Ethical Considerations

Many ethical considerations are involved in testing and treatment of HIV-infected patients. While emotionally driven sentiment has advocated on-site emergency department HIV testing, there is no rationale at this time for widespread emergency-department-based testing. Many departments have adopted strict policies against such testing due to the difficulties of ensuring adequate confidentiality, follow-up, and counseling. However, emergency-department-based voluntary HIV screening and counseling programs may play an important role in the national strategies of early HIV detection in the future, due to limitations of health care access for many at risk.29 At present, recommendations for testing and referral to designated test sites should be made when indicated.

Confidentiality regarding HIV-related diagnoses is paramount in providing appropriate care. Treatment without discrimination, as with all disease states, should be initiated in all patients unless they specifically request otherwise.

Resuscitation of patients with advanced AIDS is a controversial subject, but in reality, decision making is no different than for other debilitating conditions. Since emergency department physicians often have limited information about individual patients, their wishes, and the state of their disease, it is recommended that appropriate therapy and resuscitative measures be undertaken unless advance directives are available. There is, however, a growing consensus not to undertake "futile" resuscitation. Care should be taken that the label HIV or AIDS does not bias the judgment that resuscitation is futile. Contact with a patient's primary care physician and family early during the emergency department stay helps in decision making about care.

Management of patients with possible sexual, injected drug use, or other nonoccupational exposure to HIV has become relevant since the US Public Health Service issued a recommendation for the use of antiretroviral drugs to reduce the risk of acquisition of HIV following occupational exposure (see below). 30 The CDC has withheld making definitive statements regarding postexposure prophylaxis (PEP) for nonoccupational exposures because of the lack of data available regarding the use of antiretroviral agents in this setting. PEP must therefore be considered on a case-by-case basis and should generally be restricted to situations in which the risk of infection is high, the intervention can be initiated promptly (<36 h), adherence to the regimen is likely, and the individual is most likely to maintain risk-reduction behavior over time.31 Advantages of therapy must also be carefully balanced with the risk of medication side effects. In the emergency department, when the physician is faced with a case in which PEP is being considered, the assistance of experts should be sought. Risks and benefits of therapy should be considered in consultation with an infectious disease specialist and the patient's primary care provider. The CDC has a 24-h telephone hotline for physicians designed to assist with appropriate initiation of PEP (PEP Hotline 1-888-448-4911).

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