A 24-year-old woman comes to the office accompanied by her caseworker. This is the first time that she has been seen in the office, and she appears mildly anxious. However, she quickly relaxes once the female physician enters the room. The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend. Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant. The patient says, "I would like to go on birth control. I want a baby one day but not until I am married." The caseworker reports that the patient's mother, who was unable to attend the appointment, is extremely concerned about the patient's plan. The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child. The patient becomes tearful and says, "My mom doesn't know what's best for me. I know I can be a good mom." Which of the following is the most appropriate next step in assisting the patient with these decisions?

Question

A 24-year-old woman comes to the office accompanied by her caseworker.  This is the first time that she has been seen in the office, and she appears mildly anxious.  However, she quickly relaxes once the female physician enters the room.  The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend.  Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant.  The patient says, "I would like to go on birth control.  I want a baby one day but not until I am married."  The caseworker reports that the patient's mother, who was unable to attend the appointment, is extremely concerned about the patient's plan.  The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child.  The patient becomes tearful and says, "My mom doesn't know what's best for me.  I know I can be a good mom."  Which of the following is the most appropriate next step in assisting the patient with these decisions?

Quizplus · Accepted Answer

Explanation: There are several ethical issues raised in this situation regarding the patient's moderate intellectual disability and ability to make her own health care decisions. The priority at this time is to determine whether she has a designated guardian, as the guardian must be included in the decision-making process. It is appropriate and respectful to ask the adult patient about guardianship status first. If the patient does not know or appears confused, it is appropriate to ask the parent or caseworker. Parents are assumed to be the guardian of a patient who is a child; otherwise, a guardian may have been appointed in the event of parental death, child abuse, neglect, or other circumstances. When children reach age 18, their parents may pursue guardianship in order to continue to make decisions for those with an intellectual disability, especially if an adult child's disability is severe enough to impair global decision-making capacity or ability to communicate. However, if the parent does not pursue guardianship, the patient becomes his or her own guardian. It should be noted that guardianship laws vary by state. (Choice A) Assessing the patient's understanding of contraceptive choices is essential. However, it must be first determined if a guardian has been appointed; if so, then the discussion should be conducted with the guardian present. (Choice B) Although assessing the patient's understanding of the responsibilities of parenthood is important, the priority is to determine whether the patient is in charge of making her own health care decisions. (Choice D) Recommending tubal ligation to this patient would be coercive. It disrespects her presumed autonomy and dismisses her stated desire to have a child one day. (Choice E) This would be true only if the patient were under the age of 18 or if the mother were known to be the patient's appointed guardian. Educational objective: It is important to determine guardianship status for adult patients with intellectual disability. Guardianship should be clarified early in the medical relationship to facilitate decision making.

A 24-Year-Old Woman Comes to the Office Accompanied by Her