|
 |
|
 |
|
This Web site is a component of the SAMHSA Health Information Network. |
Ethically, caregivers need to have a clear understanding of when it is necessary and appropriate to obtain this information and to share it with others, weighing the beneficial effects against the liabilities imposed on the patient's autonomy. Legally, they must be aware of the laws and regulations governing confidentiality, and the circumstances under which patients' consent is required if they want to disclose AOD-related information. Other Ethical IssuesAlthough the importance of protecting a patient's privacy cannot be overemphasized, other important ethical issues arise concerning the issue of screening to identify AOD abuse among hospitalized trauma patients. Substance use disorders are diagnosable conditions with effective treatments. Untreated substance use disorders frequently result in serious medical conditions. In the case of trauma patients, untreated substance abuse can lead to reinjury or death -- for both the person with the disorder and others. Some researchers have pointed out that traumatic injury is so strongly associated with alcohol abuse and alcoholism, that injury, especially repeated injury, can be regarded as a symptom of alcoholism. If a clinician reviews the results of a laboratory test and suspects that a patient has a treatable disorder, is it ever ethical not to refer the patient to treatment? Under what circumstances would a physician who was treating a patient with hypertension choose not to investigate the causes of the condition or advise the patient? Could a physician claim that because the patient presented for treatment of an unrelated skin disorder, investigating and treating the hypertension was not required?
Do care providers have ethical obligations to protect society from those whose actions might cause serious harm to themselves or others, and at great financial cost? How far should society go toward protecting individuals from harming themselves? Questions such as these touch deep feelings in American society today. Screening for AOD abuse among trauma patients raises many of the issues with which Americans are currently struggling. An assumption of the consensus panel that developed this TIP is that, from a medical perspective, there is no valid reason for failing to address the underlying cause of traumatic injury. Federal Regulations Governing ConfidentialityUnfortunately, despite efforts to educate the public about the nature of substance use disorders, they remain socially stigmatizing conditions, and patients often face adverse consequences when information about substance use is disclosed. Such a patient, for example, may find it difficult or impossible to obtain insurance coverage for hospitalization costs if it is made known that his or her traumatic injuries were related to alcoholism. In turn, these adverse consequences often discourage patients with AOD problems from seeking treatment. When Federal Regulations ApplyThe Federal regulations are contained in the Code of Federal Regulations Part 2 (42 C.F.R. Part 2), Confidentiality of Alcohol and Drug Abuse Patient Records. The intent of these regulations was to encourage individuals to seek treatment for AOD abuse problems by reducing the risk that they would be stigmatized or experience discrimination as a result. Amendments to the regulations that were approved in 1987 specifically clarified which programs and records must be protected. In the general hospital setting, the regulations apply only to specialized programs that have either
In congressional testimony about the amended regulations (52 Fed. Reg. 21796, 21797 (1990)), the Department of Health and Human Services (DHHS) made clear that records generated by general medical and trauma physicians were not covered by the regulations (because those persons' primary function was not to provide AOD services). The testimony cited reasons for amending the regulations to remove these records from coverage:
DHHS went on in its commentary to explain that it believed that this change would not harm the congressional intent of ensuring confidentiality in order to attract people to alcohol and other drug abuse treatment:
From the above discussion it can be seen that in general it is not necessary for trauma centers and hospitals to implement special rules for handling patient records to comply with Federal confidentiality regulations when treating trauma patients who may have AOD problems. However, many facilities that initiate screening programs find it is both effective and cost-effective treatment to have one or more full-time AOD counselor/clinicians on staff. These facilities may also find that, especially for seriously injured patients who have longer hospital stays, beginning some form of AOD counseling and treatment in the hospital setting is an important aspect of care. It is in these situations -- that is, when an individual whose primary function is to provide AOD assessment or treatment and/or when a patient is referred for AOD treatment in the hospital -- that institutions should comply with Federal confidentiality rules. Chapter 7 offers suggestions for handling patient records in compliance with these rules. In order to emphasize the importance of respecting patient confidentiality and to provide information to facilities that must comply with these regulations, the consensus panel has included the following discussion of procedures, such as the use of consent forms, and other issues involved in complying with Federal regulations.
