A 3-year-old boy is brought to the emergency department due to a fever and stiff neck. The child is hospitalized with a diagnosis of bacterial meningitis and begins treatment with intravenous antibiotics. On day 2 of hospitalization, the mother requests to take the child home and explains that she intends to treat him with homeopathic remedies. She has 4 other children at home who have "never needed vaccinations or medications" and are "strong and healthy." The physician explains the risks of meningitis, including brain damage and death. After a long discussion, the mother says that she understands the risks but believes that homeopathic remedies will be adequate for treatment and remains unconvinced of the need for hospitalization. Which of the following is the most appropriate course of action?

Question

A 3-year-old boy is brought to the emergency department due to a fever and stiff neck.  The child is hospitalized with a diagnosis of bacterial meningitis and begins treatment with intravenous antibiotics.  On day 2 of hospitalization, the mother requests to take the child home and explains that she intends to treat him with homeopathic remedies.  She has 4 other children at home who have "never needed vaccinations or medications" and are "strong and healthy."  The physician explains the risks of meningitis, including brain damage and death.  After a long discussion, the mother says that she understands the risks but believes that homeopathic remedies will be adequate for treatment and remains unconvinced of the need for hospitalization.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Untreated bacterial meningitis is a medically dangerous and potentially lethal condition. This mother's decision to take her child home and discontinue intravenous (IV) antibiotics after only 2 days places the child and his siblings at significant risk of serious harm and death. When efforts to resolve the situation are unsuccessful, physicians have an ethical duty to advocate for the best interests of the child and challenge parental authority to make medical decisions for the child. In such cases, involvement of a state child protection agency becomes necessary. Whenever possible, efforts should first be made to collaborate with the parents with the goal of reaching a mutually agreed upon treatment plan and safe outcome for the child. Physicians should counsel and educate the parents to address any misconceptions about the illness and treatment. It also may be helpful to consult with the ethics committee who can provide input on ethical issues as well as mediate further discussion. (Choice A) There is no indication that the mother lacks decision-making capacity. She understands the risks of stopping treatment and provides a rationale for her decision. However, in this case, the best interest of the child becomes the overriding focus, rather than the mother's right to make autonomous decisions. The physician must act to protect the child's life despite parental wishes. (Choices B and E) Children with bacterial meningitis are at high risk for complications (eg, increased intracranial pressure, seizures) during the first few days of treatment and require hospital-level care for treatment and monitoring of complications, which cannot be safely done in the home setting. Oral antibiotics do not adequately penetrate the cerebrospinal fluid and are not a substitute for IV antibiotics. In addition, the mother has stated her intention to pursue homeopathic treatment and has not agreed to comply with either oral or IV antibiotics. (Choice D) Discharge against medical advice is inappropriate when there is significant risk of serious harm and death to a child. If it was the mother's own treatment at issue, then she could reasonably be discharged against medical advice. Educational objective: It is a physician's duty to advocate for the best interests of a child. When a child is at significant risk of harm, parental authority to make medical decisions can be challenged. In cases where educational and collaborative efforts fail, protective services should be contacted.

A 3-Year-Old Boy Is Brought to the Emergency Department Due