Peds AMA conundrum

[Lumberg]

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Here it is:

See a 15 mo old F c fever/vomiting. Pt was seen earlier in week by pediatrician, dx'd c OM and placed on oral augmentin 5-6 days PTA. Kid is not getting better, mom takes her back to pediatrician.

Here the hx gets kinda fuzzy but the upshot is mom brings kid to ED for IM rocephin shot but doesn't want to register. Somebody told her it was OK to just come in for shot. My charge nurse correctly informs them that they need to be seen in order to be evaluated, get meds, etc.

So I come strolling into room with no idea of the ****storm I'm walkng into.
Kid looks pretty crappy, vomiting, febrile to 104, weak cry,red throat, snotty nose. She's pretty healthy except for h/o febrile seizures. I tell mom this is probably viral URI but I'm concerned because of her clinical presentation, etc, etc. Mom goes ballistic re the need to even be evaluated, grandmother starts cursing at me. When I further say, "gee, sorry for the misunderstanding but your daughter may have a potentially serious illness and we should do some testing", the whole family starts screaming and crying. "No IV's!! My God, no IV's...last time they stuck her TWICE and I am NOT putting her through that again!!"
So, I've got a 15 mo old febrile, vomiting, been on augmentin for a week and I can't do anything except an IM shot of Rocephin. Parents refusing all testing, except the rapid strep I did on my initial exam. They want to take her and leave but are still demanding IM abx. What do you do?

How do you guys deal with this? The peds AMA thing always confuses me, because if I think they should stay don't I have a legal responsibiltiy to treat the kid? I know the legalese reads "imminent life threat" but how do I know w/o tests?

Here's the capper...CEO of hospital is "close personal friend"

 

[Seaglass]

Ask for the CEO's number, call him/her, and ask them to talk some sense into them. Seriously.

 

[Midwest Medic]

It always seems that the most obnoxious patients are "close personal friends" of the CEO....even the bums who get upset always throw that line here.

 

[EctopicFetus]

If you are worried about the well being of the child then call CPS. Thats my 2 cents, and I would tell them Ill be doing it. CPS is meant to take care of kids when their parents arent.

 

[docB]

Wow. That is a crappy situation. I've been in similar fixes. Here's what I would do:

Call the CEO (or the administrator on call who should be able to get ahold of the CEO) and ask if he knows these folks. If he doesn't then you can call BS on them if you want. If he does then tell him you're concerned and ask if he'll talk to them to make sure they understand the process and the risks of leaving. If the kid really looks bad enough that you'd consider calling CPS to prevent them from going AMA and if they do know the CEO you want him in on the discussion before the bomb drops.

Call their pediatrician. He will almost certainly say to work the kid up if he looks bad. See if he'll talk to the family and explain why the work up is needed.

Give the IM Rocephin immediately. If the kid does have meningitis or bacteremia the sooner the better. If the family is refusing IV then document that you did what you could given that limitation. You want to be able to document that you were doing everything you could within the limits set by the parents. If they do suddenly elope at least you got some abx in.

 

[KidDr]

Here it is:

See a 15 mo old F c fever/vomiting. Pt was seen earlier in week by pediatrician, dx'd c OM and placed on oral augmentin 5-6 days PTA. Kid is not getting better, mom takes her back to pediatrician.

Here the hx gets kinda fuzzy but the upshot is mom brings kid to ED for IM rocephin shot but doesn't want to register. Somebody told her it was OK to just come in for shot. My charge nurse correctly informs them that they need to be seen in order to be evaluated, get meds, etc.