How Screening Is Used in Patient ManagementIn acute management of a seriously injured person, an emergency department physician will be interested in determining whether a patient has an elevated blood alcohol concentration or has ingested other drugs. As described in Chapter 3, recent use of alcohol or other drugs will alter the patient's physiological responses and thereby affect immediate medical management. For example, an alcohol-dependent patient may experience withdrawal symptoms during acute care. Determining a patient's AOD status on admission is a starting point to gather information needed to render the best possible care, both in the hospital and during rehabilitation of serious injuries. The reasons why the information about the patient's BAC is gathered will determine how this information must be treated. If it is gathered to effect the management of the presenting condition, it is protected by general rules about patient confidentiality and need not be treated differently from any other medical information. To gain a complete and accurate clinical picture, a physician needs access to all of a patient's records concerning history and present condition. Such information should include whether there is an underlying pattern of substance abuse, since this information may have a bearing on the patient's condition. AOD screening may be done in order to identify antecedent problems or conditions that may have an impact on the medical management of the patient's presenting condition. This information, then, gathered for the purpose of managing the present condition, would not be subject to the Federal regulations. However, AOD-related information should always be handled with discretion. When Patient Consent Is RequiredIf an AOD assessment is performed by an AOD clinician, whose primary function is the provision of diagnostic, treatment, or referral services for substance abuse, in order to engage the patient in receiving services for AOD abuse, the information obtained is protected under Federal regulations (42 C.F.R. Part 2) that require the express written permission of the patient in order for the information to be shared with others. A consent form as described in 42 C.F.R. Part 2 §2.31 must be signed by the patient in order for this information to be released. The form is a specific release form comprising eight elements (see Exhibit 6-1). A general medical consent form is not sufficient. Under the Federal regulations, however, AOD-related information may be shared with other healthcare professionals who are providing services for the abuse disorder itself or for a condition arising from the abuse, without requiring the patient's consent (42 C.F.R. Part 2 §2.12(c)(3)):
The regulations define "treatment" as (42 C.F.R. Part 2 §2.11):
Application of the Federal regulations is not dependent on how AOD services are termed by an institution:
The regulations also prohibit redisclosure of AOD-related information. This prohibition means that the person or agency to which the patient consents to have the information disclosed cannot in turn disclose the information to others without the patient's written consent. Any disclosure of AOD-related information must be accompanied by a written statement that the information disclosed is protected by Federal law and that the person receiving the information cannot make any further disclosure of such information unless permitted by the regulations (42 C.F.R. Part 2 §2.32). This statement, not the consent form itself, should be explained and provided to the recipient of the information at the time of disclosure or earlier (see Exhibit 6-2). The prohibition on redisclosure is clear. Those who receive the notice are prohibited from rereleasing information except as permitted by the regulations. (However, a patient may sign a consent form authorizing such a redisclosure.) The rules about redisclosure also apply to disclosure of the information for purposes other than making decisions about medical management. For example, sharing information relating to a particular patient is sometimes done in case conferences for the purpose of bringing up a clinical problem or dilemma for discussion among a provider's colleagues. When this is done, however, the patient's identity must not be revealed; this would be redisclosing the information to others, which is prohibited by the regulations. Obtaining written releases from patients for disclosure of AOD-related information can and should be seen as part of the therapeutic process. The patient and caregiver can discuss the implications of releasing information and the patient's choice to do so. By signing forms, patients demonstrate their commitment to treatment. The caregiver demonstrates a commitment to protecting. Common Issues Surrounding AOD-Related InformationPatients Without Capacity to