Question of the Week # 28

9 year old girl is brought to the ER for a foot infection which looks serious. She needs IV antibiotics and debrideent, or you know that her foot is in danger of amputation. The mother refuses consent for antibiotics and debridement. You discuss the need for immediate treatment and the risks in the presence of a witness. But mother still refuses the treatment. Your next step:

1) order the antibiotic and the debridement, overruling the mother.
2) Get an emergency court order
3) get an emergency ethics consult
4) agree with the mother and not give the treatment

21 Responses

  1. 2

  2. Get emergency court order…

  3. ) order the antibiotic and the debridement, overruling the mother.. this is life threatening situation

  4. a

  5. a

  6. 1

  7. complywith the mother

  8. when will the answers be posted by Archer?

  9. 1

  10. 2

  11. A-This case is very serious the child’s welfare ,safety & life depend on these measures. Save the child’s life .

  12. Over-rule the mother denial. In this case child is going to loose her limb. We need to over rule the parents refusal. There is no need to take court order in this emergency case.

  13. A

  14. a

  15. No need of a court order in a life threatening situation involving a child’s life. Always remember in USA, children are given priority at the E.R. no1 gives a F*** in regards to what the parents say. Imagine, you have a pregnant woman who is a jehova’s witness refusing blood transfusion. Treat her with NS until the baby’s out of the vagina! Once, the baby is out all the Jehova’s go unwitnessed and your priority is the kid! 😉

    • Time out! Guru jee, you need a vacation. ‘F’ word?, excuse me, this is a PG 13 audience. Orgy! Orgy! Vs Jonah. Reference The Great Storm, “…Each man said to his mate, ” come, let us cast lots so we may learn on whose account this calamity has struck us.” So they cast lots and the lot fell on Jonah. So they said to him, ” Tell us, now! On whose account has this calamity struck us? … Jonah said, “I am Hebrew, and I fear the LORD God of heaven who made the sea and the dry land.”
      Jonah 1:8
      Jury: Jonah is innocent. Orgy is way out of line.
      Orgy! Vs The Queen. Reference Inaberrant Heresy of Words. “Sweet Helen make me immortal, I will be Paris, and for love of thee, and I shall hurt Archilles in the heel”. Faustus speech, shade of Helen of Troy, paraphrased.
      Jury: The Queen is not guilty. Orgy is guilty as charged.
      Penalty: $300 court fee, and a vacation to Bahamas for an encounter with Freddy the veteran stingray.

      Theme of story: Courts protects civil liberty and religious beliefs as long as individual or parent as long as the safety of others, including minors is not at stake.

      What is the role of a physician? Decides what is life threatening.
      If with-holding treatment can cause imminent death of a minor in the ER, the law favors forced treatment. A gangrenous limb with septic shock must be treated irrespective of consent.
      If withholding treatment cannot cause imminent death but can cause disability or critical condition or even death in the near FUTURE, like Diabetes type 1 or gangrene with/ without sepsis (not septic shock), one has to get a court order to initiate treatment. Yes, if the child dies because of a documented refusal to consent, the court will hold parents responsible on charges of murder. ( Wisconsin case, http://www.law.uh.edu/healthlaw/perspectives/2009/(BP)%20Faith.pdf)
      But the doctor has no right to implement forced treatment of critically ill patients unless death is likely in the ER without treatment.

      Now, let’s ask ourself, will this child die in the ER if IV fluids and antibiotics are not administered. Answer is no. So emergency court order is necessary and it will relief the doctor of professional and ethical responsibilities.
      My answer is Option B.
      But if this child presented in septic shock and he has a visible wet gangrenous limb, forced treatment is appropriate even without parental consent because the minor will die in the ER.
      Can the parents take the child out of ER against medical advice in septic shock with intent to look for alternative medicine? No, it is illegal. Forced treatment is necessary because, the child will die in the next few hours. If the parents did not come to Hospital, it is a federal crime, and if the child dies, the parents will be prosecuted for murder.
      But in this case, amputation MAY be needed. It is not indicated right now. Division of Social Services (DDS) should be involved and they can give the family the option of ‘hand-on’ surgical/ medical evaluation at a different medical facility. So since amputation is not indicated right now as an emergency, the DDS will file a claim of medical neglect if parents remain adamant and assume child custody.
      Can we let the parents sign out of the hospital against medical advice in this case of sepsis with imminent risk of amputation? No. Even if it is not septic shock. Not initiating IV Antibiotics and fluids now is below the standard of care. The child can only be transferred to another qualified medical facility for re-evaluation on request of the parents but DDS must be involved now to follow this case and they must sign consent to treatment. Resuscitation has to be started. Remember, refusal to consent is wasting time and making the child sicker. Parents can not withhold treatment unless treatment risk outweighs benefit. DDS will claim in court for custody of child on emergency grounds. Don’t assume that DDS in the other hospital will file claim if the parents don’t change their mind. This is unacceptable, claim has to be made right now because the child has sepsis which can progress to shock without treatment. If this child was on fluids and IV antibiotics and parents refuse amputation, amputation decision can be reevaluated in a different ‘hands-on’ surgical center. Bottom line, DDS needs to file emergency court claim of child custody because the child is at risk of substandard health care.