So I come strolling into room with no idea of the ****storm I'm walkng into.
Kid looks pretty crappy, vomiting, febrile to 104, weak cry,red throat, snotty nose. She's pretty healthy except for h/o febrile seizures. I tell mom this is probably viral URI but I'm concerned because of her clinical presentation, etc, etc. Mom goes ballistic re the need to even be evaluated, grandmother starts cursing at me. When I further say, "gee, sorry for the misunderstanding but your daughter may have a potentially serious illness and we should do some testing", the whole family starts screaming and crying. "No IV's!! My God, no IV's...last time they stuck her TWICE and I am NOT putting her through that again!!"
So, I've got a 15 mo old febrile, vomiting, been on augmentin for a week and I can't do anything except an IM shot of Rocephin. Parents refusing all testing, except the rapid strep I did on my initial exam. They want to take her and leave but are still demanding IM abx. What do you do?

How do you guys deal with this? The peds AMA thing always confuses me, because if I think they should stay don't I have a legal responsibiltiy to treat the kid? I know the legalese reads "imminent life threat" but how do I know w/o tests?

Here's the capper...CEO of hospital is "close personal friend"

I'm a peds EM fellow, have been in some similar situations. These are never easy. If the family has a good relationship with the primary pediatrician, sometimes it can help to call that person, explain the situation, and ask them to call the family and persuade them to go along with your plan. I've had families who were refusing testing but when the pediatrician called them and agreed with our (the ED's) plan, the family then came on board. Of course this only works if the family has a good relationship with the pediatrician, the pediatrician agrees with you, and if the family has at least a little common sense left in them...

Another thing is to try and reason with the family (though I acknowledge that some families are beyond reasoning). Offer to try a dose of oral Zofran and then PO challenge the kid. If the kid vomits a few times in front of you, maybe that'll give you more leverage with them. Or offer to have your #1 IV-starting nurse start the child's IV (I HATE doing this because in my reasoning, why should their child be treated any different than any other kid? But sometimes it's a way to avoid further trouble). Or maybe, if dehydration is your main concern, you can convince the family to allow a heelstick to check electrolytes. Let them know specifically what you're looking for on lytes, i.e., if bicarb is below 15, it's a sign of pretty significant dehydration and it's likely the baby is going to have difficulty re-hydrating herself orally because of likely ketosis, if the bicarb is 16-20, the child is significantly dehydrated and you would still recommend an IV but maybe PO challenging the kid (giving oral Zofran first) is also appropriate, etc etc etc. This isn't necessarily evidence-based stuff, just based on my experience.

Some people respond well to very objective information--is the child tachycardic? Is the perfusion decreased? Is the child lethargic? If so, point these things out as you're examining the child and explain specifically why they're worrisome signs, and what they mean.

Also, recognize that any child with a temp of 104 usually looks pretty crappy. Maybe you can get the family to agree to a dose of ibuprofen (and oral Zofran) and letting you re-evaluate the kid in an hour. Explain to the family that if at that point (when the kid's temp is down somewhat), she still looks crappy, that you'd be very concerned about significant dehydration or serious infection. But even then it's difficult, because if you can't clinically document something that would qualify as a life-threatening situation, the family can take the child out AMA. Document everything, give the Rocephin, notify the referring pediatrician, and try to convince the family to follow up with the pediatrician the next day and bring the child back to the ER if she gets worse.

The bottom line is that it depends on how sick the kid looks. If you have a child in front of you who clinically is in shock (or any number of other life-threatening situations) and you can document it, you don't need labs, and you treat the child regardless of what the parents do or don't want, and the law will support you in doing that.

I realize there's still gray areas and this approach won't work for every family, but I think some combination of the above approaches will convince most families to let you do what's in the best interest for the child.

So what ended up happening with the child you wrote about?

 

[KidDr]

Oh and yeah, I definitely agree with others who've said to get the CEO involved (or at least figure out if the family is BSing about this). Typically the CEO is a MD and will agree with you, and can hopefully talk some sense into the family.

 

[diphenyl]

Here it is:

See a 15 mo old F c fever/vomiting. Pt was seen earlier in week by pediatrician, dx'd c OM and placed on oral augmentin 5-6 days PTA. Kid is not getting better, mom takes her back to pediatrician.

