When Parents Refuse a Septic Workup for a Newborn

[J-Rad]

http://pediatrics.aappublications.org/content/128/5/966.full

Unfortunately, this isn't a free one to access from anywhere on the interwebz. But if you can get your hands on the article, it actually is quite interesting. For those that have, or that are willing to read the article, I am curious what you would do?

Here is the extract that is freely available to all at http://pediatrics.aappublications.org/content/128/5/966.extract. Unfortunately it doesn't quite give the flavor of the whole discussion. Worth reading if you can.

(Special Article
When Parents Refuse a Septic Workup for a Newborn
Elizabeth Simpson, MDa,b,c, Margaret Moon, MD, MPHd, John D. Lantos, MDc,e
+ Author Affiliations

aRoutine Newborn Services, Truman Medical Center, Kansas City, Missouri;
bDepartment of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
cDepartment of Pediatrics, University of Missouri, Kansas City, Missouri;
dDivision of Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and
eChildren's Mercy Hospital Bioethics Center, Kansas City, Missouri
Sometimes, parents refuse medical intervention for philosophical reasons. Pediatricians have an obligation to protect children from medical neglect on the part of their parents. Often, it is not clear where exactly to draw the line between parental rights and the best interest of the child. The law is clear, however. If the doctor suspects medical neglect, he or she has an obligation to notify child protective services (CPS). CPS, and eventually a judge, will then determine if the parental behavior is or is not legally acceptable. For doctors, however, there is often a trade-off between protecting the child and preserving a therapeutic alliance with the parents. We present here a case of a newborn at risk for sepsis whose parents do not want standard medical evaluation and treatment. Two general pediatricians, Elizabeth Simpson, MD, director of the general care nursery at Truman Medical Center, and Margaret Moon, MD, MPH, a bioethicist and pediatrician at Johns Hopkins School of Medicine, offer their responses to the case.

CLINICAL ETHICS CASE REPORT: PART I

A 30-year-old woman presented to labor/delivery at term gestation after a failed home delivery with a lay midwife. Her membranes had ruptured 38 hours before delivery. One hour before presentation, she had developed a temperature to 102°F. The pregnancy had been uncomplicated. She had early prenatal care and a negative screen result for group B streptococcal infection 1 week before delivery. Her white blood cell count was 49 000/μL with 18% bands.

The woman and her husband refused fetal monitoring. They insisted on carrying out their plan for a natural birth and said that, right after delivery, they wanted to be discharged and take the child home. The obstetrician recommended that the mother receive intravenous antibiotics. She agreed to this treatment.

The pediatric service was consulted 1 hour before delivery. The parents were informed that …

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[jcu]

The moment the parents decided their child be born in the hospital, legally speaking doesn't the hospital immediately become that child's advocate? I know the law is usually never black and white, but would a judge really fault a pediatrician for administering antibiotics, etc. against a parent's wishes? In my opinion, there should never be a trade-off between protecting the child and preserving a therapeutic alliance with the parents when said parents are loony pants =/

 

[Stitch]

I read the discussion and tend to agree with Dr. Moon here, though I'm a bit more blunt. We worry too damn much about being nice to people, especially when people are idiots. I had a family come to me in the ED with fever in a 1 week old. They wanted to leave AMA, I wouldn't let them.

My first obligation is to the child and the risk of sepsis is significant. We've all seen neurologically devastated kids who looked great upon arrival, then developed group B meningitis or other some such. If you want to stay at home with your kid and not involve me, that's fine, take your own risks. But let's not forget the legal implications as well. If something happens to this kid, they can still sue you and just claim they didn't understand. I've seen it happen to an OB friend of mine whose patient refused a c section then sued because the baby got stuck and ended up with HIE.

At the very least I'd call social work, then (calmly and politely) inform the parents that I was obligated to get legal involved. In the past, the 'threat' of this action is enough to get the message across that the workup isn't negotiable. I'd go so far as to contact a judge if necessary. If the judge decided they can go home, that's fine, I'm off the hook. But otherwise I'm going to protect myself and the child by following the standard of care.

 

[KidDr]

I read the discussion and tend to agree with Dr. Moon here, though I'm a bit more blunt. We worry too damn much about being nice to people, especially when people are idiots. I had a family come to me in the ED with fever in a 1 week old. They wanted to leave AMA, I wouldn't let them.

My first obligation is to the child and the risk of sepsis is significant. We've all seen neurologically devastated kids who looked great upon arrival, then developed group B meningitis or other some such. If you want to stay at home with your kid and not involve me, that's fine, take your own risks. But let's not forget the legal implications as well. If something happens to this kid, they can still sue you and just claim they didn't understand. I've seen it happen to an OB friend of mine whose patient refused a c section then sued because the baby got stuck and ended up with HIE.

At the very least I'd call social work, then (calmly and politely) inform the parents that I was obligated to get legal involved. In the past, the 'threat' of this action is enough to get the message across that the workup isn't negotiable. I'd go so far as to contact a judge if necessary. If the judge decided they can go home, that's fine, I'm off the hook. But otherwise I'm going to protect myself and the child by following the standard of care.

