Patient Confidentiality

Back when I was in residency, I had an HIV positive patient whose wife was unaware of his HIV status (apparently he didn't find out until AFTER they got married), and he refused to let anyone tell her. He'd tell his doctors that he was going to, but then never would. He would never want to answer any of our questions as long as his wife was in the room, even if it was for something non-HIV related, like how his chest pain was doing. To be fair, he took his HAART faithfully and his viral load was undetectable, but even as an intern the hypocrisy of the situation was not lost on me. He was one of the patients that no attending in the hospital wanted to accept just because he was an ass (that must be true only of teaching hospitals because in the real world we usually aren't supposed to refuse patients), and I wonder if his wife ever found out.

I'm now caring for another HIV patient whose parents don't know about his status. He'd developed a bad case of PCP, but before intubation he made it clear that his parents were not to know that he had HIV. I've seen his father fervently praying over him and wonder what sin he committed to acquire AIDS (most likely premarital sex with an infected male/female, given his age), and wonder how unforgiveable that truly would be to his parents.  I don't know what to say when his parents ask why he's not getting better and why his pneumonia just isn't going away. Can't exactly say, "Well, Mr. ___, your son doesn't really have much of an immune system because his CD4 count is one of the lowest I've ever seen in my career." Can't be judgmental when the guy's so sick, but I wonder what the end point is. If he should die, do I let his diagnosis go with him to the grave? The Tarasoff ruling allows us to break the shackles of confidentiality when there is intended harm towards another, but what am I supposed to say if this guy ends up dying and his mother asks why? The things we deal every day...