A 12-year-old girl is brought to the clinic by her parents for evaluation of decreased exercise tolerance and increased lethargy. Her parents say she becomes short of breath with minimal exertion, and for the past 2 weeks her gums have bled when she brushes her teeth. Temperature is 36.7 C (98 F); blood pressure and pulse are normal. Physical examination demonstrates pallor and hepatosplenomegaly. Laboratory results are as follows: An extensive workup indicates that the patient has acute lymphoblastic leukemia, and the parents are informed that she will need chemotherapy. The parents do not consent to the treatment plan because they believe that the side effects will be too severe and that their child's quality of life will be poor. Despite an ethics consultation and a lengthy discussion about the benefits of treatment and likely consequences if therapy is withheld, the parents insist on taking her home without scheduling follow-up treatment. Which of the following is the most appropriate next step in the management of this patient?

Question

A 12-year-old girl is brought to the clinic by her parents for evaluation of decreased exercise tolerance and increased lethargy.  Her parents say she becomes short of breath with minimal exertion, and for the past 2 weeks her gums have bled when she brushes her teeth.  Temperature is 36.7 C (98 F); blood pressure and pulse are normal.  Physical examination demonstrates pallor and hepatosplenomegaly.  Laboratory results are as follows:  An extensive workup indicates that the patient has acute lymphoblastic leukemia, and the parents are informed that she will need chemotherapy.  The parents do not consent to the treatment plan because they believe that the side effects will be too severe and that their child's quality of life will be poor.  Despite an ethics consultation and a lengthy discussion about the benefits of treatment and likely consequences if therapy is withheld, the parents insist on taking her home without scheduling follow-up treatment.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Although parents generally have the right to make medical decisions for their minor children, parents cannot refuse life-saving treatment for a child. In this case, the parents are refusing a proven life-saving treatment for their child. Treatment of acute lymphoblastic leukemia currently offers a survival rate of over 80%. Without treatment, acute lymphoblastic leukemia commonly results in death. The physician should continue to engage the parents, explaining the benefits of treatment and the consequences of withholding diagnostic tests and chemotherapy. The hospital ethics committee, social services, and hospital risk management can also assist. In some cases, this multidisciplinary approach will enable parents to overcome their fears and consent to the proposed treatment. However, if the parents continue to refuse life-saving treatment, the physician should seek a court order to proceed with the necessary intervention. (Choice A) Complying with parental wishes is not in the best interest of this child. Therefore, the physician has an ethical duty to advocate for the child and petition the court to intervene in favor of life-saving chemotherapy. (Choice C) If a delay for consent is life-threatening, emergency treatment for the child is legally authorized regardless of the parents' wishes. However, this is a nonemergency situation, so authorization should be sought through legal channels. (Choice D) Providing only supportive care is inadequate treatment for this girl's leukemia and would likely result in death. Therefore, the physician should petition the court to intervene. (Choice E) Transfer of care to another provider would delay pursuing a court order for life-saving chemotherapy. Educational objective: In a nonemergency situation in which a parent refuses potentially life-saving treatment for their child, the physician should seek a court order mandating treatment. References: Parents know best: or do they? Treatment refusals in paediatric oncology. (http://www.ncbi.nlm.nih.gov/pubmed/21951447)

A 12-Year-Old Girl Is Brought to the Clinic by Her