Extra Topic 6.1 -- Clinical Ethics (Consent) Flashcards
A 13-year-old female presents for tonsillectomy. She is accompanied by her mother.
During your preoperative interview the mother informs you that she and her daughter are Jehovah’s Witnesses.
She further insists that you promise not to give any blood products. What would you say?
(A 13-year-old female presents for tonsillectomy. She is accompanied by her mother.)
I would begin by identifying those interventions that were acceptable to her and the patient, such as albumin administration and/or intraoperative blood salvage with the blood remaining in continuity with her circulatory system.
I would then reassure her that I respect her religious beliefs and that the risk of significant blood loss during tonsillectomy is low.
It would also be important to make her aware that, absent her consent, I would seek a court order authorizing the administration of blood products in the case of life-threatening blood loss.
However, I would assure her that I would make every effort to respect her wishes and avoid the transfusion of blood, if possible.
Clinical Note:
- The legal doctrine, parens patriae, the state has an obligation to protect the interests of incompetent patients (i.e. young children), and parents (or surrogates) may not make decisions that result in grossly inappropriate treatment (overtreatment or undertreatment).
The patient tells you that she agrees with her mother and does not want a blood transfusion.
Would you now agree to withhold blood products?
(A 13-year-old female presents for tonsillectomy. She is accompanied by her mother.)
While it is important that patients of any age are involve din making personal medical decisions to the extent that their capacity permits, I believe that even a very mature 13-year-old child has insufficient capacity to make a decision that could result in serious harm.
Therefore, even though the need for transfusion is unlikely, I would not assign this child decision-making capacity in this case, where the refusal of blood transfusion could result in loss of life.
Clinical Note:
- The “rule of sevens” can be helpful in determining a child’s decision-making capacity.
- Children < 7 years of age are considered to lack decision-making capacity;
- children between the ages of 7 and 14 are unlikely to have decision-making capacity (a physician who assigns them such, may be in the position of defending their decision);
- children above the age of 14 (some sources include 14 year olds) usually have decision-making capacity (at least for fairly low risk decisions).
- If an anesthesiologist plans to assign decision-making capacity to a child between 14 and 18 years of age, it may be prudent to arrange for court-authorized support for the decision.
You are communicating the anesthetic plan along with the associated risks when the patient becomes tearful and states that she does not want to have her tonsils out anymore.
When you turn to the mother, she says, “Yes she does.”
What would you do?
(A 13-year-old female presents for tonsillectomy. She is accompanied by her mother.)
I believe that children should be involved in making decisions about their healthcare to the extent that they are able (capacity).
Furthermore, I recognize that, in the case of an elective procedure that can be delayed with very little risk, the refusal of assent may be ethically binding.
Therefore, I would first attempt to identify and allay her concerns.
If I believed that anxiety was the primary reason for her refusal, I would consider some potentially helpful options, such as removing her from the preoperative area, allowing her some time to compose herself, and/or offering her a preoperative anxiolytic.
If she continued to refuse the procedure, despite these interventions, I would initiate a discussion with the patient, her mother, and the surgeon about the risks and benefits of delaying the procedure until she was of sufficient age and maturity to make her own health care decisions, independent of her parents.
The patient is becoming increasingly upset and refuses to allow anyone to touch her.
The surgeon pulls you aside and asks if you can just use a “ketamine dart” to get her under control.
What would you say?
(A 13-year-old female presents for tonsillectomy. She is accompanied by her mother.)
I would let him know that the use of physical or chemical restraint is an option of last resort, and that my goal is to obtain her assent for the procedure to the extent that she is capable.
I would further point out that being angry and upset does not by itself indicate lack of capacity.
Therefore, I would not chemically restrain her unless the case could not be safely delayed or her behavior posed a threat to herself or staff.
The case proceeds, and the carotid artery is punctured during the procedure.
You do not believe there is time to obtain a court order authorizing emergent blood transfusion. What would you do?
(A 13-year-old female presents for tonsillectomy. She is accompanied by her mother.)
Given my legal and ethical obligation to protect the interests of the child (parens patriae),
I would provide life-saving blood products as necessary during this emergent situation.
I would only do this if I believed that to delay transfusion would place the child at an unacceptable level of risk for serious injury.
