End informed consent, but restrict some workers

A new national policy for dealing with HIV-infected health care workers was called for recently by Larry Gostin, JD, LLD, director of the Center for Law & the Public’s Health at Johns Hopkins University in Baltimore, and professor at Georgetown University Law Center in Washington, DC.¹

In calling for a change, Gostin listed five recommendations that would respect health care workers while ensuring patients receive safe care. The recommendations are summarized as follows:

1. Establish a program to prevent bloodborne pathogen transmission. Health care organizations should be responsible for planning, implementing, enforcing, and evaluating effective strategies for pre-vention of bloodborne pathogen transmission. Prevention programs should include policies and procedures for: standard (universal) precautions such as gloves, gowns, and face protection); re-processing patient-care equipment and cleaning environmental surfaces; infection control training; prevention and management of infectious conditions (e.g., HBV vaccination); injury and exposure prevention during surgical, obstetric, and dental procedures such as less invasive alternatives to conventional interventions (e.g., laparoscopy), practice changes (e.g., "no touch" techniques and double-gloving), and safer instruments (e.g., blunted suture needles and use of staples instead of sutures); and surveillance for transmission of bloodborne pathogens (e.g., reporting and evaluating parenteral injuries).

2. Outline responsibilities of infected health care workers. As professionals, health care workers have ethical responsibilities to promote their own health and well-being and to assure patient safety. They should learn their serological status through testing with informed consent. Infected workers should seek medical care and treatment, including ongoing monitoring of viral load, as well as evaluations of physical and mental health status. Health care workers are responsible for notifying patients and hospitals in all cases of significant exposure to their blood.

3. Discontinue expert review panels and special restrictions for exposure-prone procedures. Identifying infected physicians, requiring expert review panels, and adopting special restrictions for exposure-prone procedures have served to single out and stigmatize health care workers. The term "exposure-prone procedure" has not been clearly defined, so the courts have erred on the side of restricting worker practice. The requirement to disclose a health care worker’s serologic status to patients has rendered expert review panels virtually irrelevant since few patients are willing to be treated by an infected worker. Review panels, therefore, should be replaced by expert consultants who would be available for advising about the worker’s health and patients’ safety, but not empowered to restrict practice.

4. Discontinue mandatory disclosure of a health care worker’s infection status. Health care workers may feel morally obliged to voluntarily notify patients of their infection status, but the law should not require disclosure of very low-level risks. HIV, in particular, is a highly personal, and sometimes stigmatic, health condition that usually has little relevance to patient safety. Because notification represents an invasion of privacy and may result in loss of livelihood, it should not be legally mandated.

5. Impose practice restrictions to avert significant risks to patients. Public health authorities owe a public duty to assure patient safety. Consequently, health care organizations and/or public health authorities should issue practice restrictions if a health care worker:

• suffers from a physical or mental impairment that affects his professional judgment or practice;

• has exudative lesions or weeping dermatitis;

• has a history of poor infection control technique and practice;

• has had an incident of transmission of a blood- borne pathogen.

Reference

1. Gostin LO. A proposed national policy on health care workers living with HIV/AIDS and other blood-borne pathogens. JAMA 2000; 284:1,965-1,970.