      Please review this case from American Medical Association Journal of Ethics: virtual mentor.ama-assn.org/2003/08/ccas1-0308.html

      • Pls ignore this post and read my second post.

      • Sorry folks, in this post I am insidiously DUI. (Driving Under the Influence) differentials – ashwaganda, crack, hemp, speed, vodka? Yep, you guessed right. It’s ashwaganda.

  16. i guess 2 is the correct answer

  17. In minors, physician decides what is life threatening, limb threatening or sub-standard of care. In either of these three conditions, the doctor can forcefully intervene if necessary.
    In UNSTABLE condition, if with-holding treatment can cause death of a minor in the ER, the law favors forced treatment. Example, a gangrenous limb with septic SHOCK must be treated, amputation done irrespective of parental consent. This is life saving.
    In UNSTABLE condition, if withholding treatment cannot cause death but MAY (50-50) cause disability, amputation, the law favors FORCED RESUSCITATION (like fluids antibiotics and blood transfusion) but not outright amputation. (Like the patient in this question)
    If withholding treatment can cause critical condition, limb loss or even death in the near FUTURE but patient is STABLE right now like normoglycemic child with Diabetes type 1 or wet gangrene with/ without sepsis (not septic shock) on IV antibiotics and other forms of resuscitative measures, one has to get a court order to initiate treatment. In a STABLE patient forced treatment is unacceptable.
    SIMPLE APPROACH:
    Unstable means treat, stable means court.

    If stable minor dies suddenly, while parent are refusing to consent, the court will hold parents responsible on charges of murder. ( Wisconsin case, http://www.law.uh.edu/healthlaw/perspectives/2009/(BP)%20Faith.pdf) Will the doctor be held liable also? No, only if he does not involve the division of social services (DDS), court or ethical committee.

    The doctor has no right to implement forced treatment of critically ill minors beyond resuscitation unless death or limb loss or organ failure or substandard level of care is likely without needed therapeutic intervention. (I.e UNSTABLE MINOR is KEYWORD) If a surgery or procedure or treatment is limb or life saving AND patient is unstable, or at risk of substandard acute care, the doctor forcefully intervenes.

    The question is, what justifies forced treatment in our question? Parent is refusing resuscitation and CHILD is UNSTABLE and in need of acute care. So forced treatment is necessary. If parent agreed to IV antibiotics and fluids, but refused amputation, emergency court order is necessary and it will relief the doctor of professional and ethical responsibilities.
    My answer is Option A after reconsidering. Sorry for any disappointment caused.
    Some practice examples, A different child presented in septic shock and he has a visible wet gangrenous limb. Answer, UNSTABLE so, forced treatment is appropriate even without parental consent because the minor will die in the ER.
    Can the parents take the child out of ER against medical advice in SEPTIC SHOCK with intent to look for alternative medicine? No, it is illegal. Forced treatment is necessary because, the child will die in the next few hours. If the parents did not come to Hospital, it is a federal crime, and if the child dies, the parents will be prosecuted for murder.

    What if the parents consent to stabilizing their child on resuscitation alone? Amputation MAY be needed but delayed. Division of Social Services (DDS) should be involved and they can give the family the option of ‘hand-on’ surgical/ medical evaluation at a different medical facility. So since amputation is not indicated right now as an emergency, the DDS will file a claim of medical neglect if parents remain adamant and assume child custody. The key is stable or not and that directs the next step.
    Our patient in the question is being denied of resuscitation that will stabilize his condition. She is currently unstable. So forced treatment is necessary.
    Can we let the parents sign out of the hospital against medical advice in this case of sepsis with imminent risk of amputation (like in this patient)? No. Even if it is not septic shock. Not initiating IV Antibiotics and fluids now is below the standard of care. The child can only be transferred to another qualified medical facility for re-evaluation on request of the parents but child must be resuscitated first.
    Resuscitation has to be started unconditionally. Remember, refusal to consent is wasting time and making the child sicker.

    When do the DDS come in? If parents remain adamant and patient is stabilized but needs a procedure that is clearly necessary but can not be enforced because child or minor is STABILIZED already.
    Parents can not withhold treatment unless treatment risk outweighs benefit. Amputation sets a good example here. If an amputation is mandatory and parents consented to initial management only, DDS will claim in court for custody of child on emergency grounds. If this child was on fluids and IV antibiotics and parents refuse amputation in current hospital, amputation decision can be reevaluated in a different ‘hands-on’ surgical center. Bottom line, DDS must be on deck to file emergency court claim of child custody because the child is at high risk of substandard health care. DDS will ensure that parent comply where necessary but for now, forced intervention is appropriate.

    Please review this case from American Medical Association Journal of Ethics: virtual mentor.ama-assn.org/2003/08/ccas1-0308.html
    Also read other references for further study:
    http://www.law.uh.edu/healthlaw/perspectives/2009/(BP)%20Faith.pdf
    http://www.ama-assn.org/resources/doc/code-medical-ethics/10016a.pdf
    http://death.uslegal.com/right-to-refuse-lifesaving-treatment/
    http://mn.gov/mnddc/honoring-choices/cnnReports/Moral_and_Ethical_Issues4-Baby-Doe-Kappel.pdf

  18. A.

    A parent refusing treatment for a child is a form of child abuse. Child abuse management is as follow: treat medical or surgical condition first, report to CPS, and get court order if parent refuse.

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