Ethics Grand Rounds
Wednesday, December 20th, 2006
Clinical Case Vignette presented by: Orna A. Kleiman, M.D.
CC: 35-year-old Caucasian male who was found unconscious in his apartment. HPI: The patient was in his usual state of good health until 2 days prior when he started “not feeling well” per his friends. He was not specific regarding his symptoms. He was neither seen nor heard from until the day of admission when he was found unconscious on the floor of his apartment by a friend. The exact length of time he was unconscious was unknown.
Meds: “Herbal Medications”
All: NKDA
Soc: Occasional alcohol, no recreational or illicit drug use
Physical Exam
Gen: Unconscious and unarousable, spontaneously breathing VS: 98.8 HR 68 BP 112/88 RR 15 100% on RA HEENT: pupils 6mm and slowly reactive Skin: icteric
Labs:
WBC 6.2, Hemoglobin 11.9, Platelets 100 AST 45 ALT 39 T.Bili 15, D.Bili 4.2, Albumin 3.0 LDH 914, NH3 90, PT 18.3 Acetaminophen normal Salicylate normal Urine Tox negative
Radiology
Non-Contrast Head CT: No acute bleed or masses
Liver U/S: Normal sized liver with heterogeneous echotexture, patent arterial/venous system, and normal spleen visualized.
Preliminary Diagnosis
• Altered Mental Status: Differential Dx
– Hepatic encephalopathy vs toxic metabolic
• Fulminant Liver Failure: Differential Dx:
– viral vs toxic
Hospital Course
• The patient was intubated for airway protection and started on IV fluids and lactulose via oralgastric tube. • The patient developed progressive liver failure of undetermined etiology. Repeat abdominal ultrasound showed splenomegaly. Hep A IgM, HBsAg, and anti-HBc IgM were negative. • Transplant service notified. Transplant work-up was initiated.
The Dilemma
• Pt will likely die without liver transplantation
– Mandates HIV status documentation – Pt unable to consent for HIV test – No official health care proxy designated.
• Public Health Law 2780, Article 27F states:
Except as provided in section three thousand one hundred twenty-one of the civil practice law and rules, or unless otherwise specifically authorized or required by a state or federal law, no person shall order the performance of an HIV related test without first receiving the written, informed consent of the subject of the test who has capacity to consent or, when the subject lacks capacity to consent, of a person authorized pursuant to law to consent to health care for such individual.
http://public.leginfo.state.ny.us/menugetf.cgi
Patient was tested for HIV and was HIV Ab negative. He was transferred to Tisch Hospital for liver transplantation. However he developed status epilepticus the day after transfer and transplantation was canceled. Subsequently, serologies for Hep B returned positive. His care was withdrawn and the patient expired.
Final Diagnosis
• Acute Liver Failure due to Hepatitis B infection