Here the hx gets kinda fuzzy but the upshot is mom brings kid to ED for IM rocephin shot but doesn't want to register. Somebody told her it was OK to just come in for shot. My charge nurse correctly informs them that they need to be seen in order to be evaluated, get meds, etc.

So I come strolling into room with no idea of the ****storm I'm walkng into.
Kid looks pretty crappy, vomiting, febrile to 104, weak cry,red throat, snotty nose. She's pretty healthy except for h/o febrile seizures. I tell mom this is probably viral URI but I'm concerned because of her clinical presentation, etc, etc. Mom goes ballistic re the need to even be evaluated, grandmother starts cursing at me. When I further say, "gee, sorry for the misunderstanding but your daughter may have a potentially serious illness and we should do some testing", the whole family starts screaming and crying. "No IV's!! My God, no IV's...last time they stuck her TWICE and I am NOT putting her through that again!!"
So, I've got a 15 mo old febrile, vomiting, been on augmentin for a week and I can't do anything except an IM shot of Rocephin. Parents refusing all testing, except the rapid strep I did on my initial exam. They want to take her and leave but are still demanding IM abx. What do you do?

How do you guys deal with this? The peds AMA thing always confuses me, because if I think they should stay don't I have a legal responsibiltiy to treat the kid? I know the legalese reads "imminent life threat" but how do I know w/o tests?

Here's the capper...CEO of hospital is "close personal friend"

I have to agree with the previous suggestions to call the pediatrician to talk to the family. He's the one they know and someone they may trust. I would also get the patients services folk involved in this, see if they can't talk this out reasonably like explaining the need for further testing. If all of the above failed and you have serious concern for the childs health, call CPS. Get security and get the family out of the room if you have to. If you are in a situation where your hands are tied by the powers that be and they're going to go AMA, write a novel in your notes. A novel even by AMA documentation standards. If I were in the same situation I would write including the conversation with the family w/ the words "there is a possibility she will DIE w/o treatment". There is no one not even this crazy ***** family worth getting sued over.

 

[Lumberg]

Thanks for the replies.
After the initial angry exchange I realized we were going nowhere and then I brought up the possibility of CPS which only fanned the flames. The family accused me of threatening them and the situation began to escalate. I did my best to explain my clinical reasoning clearly and calmly...with the charge nurse in the room. Gave them a minute to calm down, went back with the phone and the CEO on the line. They actually DID know him, the pts mother's father was the previous CEO. Our CEO told me privately that this family was "unsatifiable and completely unreasonable"

After that they agreed to all of the testing, only after I promised to get the IV therapy team to stick her (negotiation, right?). I thought about a heel stick but was trying to reason out the number of sticks and really felt an IV would be best for access, ABx, Blood CX, etc. Got the IV easily, did a cath urine and IVF bolus. Kid had gotten ibuprofen in triage, but still febrile. WBC 21K, +bandemia, 150 ketones, neg strep, neg CXR. Looked MUCH better p IVF. Only then did I call the on-call doc covering for her pediatrician (which I now know to do immediately...thanks for the tip KidDr). Anyway, wound up admitting for obs. Doing better, now taking po. Family antogonized EVERY caregiver that entered the room. Before they went up, mom screamed at new nurse taking PR temp for her "cold-hearted technique".
Documented a "novel" in the chart.
As a junior attending I'm still learning how to navigate these difficult ethical issues. This case was one I wanted to get some feedback on re when to dig in your heels vs. parents and when to let them leave AMA.
Thanks for all of the fantastic replies and suggestions.

 

[docB]

This is actually a great discussion because I think that most EP's training kind of glosses over it. It's really not as cut and dried as the "Just call CPS." that a lot of got. Parents do have the right to make informed decisions about thier children's care. We don't call CPS every time a parent refuses vaccinations.

