Monday, November 1, 2010

what is the ethical dilemma here? what principles are in conflict?

Losing Touch With the Patient
Published: October 21, 2010

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Several years ago I helped care for a man who had been hospitalized with a severe infection of the abdominal wall. When his primary doctors discovered that the bacteria responsible was resistant to most antibiotics, they quickly isolated him, moving him into a single room with a sign on the door proclaiming “Contact Precautions” and directing visitors to put on gloves, mask and gown before entering.
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But garbing up in all those items was not a straightforward exercise. The gowns, vast swaths of baby-yellow polyester, added an insulating and sweat-inducing layer. The masks were either so flimsy they fell off easily or so unyielding they muffled voices and steamed up eyeglasses. And the gloves had such generous finger pockets that the excess latex inevitably got tangled in the loops and ties of the gowns and masks or in the dressing materials and bedding of the patient.

None of these precautions made it easy to examine or even visit him. Most of us were loath to go through the process of gearing up more than we had to; and even his wife of more than 20 years occasionally groaned as she dutifully swathed herself in the protective coverings each day. As the weeks wore on, we clinicians found ourselves minimizing our interactions, designating one team member to suit up and complete the work needed or shouting out updates and questions to the patient from the sterile safety of the doorway.

Increasingly isolated in these ways, he began to withdraw from everyone except his wife. His once daily declarations that he was going to “beat this infection” became less vocal, dimming to whispers, then disappearing altogether. He stopped turning to face us when we called out to him, choosing instead to continue staring blankly at the ceiling.

As his lungs, heart and then kidneys began to fail, his room became crammed with life-support machines and metal poles and pumps metering out intravenous medications. The small space in which he was confined eventually became a space-age pastiche of beeping machines, plastic tubes and wires, and shrouded, faceless, hovering yellow figures.

When he finally died, from cardiac arrest, more than two months later, it was hard not to remember the weeks leading up to his death and to wonder about one thing. In trying so hard to contain the infection, had we lost sight of the person?

For nearly half a century, infectious disease experts and hospital epidemiologists have relied on various methods of contact precautions to contain increasingly widespread and often virulent multi-drug-resistant bacteria. These methods of infection control — hand washing, alcohol foams, physical isolation, gowns, gloves and sometimes masks and eye protection — are now a routine part of clinical life in hospitals across the country; up to a quarter of all hospitalized patients at any time are placed under such restrictions. But while contact precautions are generally not just accepted but expected by doctors and patients alike, what has not been acknowledged until more recently are the unintended consequences of such strict limitations.

In the current issue of The Annals of Family Medicine, Dr. Leif Hass, a family practice physician working as a hospitalist at the Alta Bates Summit Medical Center in Oakland, Calif., eloquently describes some of these repercussions. After he and his daughter recuperate from mysterious arm and leg infections caused by the drug-resistant MRSA bacteria, Dr. Hass suddenly finds himself reaching for gloves every time he sees a patient in the hospital. He is torn between his sense of duty to reach out, gloveless, to “the people most in need of touch” and a gripping and not entirely irrational fear that “hospital wards that had been so familiar now seemed like uncontrollable pools of pathogens.”

Such fear of contagion among physicians, studies have shown, can compromise the quality of care delivered. When compared with patients not in isolation, those individuals on contact precautions have fewer interactions with clinicians, more delays in care, decreased satisfaction and greater incidences of depression and anxiety. These differences translate into more noninfectious complications like falls and pressure ulcers and an increase of as much at 100 percent in the overall incidence of adverse events.

“There is a misperception that infections are the single worst adverse event that can happen in a hospital,” said Dr. Daniel J. Morgan, lead author of a recent review of these studies and an assistant professor of epidemiology and public health at the University of Maryland in Baltimore. “In getting overly focused on preventing one type of infection, we fail to see the overall picture for patients.”

What may help clinicians remain focused on the larger picture while still safeguarding patients and themselves from multi-drug-resistant bacteria are less restrictive but equally efficacious precautions. In two separate studies, researchers at the Medical College of Virginia in Richmond found that the rate of infection was identical whether health care workers wore gowns and gloves with only the patients in isolation or whether they wore only gloves with all patients.

“Wearing gloves when examining all patients may become the reality of clinical medicine,” said Dr. Gonzalo Bearman, lead author of both studies and the associate hospital epidemiologist at the Virginia Commonwealth University Medical Center in Richmond.

All of this research points to one eventuality: that some type of contact barrier is in our future as doctors and patients, even though, as Dr. Hass noted when I spoke to him this week, “there are times when an I.C.U. looks like an assembly plant in Silicon Valley.” And while physicians will be forced to rely less on touch and more on other communication skills like listening and acknowledging, the risk remains that the presence of these physical — and technological — barriers will further eclipse some of the most effective ways in which doctors can alleviate the suffering of their patients.

“We just have to make sure,” Dr. Hass said, “that in the age of technology and rapid reforms, some of our best tools for healing — simple things like touching people and telling them you care and making them feel you are there for them — don’t get lost.”


