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03/03/2017

BioethicsTV: Communication Challenges

by Craig Klugman, Ph.D.

Chicago Med (Season 2, Episode 15) focused on problems with communication These ranged from offered a guide to when not to work with the media, violating HIPAA, to talking to students about dangerous treatments.

Violating HIPAA

One regulatory issue crosses several storylines this week: As I was watching, my spouse pointed out multiple violations of HIPAA. In the waiting room, the desk clerk calls patient’s names out loud when their turn to be seen arrived. My physician-spouse felt this was wrong and that most hospitals would have assigned patients a number to preserve confidentiality. In a second instance, a man who brings a woman into the ED after she collapses on the street (an apparent stroke) asks about her condition. Although one might think he deserves to know the end of the story that he helped initiate, doing so violates that patient’s confidentiality and HIPAA.

A third violation is more accidental, but avoidable. When a nurse faces a tragic loss of her fetus’s heartbeat she schedules a D&C. Her co-worker and friend happens to be dropping off records in that clinic when the calls comes in and she sees the appointment being entered into the computer. Hospitals can take efforts to preserve confidentiality using privacy screens on computers, identification codes instead of names for patients, and more. But if the staff looks at the screen when it’s not their unit or patient, then these efforts do not amount to much. Wanting to know is a human reaction. We are creatures motivated by our curiosity. But true confidentiality requires not looking where one is not supposed to.

Hope and Stem Cell Treatment
In one storyline, a patient suffering from an infection is brought to the ED by his spouse. After a car accident he is paralyzed and he has been going to Mexico for stem cell therapy in the hopes that his spinal cord will regenerate. His infection is from an abscess, likely the result of the injections. At $30,000 a treatment, they have so far seen no improvement. Dr. Choi tells the patient how dangerous this path is: Not only from the risk of infection but also that stem cells can become any tissue of the body and even cause tumors. Nevertheless, the patient insists on continuing, not because he thinks he will benefit, but because his wife has such hopes pinned on a treatment that could help him to walk again. He says that he is willing to risk his own health in order to keep her hope alive.

In real life, patients do choose risky, expensive treatment. They may engage in medical tourism—traveling to other countries to receive treatments that are unapproved in the US and even unproven anywhere. They do so in order to chase hope, to keep the possibility of cure alive. In a classic work, psychologist JC Holland says that patients seek such interventions to deal with their anxiety and “when the patient senses the doctor has “given up” and has “nothing more to offer.” The possibility of cure is low, but the desperate need for hope, to try “something,” outweighs accepting the current condition and doing nothing. It is a search for the miracle that so many patients want and expect. In regards to stem cell treatment, the FDA has not yet approved clinical stem cell use.

Allowing Natural Death
The second storyline concerns a window washer whose platform breaks and he plunges 33 stories to the ground. Amazingly, he is not dead and is brought to the ED where he undergoes multiple emergency surgeries (internal bleeding, brain swelling). Dr. Rose makes the decision that he is going to save this patient “He didn’t fall 330 feet just to die in my trauma bay.” Two interesting ethical issues arise out of this. The patient codes but has no electrical activity in his heart. In front of the patient’s parents, Rose opens his chest and directly pumps the heart by hand. He is able to re-establish a heartbeat. The parents’ reaction is not to pursue further aggressive treatments; they saw “the resuscitation was so violent.” They showed a picture of their son rock climbing and insinuate that this is the kind of active life their son would want. The viewer can tell that Rose does not want to listen to them. The administrator overhears this conversation and she says to him “I wanted you to be the hero today. But maybe it’s time to stop.” When the patient codes again, he dies without resuscitation.

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