Question 1

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?

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)

Question 2

A 1-week-old girl is brought to the emergency department by ambulance due to fever and irritability.  She was born at term via precipitous vaginal delivery and had an uncomplicated nursery course.  Prenatal laboratory results included a positive group B streptococcal screen, for which the mother received intrapartum antibiotics.  The infant's mother and father are both age 16, and the father is not involved in the infant's care.  The infant lives with her mother and maternal grandparents in their home.  The mother is present in the emergency department along with both of her parents.  Temperature is 38.3 C (101 F) and pulse oximetry is 87% on room air.  The infant is intermittently apneic and appears cyanotic.  Anterior and posterior fontanelles are bulging.  Pulmonary examination reveals tachypnea, intercostal retractions, and clear breath sounds bilaterally.  The infant's examination is concerning for meningitis and the child requires intubation and mechanical ventilation; however, the mother refuses the procedure.  Which of the following is the best next step in management of this patient?

Accepted Answer

11ec25c8_d74c_6eda_bc81_bfb100fa7a16_MD0003_00 Informed consent provides patients with information that allows for educated decision-making about their health care. The procedure and its indications, risks, benefits, and alternatives should be clearly described. Informed consent ideally is obtained from the parents of minors prior to performing a procedure. The exception is emergency, life-threatening conditions in which the parent or legal guardian cannot or does not provide consent and delaying treatment would result in harm to the patient. Although this infant's mother is a minor, she can legally consent to medical care for her child. However, parents have the responsibility to make decisions in the best interest of their child and therefore cannot refuse life-saving treatment. This infant requires intubation and mechanical ventilation to live. In situations that are not time-sensitive, the hospital legal counsel and ethics committee should be involved and a court order obtained to overrule the parent's wishes (Choices C and E). However, this patient has an unstable airway requiring emergency treatment; obtaining an ethics consult or legal counsel would delay treatment. The correct course of action is to proceed with treatment regardless of parental consent. Other situations in which obtaining consent should not delay acute care include urgent blood transfusions and emergency surgery. (Choices A and D) Consent is not required in this emergency situation, and attempting to contact the father would only delay life-saving treatment. In addition, grandparents cannot provide consent unless they are the legal guardians. (Choice B) Child protective services should be involved when parents are not acting in the best interest of their child. However, this patient is in critical condition and should first be stabilized. Educational objective: Parents who are themselves minors can give consent to medical care for their child. However, consent is not required in emergency situations, and parents cannot refuse life-saving treatment for their child. References: Consent for emergency medical services for children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/12612264) Informed consent for emergency surgery in infants and children. (http://www.ncbi.nlm.nih.gov/pubmed/16080940) Minors' rights in medical decision making. (http://www.ncbi.nlm.nih.gov/pubmed/17728582)

Question 3

A previously healthy 9-year-old boy is evaluated for a deep puncture wound to the foot.  He was walking barefoot on the beach when he stepped on a rusty nail.  His parents cleaned the wound with soap and water and applied pressure to it.  The boy takes no medications.  He has not received any vaccinations due to parental preference.  The boy's parents are divorced and have joint custody of him.  The indications, benefits, and risks of tetanus vaccination are discussed with both parents.  The mother consents to the proposed tetanus vaccination and requests that it be administered immediately.  However, his father refuses to agree to the vaccination as he prefers to explore herbal remedies.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec25c8_d74b_d299_bc81_db2d8c98d9f7_MD0003_00 This patient is an unemancipated minor, defined as an individual age <18 years who requires consent by a parent or legal guardian for medical or surgical treatment. In all states, minors may receive acute care without consent if obtaining it would delay treatment. The parents or legal guardians must be notified as soon as possible. Many states also allow minors to consent without parental notification for contraception, treatment of sexually transmitted diseases, prenatal care, mental health services, and substance use rehabilitation (Table). According to the American Academy of Pediatrics Committee on Bioethics, a parental decision to decline routine immunization for an unvaccinated child is often tolerated as the risk of acquiring infection in a community with herd immunity is relatively low. In contrast to elective vaccination, this patient is at high risk of tetanus infection from the deep puncture wound and administration of tetanus vaccination is urgent. In patients with divorced parents, only parents with custody may give consent for medical care. Parents with joint custody are each able to consent, but consent from only one parent is all that is necessary to proceed with treating the minor, especially when the decision is clearly in the child's best interests. In all cases, treatment is ideally discussed with both parents to reach an agreement that will help the child and facilitate cooperation between the treatment team and the parents. (Choice A) Unemancipated minors do not have the legal authority to consent for procedures; consent must be obtained from at least one parent. (Choice B) It is appropriate to consult the hospital's ethics committee if an ethical dilemma is present. This is not the case with this patient as tetanus vaccination is in his best interest and the mother has already provided consent. (Choice C) If both parents refuse to consent to life-saving treatment, the physician would need to seek court approval before administering necessary but nonurgent treatment (eg, chemotherapy for acute lymphoblastic leukemia in a stable patient). (Choice E) Withholding the proposed treatment is inappropriate as the mother has already consented, which is considered legally sufficient to proceed. Parents cannot deny their children life-saving treatment unless the benefits are minimal or would not alter the prognosis. Educational objective: When caring for an unemancipated minor, informed consent from one parent or guardian is considered legally sufficient to justify proceeding with therapy. Physicians should also provide care in urgent situations without waiting for parental consent. References: Consent for emergency medical services for children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/12612264) Childhood immunization: when physicians and parents disagree. (http://www.ncbi.nlm.nih.gov/pubmed/22045859)

Exam 2: Pediatric