Very interesting discussion. I haven't (yet) had to deal with parents refusing every single part of a full septic workup. I've had several refuse LPs (as we all have) but all of those who refused LPs were still okay blood and urine tests then IV antibiotics and admission. Not ideal, but at least the baby can be watched by the inpatient team (and legally, I think it removes me from liability...though maybe I'm wrong on that).

I am sure I will have to face this (refusal of all aspects of septic workup and wanting to take the baby home) some day and I really am not looking forward to it. I've thought a lot about what I would do. I've had colleagues tell me to let the family leave AMA and then document the hell out of it. But I've never felt totally comfortable with that approach.

If you told the family you were going to get legal involved, and then they tried to bolt, would you physically stop them yourself? Call security/police (if you had time) and have them place a hold on the baby? What if they got out of the ER before you could stop them--would you call child protection or the police and have them go out to the home to pick up the baby?

Dang I hate this stuff. I don't get it. Why even bring your baby to the ER if you're going to refuse everything I recommend? I'm with you--keep your baby at home and take your own risks. But once you involve me, you make things a lot trickier...

 

[Stitch]

If you told the family you were going to get legal involved, and then they tried to bolt, would you physically stop them yourself? Call security/police (if you had time) and have them place a hold on the baby? What if they got out of the ER before you could stop them--would you call child protection or the police and have them go out to the home to pick up the baby?

Never get physically involved yourself. Huge mistake. But yes I'd call CPS/police after discussing it with legal and my medical director to make sure everyone had my back. I once had a 10 yo in clear DKA and the parents told me he was 'fine' and that they were taking him home. pH was 7.08. After trying to be nice, I bluntly told them that if they tried to leave, I'd contact security, and failing that, the police. They actually called 911 after I left the room and stated I was holding them hostage.
When the police showed up in response to the call, they made it very clear that she couldn't leave without facing charges of neglect. But it's the only time I've had a parent threaten to have ME arrested!

Dang I hate this stuff. I don't get it. Why even bring your baby to the ER if you're going to refuse everything I recommend? I'm with you--keep your baby at home and take your own risks. But once you involve me, you make things a lot trickier...

Yeah, I don't get it either. Why come to the hospital? This isn't Burger King and you don't always get it 'your way,' despite the push by administrators to make it all about 'the customer.'

I'm curious what OBP would say/do. Once my partner had a parent refuse phototherapy! It took a call to a judge to bring them around.

 

[oldbearprofessor]

The moment the parents decided their child be born in the hospital, legally speaking doesn't the hospital immediately become that child's advocate? I know the law is usually never black and white, but would a judge really fault a pediatrician for administering antibiotics, etc. against a parent's wishes? In my opinion, there should never be a trade-off between protecting the child and preserving a therapeutic alliance with the parents when said parents are loony pants =/

When a child is admitted, the parents sign a consent to treat that covers routine care. However, it would not be the case that the parents are signing over their right to consent to things like immunizations, antibiotics and procedures including LPs that they do not wish. Specifically providing therapy that the parents have said they would not permit requires appropriate intervention in the form of ombusdmans, ethics committees and ultimately legal steps. It is not a simple task although in truly emergent situations, the first and key steps can be done quickly.

I'm curious what OBP would say/do.

OBP would rather stay up all night to care for 10 babies on the oscillator and iNO, etc than spend 20 minutes dealing with one parent who refuses an LP for their baby.

In terms of ethics scenerios, I'm cautious about giving a firm opinion. It's a worthwhile exercise, but tiny details are important and are lost in these discussions. In general, however, in the uncommon situation in which I'm forced to deal with these issues, my tendency is to do whatever I can to avoid involvement of the legal system and to try to work with the family. Certainly it is necessary on rare occasions to engage the legal system, but often times some compromise is possible that doesn't really harm the infant.

Keep in mind however, that I work in an NICU not an ER. It's much easier for me to forgo the LP and give meningitic doses of antibiotics for a baby in the Level 2 nursery than for the ER doc to give a dose of antibiotics and send the 2 week old home without an LP.

Gosh, I'm glad I don't work in the ER having to deal with that situation.

 

[deleted109597]

Relatively new at this game at the attending level, but I'll shoot.

Caveat: I do not routinely deliver babies. Only from a lack of planning on the part of the parents.

I do, however, take care of kids in the ED. The problem is truly a societal one, not a legal one. For every idiot parent that wants to take the septic kid home, there is another idiot one that wants me to have gyn/surg/peds come down and subject princess to untold procedures because her belly hurt after lunch today, but not now. Trying to convince people they don't need a CT is in the same boat. You have to be calm and rational. Document the calm, rational conversation. If they choose to leave, they're going to have to sneak out. I don't like to just offer up AMA papers. Once they sneak out, it's child abuse, and I'm obligated by the state to report them.
Unfortunately, since DCS bats about .500 (if you're lucky) with these cases, they frequently still get to keep the kid, but at least the kid is in the hospital during the investigation.
Remember, you can be prosecuted for holding people against their will, and even though Stitch had a sympathetic ear with the police, some cases aren't so cut and dry. However, you cannot be prosecuted for reporting what you thought was child abuse as long as you did it in good faith.