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Patients with AIDS: Ethical Considerations for Nurses

A home-care nurse cares for a patient who has been diagnosed with AIDS. Recent visits, however, are related to a recent leg fracture. The patient knows of his AIDS diagnosis, but had decided not to inform his family members, whom he feels would not let him stay in their home if they knew of the diagnosis. The nurse is aware of the diagnosis, but has accepted and respects the patient's right to privacy and confidentiality.

Unfortunately, when the primary nurse is out sick for a few days, another nurse needs to cover this patient and was unaware of the patient's decision not to inform his family. While waiting for the patient to finish in the bathroom, the covering nurse asks a family member about the patient's next appointment with the HIV doctor.

The patient's right to privacy, confidentiality and disclosure has been broken. What can prevent such errors for community and public health nurses?

Safeguarding Information
"Protecting the privacy of patients and safeguarding information, which should remain confidential, is central to maintaining autonomy and avoiding nonmaleficence," said Carl A. Kirton, MA, RN, ACRN, ANP-BC, president of the Association of Nurses in AIDS Care (ANAC).1

Prevention would have been key to not having the problem described above. If the primary nurse had adequately informed the nurse covering the visit that the patient did not want to inform the family, the verbal mistake would not have occurred.

Education is key to minimizing damage; nurses will need to clearly define HIV/AIDS and modes of transmission, in order to decrease fear or insecurity. In the situation above, the agency would need to discipline the nurse involved, including possible termination. The agency should re-inservice staff about proper procedures,  and both the agency and involved nurses could face a lawsuit.

Both the nurse and the agencies involved with also need to own up to their mistakes and take responsibility for breaking the privacy and confidentiality of the client and be prepared to make possible monetary amends.

Understanding not only the basics of AIDS care, but also the statistics, legal/ethical considerations and cultural differences toward AIDS is crucial for community and public health nurses.

The community/public health nurse can assist in the management of the AIDS population by using a holistic approach to plan "care for the patient, the significant other and the family, as well as their interaction in the community" by focusing on primary care and prevention in both "well and at-risk individuals or those who have a potential need for health care services"1

The goals for this population would include support, maintenance of present physical condition and empowerment of self-care to properly use community resources that are available.

Legal/Ethical Considerations
Policies and procedures must be in place to protect patient privacy and confidentiality and to ensure high standards of cultural competence. Cultural competence is important, as there are a large number of minorities diagnosed with HIV/AIDS. Cultural differences in decision-making process can affect informed consent, according to Cynthia Woodsong, PhD, Family Health International, Research Triangle Park, NC.2 In many societies, it "is traditional for community representatives to influence decisions regarding a range of activities," which may be at odds with the concept of autonomy and may create "coercion, subtle or otherwise."

The four principles that "are commonly used by health care professionals in dealing with ethical and legal issues in HIV care" include: nonmaleficence, beneficence, respect for autonomy and justice.1 Nurses who deal with this population must take into consideration these ethical principles, while abiding by local, state and federal laws. The American Civil Liberties Union (ACLU) notes that discrimination against people with HIV/AIDS deprives them of their basic constitutional rights.3 This includes employment, housing and public accommodations, and the ACLU works to help people make informed decisions about testing and treatments.

Hard Facts
The 1980s were the starting point of a new, devastating disease: AIDS. AIDS developed into a pandemic that has had multiple effects on health care, culture and society in the United States and around the world.1 In the last two decades, AIDS has killed over 25 million people, with the largest number of deaths in sub-Saharan Africa, according to ANAC.1

Most newly diagnosed cases in the United States occur in people younger than 25 years, with nearly equal numbers of both men and women infected. The main difference lies in the ethnicity and racial groups, as 75 percent of new infections are in women of African-America or Hispanic backgrounds.1

The largest proportion of cases was found in large, metropolitan cities with "relatively large populations of gay men and. with relatively high prevalence of injecting drug users,"according to ANAC.1 This demonstrates the highest risk factors for transmitting and contracting AIDS. The CDC estimated that approximately 1.1 million people had HIV as of 2003, yet approximately 25% of those infected are unaware of their diagnosis as of 2006.4 This may be because there can be 8-11 years between exposure and onset of symptoms .

Frances A. Maurer, MS, RN-C, and Claudia Smith, PhD, MPH, RN, BC, both from the University of Maryland School of Nursing, Baltimore, reported that the true number of HIV-positive persons cannot be determined because "people do not want to know their HIV status" and are therefore not tested and because of the availability of home testing kits.5

According to the Philadelphia AIDS Statistical Update, in 2005 in the Philadelphia area, over 24,000 people were currently diagnosed with AIDS, but fewer than 900 new cases were diagnosed.6 The numbers of people who had died from AIDS and who were currently living with AIDS were nearly identical: 12,285 deaths, 11,980 living. Over 65 percent of those diagnosed were black, 23 percent were white, and 10 percent were Hispanic. Seventy-eight percent of cases diagnosed were in men, compared with 22 percent in women. Forty percent of those diagnosed were between 30-39 years of age.

Community Resources
The Bureau of Communicable Diseases, Division of HIV/AIDS within the Pennsylvania Department of Health  oversees "responsibility for numerous HIV prevention and care programs across the state."7 The department develops and implements "multi-dimensional, coordinated strategy to prevent disease and change high-risk behaviors, as well as provide resources and direction for sustaining preventive behavior and avoiding infection with he HIV virus."

In the greater Philadelphia area, the "AIDS Activities Coordinating Office (AACO) administers federal, state and city funded HIV/AIDS programs through collaborative service contracts with community-based organizations."8  It is responsible for planning and policy activities and conducting surveillance activities in accordance with governmental laws and requirements. AACO also oversees the epidemiological activities related to HIV/AIDS, including publication of quarterly reports and conducts HIV/AIDS education and training for professional, civic and community groups.

Linda Snyder is clinical case manager and wound care consultant for Keystone Home Health Services, Wyndmoor, PA.

Patients with AIDS: Ethical Considerations for Nurses

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On the Job Archives

See, it's so hard to know what is safe to say anymore. You don't know if it is alright to mention a diagnosis to a family member or even talk about a patient's situation in front of whoever is in the room with him or her. I take this approach "If I need to talk about something, I ask if it is alright to talk about personal information with the people that are in the room" before I get started talking. And if there is something VERY personal like a "HIV status or hepatitis or any other contagious illness," I again repeat my question before I get started talking about it. I may say something like this to my patient: "I need to talk to you about very personal information about your past medical history, can I do that now in front of everyone in the room?"

Daniel Salter,  RNJuly 08, 2008
Pensacola, FL


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