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Does disclosure of the patient’s vital healthcare information to the lawful surrogate for use in carrying out obligations related to decision making violate the patient’s rights under the Health Insurance Portability and Accountability Act

Does disclosure of the patient’s vital healthcare information to the lawful surrogate for use in carrying out obligations related to decision making violate the patient’s rights under the Health Insurance Portability and Accountability Act?

6. In this case, law enforcement officials were able, without contacting the hospital, to tell the family where emergency medical services had transported the patient. If the police had instead contacted the hospital to search for the patient, should hospital staff have disclosed the patient’s whereabouts or condition to them? If so, why? If not, why not?

Please read the case and help me answer these questions. Thank you and much appreciate.

Ms. Alexia arranges a care-team meeting for the next day. A care-team meeting is a meeting for the purpose of ensuring that the healthcare professionals involved in a case have an understanding of the relevant prognostic information, treatment options, diagno ses, and management plans before they discuss these elements with the patient or family. This meeting includes only the healthcare professionals involved in the case and often also an ethics consultant, who may facilitate or lead the care-team meeting. It does not include the patient or family members, as would be expected in a family meeting. The care-team meeting includes Dr. Walman, Dr. Levi, Dr. Grant, Dr. Fox (via confer- ence phone), Dr. Ashwej, Ms. Alexia, and the ethics consultant. The ethics consultant opens the meeting by reminding participants that in the interest of protecting Mr. Lott’s confidentiality and privacy, they should discuss the case only with healthcare profession- als involved in the case. The ethics consultant then establishes the purpose of the meet- ing: "to consider whether it is ethically appropriate to seek to identify Mr. Lott’s family members and inform them of his medical condition, given his previously expressed pref- erence of limiting contact and discussions with his family." The ethics consultant frames the ethical dilemma as one involving competing moral claims concerning privacy, confi- dentiality, and provision of medical care consistent with Mr. Lott’s values and wishes and the impact such limitations have on developing a plan of care congruent with the patient’s best interests. Ms. Alexia adds that she is concerned about whether it is "legal" to "violate" Mr. Lott’s wishes. After the framing of the meeting and introductions, Dr. Grant provides an updated summary of Mr. Lott’s condition, including the fact that Mr. Lott is dependent on the ventilator. Dr. Ashwej adds that Mr. Lott most likely has an irreversible anoxic brain injury, making sentient function unlikely. Dr. Fox says he has taken care of Mr. Lott for the past 5 years, but he does not know whether Mr. Lott has any family or close friends. He reports that, although Mr. Lott is generally affable, he did not discuss his personal life. Furthermore, although Mr. Lott saw an HIV specialist in the early months of diagnosis, which was 1 year ago, he declined to take medications for his HIV and did not follow up with the HIV specialist. During the meeting, Ms. Alexia receives a page to call the MICU nurses’ station. Mr. Lott’s daughter called the hospital just a few minutes ago looking for her father, because the police told her the ambulance had brought him to the hospital. She asked the bedside nurse for detailed medical information, and the nurse was not sure how to respond. Mr. Lott’s daughter is now on her way to the hospital, and her brother is with her. In view of this new information, Dr. Walman asks whether Mr. Lott would choose to inform his family about his medical status, given his current clinical condition and his fami- ly’s concern about their father. Dr. Walman says, "Our conversation with Mr. Lott was brief. We and he certainly didn’t expect his decline, and we definitely did not talk about whether his opinion on nondisclosure would change if his circumstances changed." The team discussed several options: . Option A: Interpret Mr. Lott’s previous statements as a conclusive representation of his autonomous choice applicable to all scenarios. This option would lead the team to keep information about his medical condition private, regardless of the burdens they or Mr. Lott would experience. The appeal of this option is that it recognizes the only known autonomously expressed preference that Mr. Lott made known in the course of this hospitalization. Under this option, the decision about whether to withdraw or proceed to long-term life support will be undertaken by the team in accordance with the best-interest standard. Its limitation is that withholding vital information from a distraught family could cause collateral damage, creating family distrust and stress. . Option B: Present the minimum information necessary for the family (surrogate deci- sion makers) to make a treatment decision on behalf of Mr. Lott, but refrain from disclosing his HIV-positive status. The appeal of this option is that it allows for substi tuted decision making, grounded in patient preferences. Its limitation is that discus- sions about informed consent for treatment will be incomplete if family members do not know about Mr. Lott’s HIV status. In addition, Mr. Lott requested that his family not be involved in decision making, and this approach undermines that preference. . Option C: Disclose everything to the surrogates. The appeal of this option is that it allows for informed decision making and life-sustaining treatment decisions grounded in substituted judgment. The limitation of this approach is that it completely contra- dicts Mr. Lott’s previously expressed preference for nondisclosure. Recommendations At this point in the care-team meeting, the ethics consultant recommends Option B and gives her justifications for that recommendation. She says privacy interests may be outweighed in this case, given (a) the uncertainty about how Mr. Lott would feel about his previous stated preference for not contacting family members in his current clinical situation; (b) the inability to optimize decision making and obtain informed consent if essential information about Mr. Lott’s values and preferences is not provided; (c) the fact that family members were coming to the hospital and that it would be difficult to with- hold all information from family members if they requested it; (d) the possibility that the family could provide insight into Mr. Lott’s preferences regarding life-sustaining treat- ment, which would be ethically preferable to the alternative of having the clinical team making decisions on his behalf without any knowledge about Mr. Lott’s values, goals, and preferences (some hospitals and states allow this in limited circumstances, although having clinicians make decisions on behalf of patients is ethically controversial); and (e) the likelihood that the family and care team-because Mr. Lott’s current predicament and prognosis are thought to be unrelated to his HIV-positive status-could engage in conversations about the goals of care without the need for the care team to disclose Mr. Lott’s HIV-positive status, which was likely his main privacy concern. Therefore, the privacy consideration would still be protected to a degree.

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