CommunicateHealthcare workers sometimes must obtain relevant clinical information from others when a patient lacks the capacity to communicate -- for example, when a patient is in a coma. In such a situation, can a caregiver speak with others, such as family members or friends? How does he or she talk with others without compromising the patient's confidentiality? One approach is to make general inquiries concerning the patient's health, lifestyle, and medical history (such as inquiries pertaining to chronic medical conditions or to other injuries). These questions themselves may prompt the family member to volunteer information about the patient's AOD problem. Another approach is to ask questions that will elicit information without disclosing confidential information about the patient. For example, a family member can be asked whether he or she has ever been concerned about a patient's drinking. Family members are often eager to discuss a patient's AOD problems. Disclosures to Outside Agencies and OrganizationsTreatment providers often find it necessary to communicate with individuals or organizations outside the hospital about a matter related to a patient's AOD abuse. A common scenario is one in which a patient needs to request a change in work shift in order to be able to attend therapy sessions or classes. Under such circumstances, what may a care provider communicate to a patient's employer, and how can this be done without inviting adverse consequences for the patient? Because of the potential for discrimination against a patient with an AOD abuse problem, the caregiver should carefully discuss with the patient any proposed communications with the patient's employer beforehand. Most patients have a sense of whether negative consequences are likely to ensue from employers' knowledge of their AOD abuse. In some cases, such as when a patient expects to be fired if his or her employer were to learn about the AOD abuse, the caregiver may need to explore other treatment modalities. If the patient feels that the employer's knowledge would not constitute a major obstacle or result in discrimination, a caregiver can proceed with the communication after a proper consent form has been signed by the patient. Because a disclosure will be made to the employer when the caregiver requests a change in the patient's work schedule, the least possible amount of information that is necessary to achieve this goal should be disclosed. For continuing communications, the same rule applies: the employer should be provided with the least possible amount of information to satisfy the employer's needs. Often such communications involve simply stating that the patient attends treatment and is making progress in treatment. No clinical information, such as statements about the patient's mental status, should be given to the employer.
Providers also often need access to records from another treatment program in which a patient was previously enrolled. In such a situation, two consent forms are involved. First, the patient must sign a consent form to allow the provider to communicate with the other treatment program. The patient must then sign a release form allowing the treatment program to release the records to the provider. AOD-related information is often requested by patients' insurance companies in order to reimburse a claim. Insurance companies often withhold payment until they receive the information they have requested. Many times, however, insurance companies may be seeking more information than they have the right or need to know. It is prudent for the hospital to send the least amount of information required for reimbursement in order to protect the patient's confidentiality. A similar situation exists with managed care groups that act as gatekeepers for insurance companies. Court Requests for AOD-Related InformationHow should caregivers and hospitals proceed when medical or AOD intervention records are requested by legal authorities because a patient caused death or injury to someone else? In the case of United States v. Eide, (875 F.2d 1429 9th Cir. 1989) the court held that emergency department records were protected and could not be used in a criminal investigation or prosecution of a patient. However, it is not clear to what extent this protection extends and whether it applies to a patient's entire hospital record. It is also unclear whether a provider or hospital administrator is required under the law to divulge a patient's BAC if requested by legal authorities; this requirement may vary from State to State. Hospitals should be aware of these issues, however, and should consult legal counsel about how to address the release of information to legal authorities, as well as possible subpoenas of treatment providers. These policy decisions must be made before such a situation arises.
