Case Study: Should We Protect Families from Patients?

Abstract

Mary B, a twenty-three-year-old woman with a history of HIV, was admitted to an urban teaching hospital with a diagnosis of normal intrauterine pregnancy (35 weeks), Pneumocystis carinii pneumonia, sepsis, and hepatitis B. Upon admission, the patient complained of lower back pains, shortness of breath, and nonproductive cough. A physical exam indicated that both lungs were infected. A chest x-ray was ordered, and a skin test and three AFBs (a laboratory test to identify the presence of bacteria in sputum) were ordered to rule out the possibility of tuberculosis. Shortly after admission, Mary B was having contractions every three to four minutes, and fetal monitoring suggested slight signs of fetal distress. The patient was started on AZT and acyclovir IV, and preparations were made to proceed with a C-section because she was known to have active herpes. The NICU was informed. Within three hours after admission, the patient experienced increased difficulty breathing and was placed on oxygen, but continued to deteriorate rapidly. Half an hour later she had no heart beat or respiration. The patient received chest compressions, was intubated in the labor room, and was brought to the delivery room with full code in progress. The infant was delivered with a slow heart beat and died despite resuscitative efforts. Mary B was pronounced dead shortly after the delivery of the infant. Fifteen relatives and friends arrived at the hospital two hours after the patient's admission. Only one relative, an aunt, was aware of Mary B's HIV status and the seriousness of her medical condition. Other relatives and friends came only to celebrate the birth of the baby. When informed of the death of the patient and the infant, several family members became extremely emotional. One relative threw herself onto the floor; other family members wandered into restricted areas of the hospital. One relative hyperventilated, passed out, and was treated in the emergency room. Several family members insisted on viewing the woman's body. The deceased baby was transferred to the NICU. The patient was placed on a gurney in the labor room. Her face, arms and upper body were washed, and a blanket was tightly wrapped around her body leaving only her face and neck exposed. Three female relatives entered the room to view the body. A nurse and chaplain were present. Family members touched, kissed, and embraced the body of the patient, causing the blanket to unwrap. After a few minutes, the nurse and chaplain left the room to give family members privacy with the deceased. Should the health care team have insisted that family members and friends use universal precautions? Perhaps even told them of Mary B's HIV status to protect them from exposure? commentary by Florence Gelo To minimize risks of infection from exposure to contaminated blood and body fluids, universal precautions are required by the Occupational Safety and Health Administration for all clinicians. However, no practices of risk management are mandated to protect family members who may be at increased risk of contracting a communicable disease. The case cited above presents a vivid example of such potential risks. Mary B's death was sudden and unexpected. Those family members who were present for the birth of her child had no indication that she and the infant might die during childbirth. Furthermore, they were unaware of her infectious state and of the risks they might encounter if exposed to her blood or body fluids through percutaneous exposure. Those who are bereaved due to a sudden or traumatic death are in a state of numbness and disbelief and are often unable to grasp the full reality of death of a loved one. They may be filled with overwhelming emotions and doubts. When family members ask to view the body of the deceased, they almost always do so in order to pray, to grieve, to wrestle with the fact of the loss. …