We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place.

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Case #23 (see below for responses)

After languishing on a floor for several weeks, the chaplain was asked to visit a patient to see if a chaplain intervention could help move the case along. The patient was a female in her late-50's and was non-compliant with the course of treatment she was receiving. She had difficulty expressing herself in general, was somewhat disoriented/overwhelmed by the hospital, and the chaplain was not fluent in the patients’ native language, but concluded from the initial visit that in some ways she felt it was better to have an extended (endless?) stay in hospital than the alternatives. She was living with her elderly mother, but was ineligible for psychiatric or physical treatment at home because she was not a legal U.S. resident. With the help of social work we pieced together the fact that her husband had dumped her in this country with her mother and then flew back home with her passport. The patient has a brother in this country but he was not willing to get involved in the case.

The Social Worker wondered if the chaplain could contact the clergy of the mother or brother and perhaps ask their community to raise some funds to send the patient back to her home country, or possibly ask the clergy to speak to (or shame?) the brother into coming up with the finances himself.

Knowing the community she belonged to, the chaplain was fairly sure that an intervention of this nature (i.e. speaking to the family's clergy) would work.

Assuming this is a HIPAA violation, does the end justify the means?

Responses:

Are there any interpretation services offered that would help clarify the situation? If the patient gives permission for the hospital to talk to clergy, then it would not be a HIPPA violation. I think getting her faith community involved would be helpful in finding options for better care.

Jonathan Scott, Chaplain
Day Kimball Hospital
Putnam, CT

This case illustrates some necessary procedures that seem to be missing. How was a patient kept for several weeks without active intervention using an interpreter as well as regular visits from the staff chaplain? How is it possible to be non-compliant for treatment and remain hospitalized?

What is in this woman’s best interests? With her permission, her embassy may be able to assist in passport needs, her own clergy can assist with resources from their community, family can be educated about needing to be involved. In the meantime, there are other resources to help the woman with living better, making better choices. The problem is not stated, but an appropriate 12-step group may be one place to begin.

The problem was to be a HIPPA concern. Belated concern for this person in crisis may be more of an ethical issue.

Deborah Heen, NACC, BCC
Chaplaincy Services
Avera Queen of Peace
Mitchell, SD

I wonder if I might suggest rephrasing the posed question to read, "Assuming this is a HIPAA violation, is it worth compromising my covenant with my employer and losing my job?" We have an ethical and legal obligation to abide by HIPAA regulations and to advocate for their adherence. The ethical principal involved here is patient autonomy that includes patient rights and self determination.

I can not imagine why a chaplain would think about such violation for the sake of a "length of stay" concern. In my thinking, Case Management functions to reduce length of stay. Social Work functions in part to establish social history, family functions, and to develop a discharge plan that utilizes community resources. Chaplain functions include helping to discover and to support the essential person who happens to be our patient at this time. Discovery includes establishing a method of functional communication (translator), and establishing if there is functional decisional capacity. Even if the patient is not able to give consent to involve outside persons and agencies, there is family (her mother) who could.

In my thinking, the main problem here is not the complexity of this case; it is the confusion about the roles and functions of the hospital chaplain as part of the interdisciplinary team.

Stan Dunk, M.Div., BCC
Director of Pastoral Care
The Fort Hamilton Hospital
Hamilton, OH

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