Ethical Considerations: Weighing Benefits and Harms to Society and the IndividualPatient Autonomy vs. Potential Harm To OthersAlthough severely injured patients are often helpless and even unconscious, their right to autonomy -- and to privacy and confidentiality -- is not thereby suspended. A physician is expected to make decisions in the patient's best interest. However, in certain situations, what may maximize the patient's health (AOD intervention and treatment) may be in conflict with the patient's autonomy and, by extension, with the patient's privacy and confidentiality. Most clinicians have encountered this dilemma, and that tension exists in their minds. Ethical thought always weighs benefits and burdens, harms and goods. The disease of addiction has far-reaching implications not only for individuals, but also for the common good. The social dimension of AOD abuse can be seen, for example, in the extensive role that it plays in traumatic injury and in damage to family relationships. If caregivers invade patients' privacy in the name of society's greater good, patients will lose trust in caregivers and the benefits of treatment. They may avoid treatment because of realistic fears of loss of job, home, access to family and children, and so forth, if confidentiality is breached. The primary purpose of the Federal confidentiality regulations is to ensure that these fears do not prevent persons from seeking treatment. Even though our society greatly values the individual and individual liberties, protecting the common good sometimes justifies some degree of abridgement of individual liberties. The most common -- and extreme -- example of this abridgement is the withdrawal of civil liberties from a person who has been convicted of a crime. However, in the case of AOD abuse and dependence, it is only individuals who can take actions to change their behaviors. Individual choices are the basis by which changes occur in the large society. Therefore, respecting patients' autonomy -- their right to make choices -- is central to encouraging change. The caregiver must continually ask what the least amount of patient information is that is needed to diagnose and treat the patient. Although the larger social implications of a patient's AOD abuse should be considered in decisions relating to the handling of AOD information, protection of these broader interests should not come at the cost of the patients' right to confidentiality.
Limited AOD Treatment ResourcesValid ethical concerns surround 1) the identification of problems for which appropriate treatment resources may be limited or unavailable because of limited treatment capacity in the local area or 2) the patient's lack of insurance coverage for needed types of treatment. As discussed in Chapter 4, the effectiveness of even minimal interventions by the physician or other staff should not be discounted. In addition, caregivers with knowledge of valid self-help groups in the community may refer the patient to one of these groups. Strategies for increasing the effectiveness of referrals are discussed in Chapter 4. Patient ChoicesAOD disorders are life threatening and health threatening. Some patients who are using AODs hazardously can benefit from information about their problem; some of these individuals may not need formalized treatment and may be able to cut down or stop their AOD use on their own. By having all the available information, patients can be given the choice of taking responsibility for modifying their behavior. Denial is a common characteristic of individuals with AOD abuse problems. Many patients fail to recognize the existence of their addiction and its relation to the adverse consequences caused by it. Some patients may understand that they are addicted but deny or minimize their condition because of fear of entering treatment and ambivalence about giving up alcohol or other drug use. The physician should give the patient all the relevant information and explore how the patient sees his or her problem. A great deal depends on the extent and sensitivity of the provider-patient relationship and whether the patient is placed at the center of the process. Intrusively confronting the patient will not achieve the type of understanding necessary to accomplish the goal of change. Ethical Issues in the Protection of RecordsLarge numbers of people handle charts, and some are not well trained to think in terms of confidentiality. Further, the gossip value of medical information should never be underestimated, from dinner party small talk to hospital elevator chatter. The computer age has made this long-standing problem far worse. Computerized information, as the newspaper stories continue to point out, is fairly easily accessible to many computer "hackers" with nothing more malevolent than mischief on their minds. However, computerized information may be desired by employers and insurers with other purposes in mind. The possibility of healthcare reform's bringing with it a "national health card" computerized throughout the country, with patient information available from the card, exponentially increases the dangers of charting information that stigmatizes the patient. It is helpful for caregivers to ask the following questions in these and other specific instances in which a potential ethical problem arises:
There is generally no "right" answer to these questions, or they would not constitute the moral dilemma that they pose. Ethics is a constant weighing of facts and values, and data and beliefs to reach the most moral solution for the particular case at a particular time. Some basic ethical principles, however, can help guide these decisions:
