treatment of hypoxic respiratory failure due to suspected Pneumocystis pneumonia is recommended.  The patient agrees but does not want any of his family members to know about the HIV diagnosis.  Which of the following is the best course of action?

Quizplus · Accepted Answer

Protected health information (PHI) (ie, personally identifiable information regarding diagnosis and/or treatment of any medical condition) should not be disclosed to others without patient consent. This patient's request not to discuss his diagnosis with his family should be respected. However, he has Pneumocystis pneumonia with signs of significant respiratory instability (ie, tachypnea, hypoxemia, labored breathing) and is at risk for unexpected, acute deterioration in clinical status. Therefore, it is important to discuss his wishes regarding a surrogate decision-maker in the event he is unable to communicate his decisions for himself. In most jurisdictions, when a patient is unable to make decisions regarding medical care and has not designated a surrogate decision-maker, decision-making falls to the next of kin default surrogate. In this case, this possibility would greatly complicate the patient's care because he does not wish to share the details of his condition with his family. Therefore, the care team should promptly discuss designating an alternate surrogate decision-maker outside the family (eg, close friend). next of kin (Choices B and C) The patient should be aware that it can be extremely difficult to indefinitely conceal chronic conditions (eg, HIV) from immediate family. However, only the patient can decide whether, when, and to whom PHI may be disclosed. He should not be pressured to disclose information to his family before he is ready. (Choice D) The attending physician and care team should always provide appropriate counsel to patients and surrogate decision-makers, but in general a treating physician may not be designated as a decision-maker. A more appropriate surrogate decision-maker should be identified as soon as possible. (Choice E) There is no obligation to disclose PHI to a family member without patient consent. If a family member insists on discussing PHI with the physician, the physician should simply state that he or she does not have the patient's consent for disclosure. Educational objective: When a patient is unable to make decisions regarding medical care and has not designated a surrogate decision-maker, decision-making falls to the next of kin default surrogate. Patients who wish not to inform family members of protected health information should designate an alternate surrogate decision-maker.

A 37-Year-Old Previously Healthy Man Comes to the Emergency Department