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Principles of Oral Health Management for the HIV/AIDS Patient

Principles of Oral Health Management for the HIV/AIDS Patient. A Course of Training for the Oral Health Professional.

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Principles of Oral Health Management for the HIV/AIDS Patient

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  1. Principles of Oral HealthManagement for the HIV/AIDS Patient A Course of Training for the Oral Health Professional Made possible from a grant to the New York State Department of Health AIDS Institute from the HIV/AIDS Bureau, Division of Community Based Programs, Health Resources and Services Administration, DHHS

  2. Dental Care for People withHIV Infection: Legal Issues Mark Rubin, LLD The legal information contained in this section is current as of September 1999.

  3. Are The Lives Of • Prison Inmates In Alabama • More Valuable Than • The Lives Of Dental Workers • In Maine???

  4. PRIMARY LEGAL CONSIDERATIONS • CIVIL RIGHTS/DISABILITY • “MALPRACTICE”

  5. COMMON THREADS • HIV-infected patients can be safely treated in the private dental office • Infection control works; universal precautions are efficacious • Dentists are (probably) treating HIV-infected patients whether they know it or not

  6. LEGALLY “SAFEST” APPROACH • TREAT • TREAT RIGHT

  7. RISK MANAGEMENT APPROACH • Treat HIV-infected individuals like other patients • Like patients with other infectious diseases or chronic conditions • DOCUMENT

  8. CIVIL RIGHTS/DISABILITY LAWS

  9. BRAGDON V. ABBOTT • FIRST UNITED STATES SUPREME COURT CASE ON: • The Americans with Disabilities Act • HIV/AIDS

  10. CIVIL RIGHTS/DISABILITY LAWS • FEDERAL LAWS • STATE AND LOCAL LAWS

  11. FEDERAL LAWS -- Americans with Disabilities Act -- Rehabilitation Act STATE and LOCAL LAWS Civil Penalties Injunctive Relief Attorneys Fees ($$$) Similar, plus exclusion from program participation Similar, plus monetary damages CIVIL RIGHTS/DISABILITY LAWS

  12. “…If you feel you have been discriminated against in the provision of dental care because of your HIV and/or AIDS status you should call the Department of Justice in Washington, D.C. at 1-800-514-0301.”

  13. NOT TO MENTION

  14. DEFINITION OF “DISABILITY” • Actual Disability • "a physical or mental impairment that substantially limits one or more of the major life activities of such individual.” • Record of Actual Disability • Regarded As Having A Disability • This can include other • infectious diseases (HIV/Hepatitis/TB…)

  15. THE SUPREME COURT ON “DISABILITY” • Individualized determination • substantial limitation, not utter inabilities • “Correctable disabilities" • disability determined with reference to mitigating measures • Safest bet today: treat HIV as a disability • some impairments may invariably cause a substantial limitation of a major life activity

  16. DISCRIMINATION • “No individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages or accommodations of any place of public accommodation…”

  17. DISCRIMINATION(con't) • Denial of participation, participation in unequal benefit, provision of separate benefit… • Integrated settings • “Associational” discrimination

  18. PLACES OF PUBLIC ACCOMMODATION “…Professional Office of a Health Care Provider…”

  19. SOME COMMONLY ASKED QUESTIONSABOUT HIV ANDCIVIL RIGHTS/DISABILITY LAW

  20. CAN RISK OF TRANSMISSION JUSTIFY A REFUSAL TO TREAT? • What is the risk? • Efficacy of Universal Precautions

  21. “DIRECT THREAT” • “…a significant risk to the health and safety of others that cannot be eliminated by a modification of policies, practices, or procedures or by the provision of auxiliary aids or services…” • NOTE: Burden of proof

  22. “DIRECT THREAT”(con't) • General rule: No direct threat • (for routine care of HIV patients) • No case law yet for complex cases and/or AIDS care

  23. “DIRECT THREAT”(con't) • "We thus hold that when transmitting a disease inevitably entails death, the evidence supports a finding of 'significant risk' if it shows both (1) that a certain event can occur and (2) that according to reliable medical opinion the event can transmit the disease. This is not an 'any risk' standard: the asserted danger of the transfer must be rooted in sound medical opinion and not be speculative or fanciful. But this is not a 'somebody has to die first' standard either: evidence of actual transmission of the fatal disease is not necessary to a finding of significant risk."

  24. INFECTED PROVIDERS • The Legal Wildcard? • Early Case Law • A pending case against a hygienist

  25. LIABILITY FOR STAFF REFUSALS • Front desk “mistakes” • The unwilling team member • equal services? • employment law questions • Note: personal liability

  26. PATIENT CARE ISSUES • Inquiring about a patient’s HIV status • Mandatory patient testing • Extra precautions • Special scheduling • Common theme: • professional judgment or pretext?

  27. REFERRALS • Oral health professional does not have a duty to treat beyond area of expertise • Same referral for non-HIV positive patients with similar conditions? • Beware the referral for “specialty” HIV dental care • -- dental basis or pretext? • -- what is the “specialty”? • -- is this a referral or a refusal?

  28. THE NON-COMPLIANT PATIENT • Compliance • Patients who “lie” about their sero-status • Patients who miss appointments • Common Themes: • Generally applied policies? • Reasonable modifications of policies, practices and procedures?

  29. “MALPRACTICE”

  30. PRACTICAL CONSIDERATIONS • Damages like any other malpractice case? • “Then” and “now” -- combination therapies, protease inhibitors, etc.

  31. ABANDONMENT • Refusal to treat • is more than a discrimination issue

  32. CONFIDENTIALITY • Same protections afforded to all patients • Plus specific state protections re HIV status • Common Concerns: • Staff • Record keeping • Consulting with physicians • Other third parties (e.g., insurance carriers)

  33. DIAGNOSIS • Malpractice risk • failure to timely diagnosis or refer to a physician • scope of practice issues (oral versus systemic) • misdiagnosis • Risk management considerations • take good histories • always look for malignancies/infections, etc. • Stay within the scope of dental practice

  34. COORDINATE WITH PRIMARY CARE TEAM • There exists a malpractice risk if you fail to do so, when needed • Do so for patient care--not to discriminate or delay treatment • Follow state law, e.g. consent

  35. TREATMENT • Most oral care can be provided by any competent dentist • Malpractice Risk • Refusing to treat for inappropriate medical reason • Providing treatment that patient cannot tolerate

  36. TREATMENT(con't) • Some Risk Management Considerations • Follow recommended guidelines (CDC/ADA) • Provide care based on medical/dental status • Coordinate care with physician if/when appropriate • Analogy to other medically compromised patients • Refer (for “specialty” care) only on a scientific basis • Document rigorously

  37. THE INTERFACE BETWEEN MALPRACTICE AND DISABILITY LAW • For malpractice purposes, treat and treat properly • Note discrimination risk with any other assumption

  38. “SAFEST” LEGAL MODEL • Treat HIV-infected individuals like other patients • Treat like patients with other infectious diseases or chronic conditions • Good, science-based practice is best for you and your patients • Document • Keep abreast of scientific and legal developments

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