The principles above may seem difficult to reconcile. However, as caregivers become familiar with ethical theory, reconciling them will become less difficult. Caregivers should feel free to call upon ethicists to help with especially difficult cases, if ethicists are available in local communities. The institution's ethics committees can be helpful in setting policy guidelines as well as in thinking through individual cases. The Role of Hospitals and Other AgenciesEnsuring respect for patient privacy and confidentiality is not the sole responsibility of individual medical personnel. The institution as a whole must be committed to this approach, and administrators should institute policies and procedures that keep staff sensitized to confidentiality issues and that provide quality assurance in this area. Hospital administrations should
Case ExampleA case example may help to illustrate and clarify some of the points relating to the legal and ethical aspects of preserving the autonomy and confidentiality of patients who are hospitalized for traumatic injuries. Herman S is a 50-year-old male who is brought to the emergency department with injuries from a motorcycle crash. He is awake and aware enough to sign consent forms for treatment in the emergency department, which routinely includes consent for a urine toxicology screen. The screen is positive for cocaine; the BAC is 300 mg/dl. Herman signs the necessary forms to be admitted to the hospital. Because the results of toxicology and BAC determinations were obtained to help treat Mr. S's traumatic injury, this information can be included in his general medical chart and is not subject to Federal regulations. The following are the notes made in Mr. S's chart by the attending physician upon Mr. S's admission to the emergency department: Patient: Herman S Presenting problems: Blunt abdominal trauma, right fractured femur. Subjective data: Patient relates drinking the day of injury, denies alcohol problem; reports drinking for 10 years; two previous motorcycle crashes associated with alcohol intoxication. Objective data: Stable vital signs, decreased bowel sounds, tenderness in right lower quadrant with some rebound. Angry, belligerent responses to questions about alcohol use. BAC=300, urine positive for cocaine. Normal CBC and electrolytes; GGT = 190. Rectal exam: Hematest negative. Assessment: Fractured femur (R); alcohol intoxication; rule out abuse or dependence. Information pertaining to Mr. S's responses to questions about his alcohol use is included because it relates to the caregiver's suspicion that alcohol use may be a complicating factor in Mr. S's condition. The provider also believes that the information shows a behavioral baseline against which subsequent changes can be compared. Yet, note again that because the information about Mr. S's possible alcoholism is needed to manage the patient's presenting medical condition and was not gathered by staff whose primary function was providing AOD diagnosis, treatment, or referral, it is not subject to Federal confidentiality regulations and need not be treated differently from any other medical information. To be sure, there are medical reasons for determining on admission whether Mr. S is dependent on alcohol. Alcohol dependence will increase the risks involved with surgery, including increased risk of bleeding due in part to an enlarged liver, poor healing, and increased risk of wound infection.
The attending physician, Dr. G, comes to see Mr. S a day later. From the chart, Dr. G sees that the patient has a benign abdomen and a fractured right femur. The patient's mental status is such that information about possible alcoholism must be obtained because of the danger of withdrawal symptoms. But since this information is for medical management and is not being gathered by an AOD clinician for the purpose of introducing AOD services, it is still not protected under Federal regulations. Therefore, while Dr. G may well need to ask Mr. S a number of questions about possible alcoholism, he should carefully consider which answers, if any, should be in the medical record, because the information will be open to many parties. Mr. S is angry and hostile when asked about the possibility that he might have a "problem" with alcohol. He acknowledges that other people, particularly his sister, Peggy, have "pestered" him about his drinking, but claims that she does this because she is a "bitch" and tries to cover up some unspecified other behavior. Dr. G explains to Mr. S how alcoholism can affect the manner in which he is treated for his injuries, both in terms of the need to prevent withdrawal symptoms and to adjust dosages of pain medications. Mr. S refuses to talk to Dr. G about his drinking, saying "just do whatever you have to do to get me out of the hospital and leave me alone." Dr. G is concerned that the root cause of Mr. S's injuries will go untreated and would like to speak to Peggy S, the sister, to get information that can help him treat his patient. However, there are legal and ethical problems, as well as social problems. It is always useful to providers to remember that they do not know familial interactions, may do harm with information-seeking questions, and may receive questionable data. Further, legally and ethically, Dr. G cannot reveal information such as Mr. S's laboratory test results to Ms. S. And he needs Mr. S's consent to tell Ms. S his suspicions regarding the patient's alcoholism.
