Ms. P is a 66-year-old female with a past medical history of chronic obstructive pulmonary disease, asthma, acute respiratory distress syndrome, and an acute kidney injury. She presented to the hospital with Covid-19 symptoms after having tested positive during a previous admission in the same hospital. After discharging from her initial hospital admission, she returned home. Less than 1 week after discharging, her symptoms worsened and she returned to the hospital.
Ms. P. lives in an apartment with several members of her extended family, including her daughter, several grandchildren, and her elderly grandmother. Ms. P reports that after discharging from the first admission, she returned to the apartment and self-isolated in one of the bedrooms. During this hospital admission, Ms. P reports that at least one of her grandchildren has already tested positive for Covid-19, but it is unclear when and how it was contracted.
According to the care team, Ms. P is now demanding to leave against medical advice (AMA). As per one member of the care team, Ms. P exclaimed, “I know this virus is going to kill me. I want to die at home where I am surrounded by my family.” She is aware the hospital has implemented a strict no-visitation policy due to the communicable nature of the coronavirus, but remains upset and frustrated her family is unable to visit. Although Ms. P's prognosis is poor, the team believes her best chance of surviving is to remain in the hospital under the care of trained medical professionals. More importantly, the team is morally concerned about allowing her to leave while still contagious and potentially endangering her family and the community.
Q: Is it ethically permissible to allow a patient who is Covid-19 positive to leave AMA and return to her family?
One of the core values in the United States medical system is the principle of autonomy, which provides for patient choice and control over their medical treatment. Included under the umbrella of autonomy is the option for patients to refuse any medical treatments and testing that are not consistent with their medical values and treatment preferences. This right can manifest in a patient choosing to leave the hospital and be discharged against medical advice (AMA). While AMA discharge cases often present ethical challenges in and of themselves, the ethical issues become drastically more complex when a patient's autonomy clashes with the interests of public health. Health care providers in these situations are confronted with the dual obligations (1) to promote patient values and (2) to protect third parties from harm and, depending on the severity of the illness, the threat to the public is prioritized, for example, providers often do not allow patients with active tuberculosis (TB) cases to leave the confines of the hospital even if requested.
In the case discussed previously, Ms. P has expressed a clear and intentional desire to leave the hospital. She is convinced that Covid-19 will certainly kill her and prefers that her final days are carried out at home surrounded by family rather than in the hospital. Ms. P recognizes that she is removing herself from the care of medical professionals who are best equipped to treat the virus, or at least offer therapies and medications to reduce suffering and maximize comfort. Moreover, she understands that leaving AMA in her current state will undoubtedly result in her death. Under ordinary circumstances, respect for patient autonomy would mandate that Ms. P's value to be surrounded by family and preference to leave AMA must be honored and respected.
However, given the nature of Covid-19, a highly contagious and potentially life-threatening virus, allowing Ms. P to leave AMA, poses a significant ethical challenge for the care team. First, as with many AMA discharge cases, Ms. P poses a threat to herself. She had already discharged from the hospital once and her symptoms significantly worsened, requiring her to readmit. Second, by returning home, Ms. P poses a threat to the public, especially those who come into contact with her, namely her family. Although Ms. P has demonstrated some effort to self-isolate (quarantining in one room of the apartment), she poses the greatest threat to the several family members who live with her as they will likely be tending to her and caring for her. While understandable that she wants to be surrounded by family, Ms. P threatens to expose and harm the people she loves most by returning home. Although the care team certainly has a duty to respect the autonomous rights of their patient, they also have a responsibility to protect and promote the health of the public.
Before Ms. P leaves AMA, a member of her care team should feel empowered to use a few techniques to better understand Ms. P's perspectives, elucidate her values, address questions, and either persuade Ms. P to remain in the hospital or identify a discharge plan that maximizes her safety while protecting the public. First, a member of the care team should engage in a discussion with Ms. P about her understanding of her condition and prognosis; encourage Ms. P to ask questions about her illness and explain why she thinks returning home is her best option; next, explore Ms. P's values, preferences, and goals. Ms. P has already expressed she believes there is no prospect of survival. Perhaps if she learns a chance of survival exists, albeit a low one, she may feel encouraged to continue with treatment in the hospital. Third, Ms. P should be reminded that the care team respects her autonomy. At any point during her hospitalization, if she does not want to do something, her wishes will be respected and honored. Next, inquire if Ms. P is amenable to staying in the hospital at least one more day. Include the caveat that each day a member of the care team will reevaluate next steps and goals of care with her. Finally, if she is agreeable, describe short-term goals and the anticipated care plan, including medications, risks, benefits, and potential complications.
Should Ms. P persist in her wish to leave AMA and refuse to inform her family of her positive Covid-19 status, there are additional ethical responsibilities/steps that the care team should take to mitigate avoidable harms. The responsibility to inform third parties over the objection of a patient to avoid potential preventable harms is ethically supportable in other infectious diseases such as HIV and TB. While the novel coronavirus is different from the previous examples, an analogous ethical analysis can be appropriately applied. Should a medical professional encounter this dilemma, it would be ethically supportable to not only notify the public health department, but also to inform third parties of the patient's Covid-19-positive status as well as steps they can take (such as wearing a mask and maintaining social distancing) to best prevent exposure. Disclosing to third parties in these contexts is justified when the harm to be avoided by the unauthorized disclosure outweighs the patient's values, namely trust in the health care system and autonomy. As in other communicable situations, this justification hinges on there being an identifiable third party at risk, disclosure will avoid or mitigate the harm, and the provider would do the same in all similar situations.