A 43-year-old woman with advanced non–small-cell lung cancer who has been undergoing treatment on and off for a year is admitted to the hospital with progressive pain and dyspnea. The patient’s disease is described as very advanced (“more tumor than lung”); however, the patient’s performance status has been relatively preserved. She works as a registered nurse in a medical-surgical unit. Her situation requires large increases in her opiate doses. She is adamant about her desire to go back to work and has told me that she plans to go back to taking care of patients against your recommendations. I feel strongly that her ability to practice is likely to be compromised by the opiates. What are my responsibilities to inform her employer that she may be putting patients at risk? Would this be an ethical or legal violation of her privacy?
Dr. Helft Responds
Paul R. Helft, MD
In order to reach some clarity about how to manage this situation, it is important to distinguish the medical ethical issues from the legal issues. With the caveat that I am not a lawyer and that any real legal advice should come directly from one’s own hospital counsel, the legal obligation with respect to this patient is to ensure that the details of your conversations regarding the limitations that apply to taking opiates are carefully documented in the record. In some instances, if an employee is on medical leave, he or she may be required to provide a physician’s statement indicating that he/she is cleared to return to work. If that is the case here, then I recommend that the clinical recommendations and limitations be documented on this form as well. The patient’s legal obligations are to ensure that when she goes to work she is able to perform the essential functions of her job. Clearly, HIPAA and the ethical duty to maintain confidentiality prohibit the physician from sharing the details of this patient’s medical condition with anyone the patient doesn’t want them shared with. In this case, I do not think the situation is directly analogous to situations in which a physician learns of an imminent harm (eg, a psychiatrist who learns that a patient has a plan to commit homicide); it is more a matter of professional judgment than an obligation to report a direct threat.
The ethical implications of situations such as this one can be usefully understood by thinking about our roles and obligations as physicians, and the limits thereof. We are not officials or members of law enforcement, and it is not our job to enforce professional sanctions. We must have our patients’ best interest at heart, however, and sometimes that means we must attempt to convince, cajole and persuade them to do the right thing, up to—but not including—the point of coercion or threats to reveal their information. Be sure you’ve allotted sufficient time to have an in-depth conversation with this patient about the dangers of working in high-stakes situations while under the influence of opiates. Perhaps share with her instances you are personally familiar with in which the effects of opiates had serious consequences, or discuss what the ramifications would be if she were to make a medical error—whatever tactic you think would be most likely to have an impact on her.
I think these are the proper actions here.
Disclaimer: The advice offered in this ethical consultation feature is based solely on the information supplied by readers, and is offered without benefit of a detailed patient history or physical or laboratory findings. The information is offered as a discussion of ethical issues and is not intended to be medical or legal advice and, therefore, should not be considered complete or used in place of a formal ethics consultation or in place of seeking advice from your ethics committee, legal counsel, or other available resources. One should never disregard or change medical advice or delay in providing it because of something that is printed here. The opinions expressed here are only those of the author and do not reflect the viewpoint of Cancer Network.