But after leaving the patient's room, Dr. G sees Ms. S in the corridor. She volunteers that the patient drinks a lot, that this crash was "just the latest in a series" of alcohol-related incidents, that Mr. S stays up late into the night drinking, and is usually passed out in the morning. She further says that both their parents were alcoholics, and that she has been after her brother for years to cut down or stop his drinking. She acknowledges that this enrages Mr. S who attributes her behavior to the fact that their parents preferred him to her, so she is "taking it out on him." Ms. S has raised the subject of the patient's alcoholism herself. Thus, Dr. G may freely pursue the extent of his patient's drinking to judge its depth and whether he may need to institute management to prevent withdrawal. Dr. G may ask Ms. S if she knows if her brother is using other drugs, but he should not reveal the results of the toxicology screen, which would violate Mr. S's privacy. Later that afternoon, Dr. G returns to Mr. S's room and asks how he is feeling. Mr. S complains that he is experiencing a lot of pain from his leg, particularly at dressing changes. Dr. G suggests that the dose of pain medication he is getting be increased and explains the importance of debridement (removing dead tissue) in order to prevent infection. He changes the dosage schedule to coordinate with dressing changes so that the maximum pain relief is achieved during that procedure. Dr. G has now shown Mr. S that his primary interest is in Mr. S's welfare and comfort, not in accusing him. This is an important step in building provider-patient trust, and developing a therapeutic bond. The vignette also illustrates another reason to look for information about patient AOD abuse, as these patients often need higher levels of medication for adequate control of pain. Dr. G visits Mr. S the next morning. He notes in the chart: "Abdomen is normal, patient is eating." His responsibility to Mr. S now centers on his alcohol intoxication on arrival in the emergency department. Dr. G tells Mr. S that Ms. S has talked to him about Mr. S's drinking, and that he responded with some questions, but did not reveal any information about his BAC or other test results. Mr. S becomes belligerent, asserting again that his sister has other motives for making these statements. Dr. G is accepting of this, saying he is not taking the statements at face value. He asks Mr. S about his other crashes and whether his BAC was checked then. Mr. S responds with a half-hearted obscenity, saying he doesn't know the answer to the questions. Dr. G waits quietly and Mr. S concedes that he had been drinking at the time of those incidents. He is vague about the amount. Dr. G tells Mr. S that more than half of motor vehicle crashes are linked to alcohol use. He tells him that continuing to drink is likely to lead to another crash. Mr. S is skeptical, saying he can take care of himself. Dr. G stops here to suggest that he send someone in to talk to Mr. S who can explain the effects of alcohol. Mr. S is still hostile, but grudgingly accepts the suggestion. From a purely medical standpoint, Dr. G needed only a minimal amount of information about Mr. S's alcohol use in order to manage his patient's trauma-related injuries. He kept to this minimal standard, knowing he could not adequately protect the information. However, more information was needed for him to determine whether an AOD abuse intervention might be appropriate. His probing for information at this point is not for the purpose of guiding medical management, but rather to attempt to get Mr. S. to acknowledge the problem and to present some options to explore it, as a means of protecting Mr. S's life and health.
