A 4-year-old girl is sent to the emergency department from her day care center due to fever, right ear pain, and repeated vomiting. Examination shows a bulging, cloudy tympanic membrane associated with erythema, swelling, and tenderness over the right mastoid. CT scan reveals opacification of the mastoid air cells with destruction of bony septa. When the patient's parents arrive, they report that the patient has had recurrent episodes of otitis media. However, the parents decline antibiotic therapy, stating, "In our family, we believe that natural healing techniques are better than shooting up our children with chemicals." Which of the following is the most appropriate response to the parents' statement?

Question

A 4-year-old girl is sent to the emergency department from her day care center due to fever, right ear pain, and repeated vomiting.  Examination shows a bulging, cloudy tympanic membrane associated with erythema, swelling, and tenderness over the right mastoid.  CT scan reveals opacification of the mastoid air cells with destruction of bony septa.  When the patient's parents arrive, they report that the patient has had recurrent episodes of otitis media.  However, the parents decline antibiotic therapy, stating, "In our family, we believe that natural healing techniques are better than shooting up our children with chemicals."  Which of the following is the most appropriate response to the parents' statement?

Quizplus · Accepted Answer

11ec160b_3660_1324_9249_cd5edfdcb18f_MD0001_00 This child with a history of recurrent otitis media now has acute mastoiditis, a purulent infection of the mastoid air cells. Untreated mastoiditis can lead to serious complications, including brain abscess and death, and requires aggressive management. Initial treatment includes parenteral antibiotics, and patients often require surgical intervention. Patients and surrogate decision-makers (eg, parents, guardians) often have limited understanding of serious but uncommon conditions, such as mastoiditis. They also may have misconceptions regarding the potential risks and benefits of medical treatment. Decision-making can be further complicated by the urgency to make life-or-death decisions quickly in unfamiliar environments (eg, emergency department). The initial step in counseling patients and surrogate decision-makers regarding refusal of treatment is to calmly probe their understanding of the disease process. This can be followed by counseling and education tailored to the decision-maker's level of understanding and health literacy and an objective assessment of treatment options. Although a court order may be necessary to compel the parents to allow life-saving treatment, legal action can be distressing to all involved. Often, once the disease process and treatment options are better understood, decision-makers become less resistant to treatment. (Choice B) For non-life-threatening conditions for which standard therapies are undesirable or ineffective, clinicians can lend their expertise to patients regarding nonstandard therapies, even if the clinician does not fully endorse such therapies. However, there are no nonpharmacologic therapies that are adequate for treating mastoiditis. (Choice C) This statement begins with an appropriate gesture of concern. However, it is inadequate because it simply reiterates treatment recommendations and does not attempt to provide the information needed for the patient's parents to make an informed decision. (Choice D) Although discussion with this child's family should include the risks of untreated mastoiditis, presenting scare tactics and worst-case scenarios is likely only to further distress the family and inhibit rational decision-making. (Choice E) Delayed treatment of mastoiditis is not recommended. Wasting time with ineffective treatments will only delay having a more appropriate conversation. Educational objective: Patients and surrogate decision-makers often have misconceptions regarding medical conditions and the potential risks and benefits of treatment. The initial step in counseling patients and surrogate decision-makers regarding treatment refusal is to calmly probe their understanding of the disease process. This can be followed by counseling and education tailored to the decision-maker's level of understanding and health literacy.

A 4-Year-Old Girl Is Sent to the Emergency Department from Her