  1. While there are some very good points made in this article, the ethical dilemma here is the conflicting weights of duties. The doctors have a duty to the patient to provide him with necessary care and do all in their power to help him "beat this infection"; however, they also have a duty to themselves to not risk catching this deadly infection, as well as a duty to the community to not spread this infection. Unfortunately, the duty to the patient conflicts with the latter responsibilities. In order to give the patient the best quality care they can offer, the doctors must treat him without the proper safety precautions(masks, gowns, etc.). However, this contact with the patient could result in a spreading of the infection to the doctors, and possibly to others in the community. The doctors in this situation weighed their responsibilities and decided that the latter two were of more importance, though they required a very high price.

  2. Situations like this make it so difficult to decide on what the right thing to do really is. On one hand, I can understand the doctors hesitation to contact in order to not catch the disease themselves, but on the other hand, how can they watch a dying man sit in a bed all by himself with the feeling that nobody cares for him in the world. I found it extremely upsetting that even his wife found putting on the gowns and protective gear to be frustrating. I found that all of those people who felt that way and used it as a reason to not visit him were extremely selfish. They never even thought about how lucky they were to still be alive and healthy while he was suffering alone in a hospital bed. I think if the protective gear is such a big issue, then companies should start creating more comfortable and effective products. Isolating a patient, the way this man was, and not using ANY form of contact really kills any happiness, optimism, and most importantly relationship the patient has with the outside world. Doctors need to remember that one of their duties is to practice beneficence. So wouldn't making their own patient feel like an outsider and unworthy of care and happiness go against this idea of "doing good"? Caring for a patient involves both their physical AND mental health.

  3. This scenario reflects the great difficulty that physicians can face in deciding how to balance their duties and responsibilities to their patients, themselves, and society as a whole. A physician’s concern for their own health is certainly understandable but the problem arises when they allow the discomfort and difficulty of the examination process to interfere with their treatment of the patient. There is no justifiable reason for the lack of interaction between the patient and physician when the physician has access to the necessary gowns and gloves. Although, it could possibly be argued that the excessive time spent on the extra steps involved in the examination this patient could take away from valuable time spent with other patients. Physicians have the duty to not only help their patients but also to do no harm to their patients. Placing a man in isolation and then failing to provide him with relatively standard care and interaction, as it appears to have been the case here, is undoubtedly doing harm to the patient. Regardless of the fact that examining and interacting with the patient may have been a nuisance due to the need for gowns, masks and gloves, these doctors were obligated to provide him with better care than he received.

  4. This is a very difficult and frustrating situation to deal with. While physicians know that their jobs include compassion and caring for the sick they cannot seem "disgusted" by their patients. While physicians might not be disgusted some patients may perhaps interpret this fear of touching them without a certain barrier as "oh my doctor is grossed out by me and won't dare touch me without gloves." However, we all want to take care of ourselves and greatly reduce the risks of getting sick, which most of us every day people can easily do. But, when you are in a profession such as the medical field, things get a little complicated and situations like these arise. I personally understand completely where these doctors are coming from, especially if they have experienced first hand getting sick and risking dangerous outcomes because f contact with a certain patient- as had happened with the doctor and his daughter with the infection of MRSA. This is even worse because its not just the doctor being affected by his profession but his daughter also got infected with MRSA because of her father's contact with a sick patient. I do believe that the option to dress in various barriers such as the ones mentioned in the article should be an option for everyone and not have to be looked down upon. Patients should understand the risk that doctors face every day and some patients may also face this risk. For example if a doctor had seen a patient that was infected with something and then the doctor also got infected and went to see another patients who may also get the infection. So, patients should understand that if physicians chose to wear gloves or dress in barriers--it is for their safety and shouldn't feel bad about it. However, I also believe that for example the wife f the dying man shouldn't have to dress in all of these barriers if she didn't want to. In the end, it is her family, her husband, whom she has spent years with and if she doesn't feel the need to wear anything when going in to see him then she runs the risk of infection but should be allowed to do what she desires. For the case of this man, I do believe he deserved better care from his physicians and no need for them to only poke their heads in and treat him from the doorway. Whether a patient is sick with a dangerous infectious disease or just has something like a broken bone, everyone deserved equal care and good quality of care. This man was not delivered with proper care and this perhaps may have been the reason for his death. What the doctors should have done is protect themselves, dressing in however many latex layers they want in order to prevent infection, but still treat him as any other patient and give him the contact and care that he deserved.

  5. The ethical dilemma is that doctors must decide whether to put on adequate protection when visiting patients who have infectious diseases but at the same time losing the sense of touch with patients, which has an effect on patients’ health. The trade-off is the fundamental dilemma. The major players are the physicians, patients, those who care about the patients’ well-being and other healthcare professionals who have the possibility of taking care of the patient’s illness when it reoccurs. The principle of beneficence, the intention of helping others which is in the core mission of physicians, is in conflict with the principle of justice. The principle of justice requires all patients to be treated equally, whether they are infected with resistant bacterial infection or not. The consequence of not containing the affected individuals could potentially lead to the spread of microbes to other patients. The benefit of isolating, with the perspective of the community, far weights the harm of the community. Not having eye to eye distance conversations and unnecessary protection with the intention of islation will further eclipse some of the most effective ways in which doctors can alleviate the suffering of their patients.
    -Handi Wu