Federal regulations governing confidentiality apply to the information gathered by the person Dr. G has suggested, who is one of the hospital's AOD clinicians. The clinician has specialized training and her primary function is to visit patients on various units and determine whether patients need AOD treatment. The next day, the AOD clinician visits Mr. S to discuss his AOD abuse problem. It is a difficult but finally productive meeting. Subsequently, when Dr. G visits Mr. S, he hears a report of feeling better emotionally as well as physically. Mr. S tells Dr. G about his long history of alcohol use, his failed attempts to stop, and his feelings of hopelessness. He now has some hope that it may be possible to stop, and although he feels frightened, he is considering going into treatment. Dr. G notes in the chart: "Patient has had a good talk with the AOD clinician. Assessment: Alcohol dependence; patient willing to go into treatment. Plan: work with AOD clinician to develop treatment options." Dr. G needs this information because it has a bearing on how he will interact with and care for his patient in the future. However, it would be a good idea to keep this information separate from the rest of Mr. S's chart, whether it is placed in a special, AOD-related section of the chart or kept in a secure, separate location (see Chapter 7). Only essential information should be recorded, even in this context. Dr. G now wants to talk further with Ms. S. It was evident to him during their first conversation that she also suffered the consequences of Mr. S's alcoholism, and he wants to talk with her about her concerns. The family's history is also sufficiently muddied by Mr. S's statements that he is concerned for Ms. S's health and welfare. He approaches her to see whether there is anything she might want to talk about in relation to her brother's drinking or in their interactions. Concern for family members, both for their own sake and for that of the patient, must be balanced with issues of confidentiality. A question could even arise about whether Ms. S is now a patient of Dr. G's. If Dr. G does not intend to take on Ms. S as an additional patient, his interaction with her can be couched in terms of Mr. S's aftercare, particularly if she is her brother's primary support person. Dr. G may need to determine, for example, whether she is able to provide the needed support for Mr. S and whether she understands what her involvement will be if he goes back to live with her after he is discharged. Dr. G may also inquire whether Ms. S is overwhelmed and unable to play this role, whether the long-established interaction with her brother is possibly destructive to both of them, and whether they would benefit from professional assistance. At this point, Dr. G has clearly stepped out of the role of medically managing Mr. S's traumatic injury. For this reason, it would be a good idea for him to record notes about this conversation -- if he decides to make any -- in Mr. S's chart in the section for information that is protected by Federal regulations. If Dr. G is concerned about Ms. S's problems for her own sake, he can let her know what her options are in case she needs and accepts support. If Dr. G feels responsible for looking at Ms. S's problems individually, however, then the question arises of whether or not she herself becomes his patient. At that point, his responsibilities to her include protecting her autonomy and confidentiality, as he has done for her brother. Does Ms. S acknowledge a problem and accept the concept of support for it? What are her views on the family's history and interaction? In this case, information pertaining strictly to her (for example, that she is emotionally stressed) should not be recorded in Mr. S's chart. Again, Dr. G must ask the question, "What information do I really need to medically manage this patient and to treat the problem?" This is the minimalist approach, well suited to protect autonomy, confidentiality, and provider-patient trust.
As an optional scenario, suppose Mr. S refuses to talk to the AOD clinician and checks out of the hospital against medical advice. Ms. S comes to pick up her brother at the hospital. Later, she calls Dr. G and expresses hopelessness about Mr. S's behavior and seems resigned to her role of taking care of her brother while putting up with his alcohol problems. In this case, Dr. G can present options to Ms. S, such as where to go for support, or can point out to her that she could let her brother fend for himself. If Dr. G wants to provide counseling or care for Ms. S, however, he must take her on as a new patient, with her own medical record and her own confidentiality issues. SummaryThe "raw materials" gained from screening tests and from patients in the form of information about their AOD use and abuse should be used for the maximum potential benefit of those patients. Because this information is necessarily gained at the cost of the patient's privacy and confidentiality, the benefits to be gained must be carefully weighed in order to determine whether they justify these impositions. In evaluating questions of how, when, and why to gather and disclose AOD-related information, caregivers should be guided by the tenet that the minimum amount is best and more is not better. The goal is good treatment, while protecting the patient from the real dangers of the breach of privacy and the loss of moral choices. Good stewardship of this information by those who have been entrusted with it is critical not only to protect patients' rights but also to strengthen the trust between providers and patients and to maximize the benefits of AOD treatment for individuals and for society. |
| ||||||||||||||||||||||||||||||||||||||||
| Initiatives | Funding | Home | ||||||||
|
Site Map
Help
Account
Cart
Home
