Patient’s Confidentiality

Case Study: Confidentiality and Teen Pregnancy

Yasmine Kamal is a 14-year-old high school student. She is being treated for major depressive disorder at an outpatient mental health facility. She currently sees a psychologist for weekly therapy sessions, but has made little progress. The psychologist refers her to the psychiatric nurse practitioner (NP) to determine whether antidepressant medication might be beneficial. The patient and her mother discuss the issue with the NP, and they all decide that a trial of a low-dose antidepressant is warranted. Prior to prescribing medication, the NP orders routine laboratory work according to the facility’s protocol, which includes a pregnancy test for any female of childbearing age. The laboratory results are all within normal limits, and the pregnancy test is positive. The law of the state in which the case occurred requires written permission from any patient age 14 years and older to discuss information with a parent. Yasmine has not signed the permission form. On the follow-up visit, the NP sees Yasmine alone and explains the results of her pregnancy test. Yasmine bursts into tears and begs the NP not to tell Mrs. Kamal, Yasmine’s mother. The Kamal family is of Egyptian descent and very active in their church. They believe it is important that a girl remain a virgin until marriage. Yasmine feels that she cannot face her parents, and that it was a one-time consensual sexual encounter with her boyfriend. She is ashamed and does not know what she wants to do. The NP calls in the psychologist and they discuss with Yasmine the pros and cons of Yasmine telling her mother about her pregnancy, but Yasmine still insists that she does not want her mother to know yet. The NP explains that she will not prescribe an antidepressant at this time, and that it is extremely important that Yasmine continue to see the psychologist to discuss her options, and to continue psychotherapy to treat her depression. Yasmine promises that she will keep seeing the psychologist. After determining that Yasmine is not in danger of harming herself, the NP and psychologist agree that she can leave after making an appointment to see her the following week. The NP and psychologist discuss the case and decide that they should meet with the facility’s medical director for further advice. The next day, there is a phone message for the NP from Mrs. Kamal inquiring why Yasmine did not get an antidepressant prescription.

Discussion Questions

1. How did the NP and psychologist respect the patient’s confidentiality?
2. Is discussion of the case with the medical director a breach of confidentiality? Why or why not?
3. How can the NP and psychologist maintain a trusting relationship with both Yasmine Kamal and her mother without violating confidentiality?
4. How should the NP respond, with honesty, to Mrs. Kamal’s question regarding why no antidepressant was prescribed?

1. The NP and psychologist respected the patient’s confidentiality by initially seeing Yasmine alone to discuss the positive pregnancy test result. They provided Yasmine with a safe and confidential space to share her feelings and concerns without involving her mother initially, as required by state law. They also engaged Yasmine in a discussion about the pros and cons of disclosing the pregnancy to her mother, allowing her to make an informed decision about sharing this sensitive information.
2. Discussion of the case with the medical director is not necessarily a breach of confidentiality. Healthcare professionals often consult with their colleagues, supervisors, or other members of the healthcare team to seek guidance and advice in complex cases. In this situation, seeking advice from the medical director is a responsible and ethical decision, as it can help ensure the best possible care for the patient. However, the NP and psychologist should ensure that they do not reveal Yasmine’s identity or any other identifying information when discussing the case with the medical director to maintain confidentiality.
3. To maintain a trusting relationship with both Yasmine Kamal and her mother without violating confidentiality, the NP and psychologist can consider the following approaches:
   • Continue to respect Yasmine’s autonomy and right to privacy regarding her pregnancy status, as she is of the age of consent in the state.
   • Encourage open communication with Yasmine, allowing her to express her feelings and concerns about involving her mother.
   • Provide Yasmine with information about her options regarding the pregnancy, including discussing potential ways to address the situation with her mother when she feels ready.
   • Reiterate the importance of continuing therapy to address her depression and provide emotional support throughout the decision-making process.
   • Offer to involve a neutral third party, such as a social worker or counselor, to facilitate a family discussion if Yasmine chooses to disclose her pregnancy to her mother.
4. When responding to Mrs. Kamal’s question regarding why no antidepressant was prescribed, the NP should uphold patient confidentiality while providing a general explanation for the decision. The NP can say something like, “I’m unable to discuss the specifics of Yasmine’s care without her consent due to patient confidentiality laws. However, I can assure you that we are actively working to address her mental health needs, and I would encourage you to discuss her treatment plan with her directly or involve her in that conversation when she’s ready.” This response respects Yasmine’s right to privacy while acknowledging Mrs. Kamal’s concerns and offering an opportunity for future communication when appropriate.