A 5-year-old boy is brought to the emergency department by his babysitter due to his becoming increasingly irritable and sleepy. She says that the patient had a fever this morning; since then, he has become progressively sleepy and is now difficult to arouse. The child is refusing food and liquids and has vomited twice. The babysitter has watched the boy for the past 2 days while his parents attend a wedding. She tried calling the patient's parents on the way to the emergency department but was unable to reach them. The child's immunization status is unknown. Temperature is 38.9 C (102 F), blood pressure is 90/50 mm Hg, pulse is 114/min, and respirations are 20/min. Physical examination shows a lethargic, pale child who is difficult to arouse. Pupils are 4 mm and reactive to light. A funduscopic examination is deferred due to patient agitation. Nuchal rigidity is noted. Deep tendon reflexes are 2+ in all extremities. Before treatment is initiated, the parents call and say that they will arrive at the hospital within 15 minutes. They state that they will take the boy home and refuse all medical treatment because their religious beliefs preclude them from "interfering with God's will." They offer to have their minister contact the emergency department to explain their beliefs in detail. Which of the following is the most appropriate next step in management of this patient?

Question

A 5-year-old boy is brought to the emergency department by his babysitter due to his becoming increasingly irritable and sleepy.  She says that the patient had a fever this morning; since then, he has become progressively sleepy and is now difficult to arouse.  The child is refusing food and liquids and has vomited twice.  The babysitter has watched the boy for the past 2 days while his parents attend a wedding.  She tried calling the patient's parents on the way to the emergency department but was unable to reach them.  The child's immunization status is unknown.  Temperature is 38.9 C (102 F), blood pressure is 90/50 mm Hg, pulse is 114/min, and respirations are 20/min.  Physical examination shows a lethargic, pale child who is difficult to arouse.  Pupils are 4 mm and reactive to light.  A funduscopic examination is deferred due to patient agitation.  Nuchal rigidity is noted.  Deep tendon reflexes are 2+ in all extremities.  Before treatment is initiated, the parents call and say that they will arrive at the hospital within 15 minutes.  They state that they will take the boy home and refuse all medical treatment because their religious beliefs preclude them from "interfering with God's will."  They offer to have their minister contact the emergency department to explain their beliefs in detail.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has fever, vomiting, altered mental status, and nuchal rigidity, findings highly concerning for life-threatening bacterial meningitis. Blood cultures and lumbar puncture are required with immediate initiation of parenteral antibiotics. Delaying treatment can result in rapid deterioration and death. In emergency situations, such as this case, the inability to obtain consent or parental refusal of consent should not delay care. Parental refusal to consent to an intervention that may prevent severe injury or death may be considered an act that is not in the best interest of the child, and medical providers should proceed with treatment. A court order should also be sought to legally overrule a parental decision; however, treatment should not be withheld while awaiting a decision, due to the risk of severe disability and death (Choice E). (Choices A and C) In nonemergency cases, organizing a family conference and consulting the hospital's ethics committee are appropriate measures to facilitate an agreeable and ethical course of action. (Choice D) Adults and emancipated minors (eg, financially independent, married) may lawfully refuse their own care based on religious beliefs. However, if religious beliefs interfere with potentially life-saving treatment in a minor, treatment should proceed without delay. Discussion with a minister is an additional obstacle to providing immediate treatment to this patient. Educational objective: If a parent refuses medically necessary care for a child in an emergency situation, treatment should proceed while simultaneously seeking a court order to continue care. References: Conflicts between religious or spiritual beliefs and pediatric care: informed refusal, exemptions, and public funding. (http://www.ncbi.nlm.nih.gov/pubmed/24167167)

A 5-Year-Old Boy Is Brought to the Emergency Department by His