A good example we all run into frequently is the LP. Parents will sometimes refuse the LP. I've gotten into situations where a parent asks what I will do without the LP. The answer is usually admission and antibiotics and monitoring. To play devil's advocate you can just treat like it's a meningitis but not make the csf diagnosis. A parent can fixate on that and decide that the LP is unnecessary. Would you call in CPS in that situation?

There's a difference between the well meaning but obstructionist parent and the abuser. If you suspect abuse then you have to call CPS period.

The line between making informed refusals of care and child endangerment is blurry and is another situation where EPs get stuck in the middle.

 

[southerndoc]

I tell parents that if we treat for suspected meningitis without a LP, then it obligates the kid to receiving 4-6 weeks of antibiotics, placement of a PICC line, etc. Most then allow the LP.

I once told a patient and their family who was overly demanding of the nurses time, my time, critical of everyone, etc. that it is highly unlikely that I will be able to satisfy their every wish, and if they wanted to seek care elsewhere I would be happy to arrange for the transfer. After that, they actually calmed down and stopped whining about every little thing.

 

[EC3]

The customer is always right. You should've just obliged them so that your QA/QI department doesn't get a sternly-written letter about your inappropriate behavior.

 

[docB]

The customer is always right. You should've just obliged them so that your QA/QI department doesn't get a sternly-written letter about your inappropriate behavior.

Ahh, I see you've had you HCAHPS training.

 

[PeepshowJohnny]

Gave them a minute to calm down, went back with the phone and the CEO on the line. They actually DID know him, the pts mother's father was the previous CEO. Our CEO told me privately that this family was "unsatifiable and completely unreasonable"

Haha, imagine if you got pissed enough to let this slip out.

Family: Blah blah blah, Well, we're going to call the CEO of this hospital!

Doctor: Oh yeah? Well, I already called him and he told me you guys were douchebags!




Although I doubt I'd ever rise to the level of CEO, it's always been a fear of mine that certain family members and friends will end up using my status as a physician in the future. The ones I'm thinking of are good people and I like them, but they're the type who lose their cool in situations like this and tend to think everyone is out to scam them. Don't think there's any way to prevent it, just maybe play the mediator if my name is ever brought up as a "trump card".

 

[SoCuteMD]

The customer is always right. You should've just obliged them so that your QA/QI department doesn't get a sternly-written letter about your inappropriate behavior.

I'm sorry, but where I am we don't have "customers" just "patients."

 

[roja]

I agree with your point, socute!

 

[EM2BE]

If the patient (customer according the the person above) is always right, why would social services ever exist? (this is assuming you were referring to the parents, not the child, as the "customer") Just my 2 cents on this one.

 

[southerndoc]

I'm sorry, but where I am we don't have "customers" just "patients."

In a non-academic setting, they are just as much customers as they are patients. They often have a choice where they go when multiple hospitals are around, and this makes them customers. If a CEO notices customers are no longer coming to your hospital and are going to XYZ hospital instead because they offer better customer service, then trust me, you'll know about it.

 

[bartleby]

Documentation is one of the biggest thing you can do in this situation for sure. But the things that it is specifically important to mention is what you have offered the patient and recommended as a course of treatment, the fact that the patient has refused (and why they are refusing it), the fact that you have attempted to address their complaints ("pt states that he will not stay in the hospital because he is cold. Pt was given two warm blankets and two pairs of grippy-soled hospital socks and warm coffee. He still refuses to stay") and to document the fact that the pt voices their understanding. In the OP's peds case, the parent cannot really refuse care if there is an imminent threat to the pt, but if things get bad enough that you need to call DCF and they complain about you, you need to have all this down on paper contemporaneously (documented this all two weeks later after you've found out they've complained is no good).

The other thing is that you should talk to everyone. When it comes to patient relations, the best defense truly is a good offense. The hospital CEO was going to have a completely different approach to the hysterics of the OP's family when he got a heads up from the ED doc than if he got some crazy voicemail when he got to the office the next morning. Same goes for the PMD.