Discussion – Neonatal, Child & Women’s Issues
Choose one of the following case studies. You then will answer the accompanying questions to your ONE chosen case study and post your answer-viewpoints to the discussion board. Also respond to at least one of your classmates posts within the first 24hrs of the assignment due date to encourage discussion.
Case Study #1: Critically Ill Newborns
The newborn intensive care unit (NICU) is a common setting for difficult ethical challenges, often involving life-and-death decisions. These may include withholding treatment such as resuscitation, mechanical ventilation, or surgery, or withdrawing life-sustaining medical treatment such as mechanical ventilation and artificial nutrition and hydration. Such decisions are frequently faced because of the high morbidity and mortality of some conditions commonly encountered in this setting, such as extreme prematurity, perinatal asphyxia, and major congenital anomalies. Who should decide when a treatment should be withheld or withdrawn? Ideally, decisions are made by the parents, providers, and nurses working together, but what is to be done when they disagree? On what basis should decisions be made? Ideally, a careful ethical analysis is carried out, based on solid clinical and prognostic data and the values of those involved in making the decision. In reality, data are often very vague and values are often not shared in common, but a decision must nevertheless be reached.
Such critical ethical decisions may be more common in the NICU than in other pediatric settings, but they are certainly not unique to the NICU. Nonetheless, is there something unique about ethical problems encountered with this patient population? For example, is borderline viability based on extreme prematurity a unique situation in pediatrics, or is it analogous to other problems sometimes encountered in the care of older children? Are clinicians more willing to withdraw or withhold life-sustaining treatment for this patient population than for others in pediatrics or adult medicine? If so, is this justified?
A 36-year-old woman who has been pregnant 3 times but has no living children presents to the hospital in active labor and ruptured membranes at 22 weeks and 5 days’ gestation. The fetus is a female singleton, the product of in vitro fertilization. Pregnancy was otherwise unremarkable, including several normal ultrasounds. Estimated fetal weight is 530 grams. On physical examination the cervix is dilated and the obstetrician believes that delivery will occur within the next several hours. The pediatric team meets with the woman and her husband to share information, answer questions, and discuss the plan.
1. What options should be offered to the parents for resuscitation and treatment?
2. If informed parents request resuscitation and intensive care but the clinical team feels they are inappropriate, is the team nevertheless obligated to provide it?
3. If informed parents decline resuscitation and intensive care measures but the clinical team feels it is inappropriate to withhold those measures, is the team nevertheless obligated to withhold those treatments?
4. What ethical principles or approaches can be applied to guide clinicians and parents through the care provided to this child?
Case Study #2: Maternal-Fetal Conflict
Pregnancy is a unique circumstance in medical ethics because of the absolute requirement to access the fetus only through intervention on the pregnant woman. Increasingly, as medical advances have offered the promise of therapy to the fetus, fetal interests have been considered separately from maternal interests by clinicians, policy makers, and the bioethics community. This is a somewhat artificial distinction, as usually maternal and fetal interests are aligned, and care of the fetus is intertwined with and dependent on care of the pregnant woman.
When conflict arises between maternal and fetal interests (eg, treatment of cancer during pregnancy that may result in fetal demise), a variety of ethical frameworks may be useful to consider for conflict resolution and decision-making. Helpful theoretical approaches include case-based analysis, the ethics of care, feminist theory, and traditional ethical principlism that uses the framework of autonomy, beneficence and nonmaleficence, and justice. In addition, societal and practitioner values can elevate emotionally laden issues of obstetric conflict and benefit from a comprehensive, thoughtful analysis from a variety of perspectives.
Different theoretical approaches all agree with the importance of promoting the autonomy and bodily integrity of the pregnant woman, ensuring that she has the information to provide a fully informed consent that is consistent with her values regarding pregnancy outcome.
In cases in which her decision may harm her fetus, coercion to force treatment is never justified. In extraordinary cases, legal intervention has been attempted. Using the courts to enforce treatment compliance by pregnant women has frequently been unsuccessful or has activated processes that are hasty and incomplete, and such court rulings are frequently overturned on appeal. Evidence shows that continuing a trusting, compassionate, professional relationship with the pregnant woman generally results in greater success in improving maternal and child health. Feminist ethics perspectives can help detect subtle, gender-based biases in clinicians’ approaches to conflict resolution and support collaborative decision-making for the pregnant woman and her health care team.
Jesse is a 24-year-old who presents in active labor with no prenatal care. The fetus appears to be term, quite large, and at risk for dystocia. Jesse is told that a cesarean birth is the best route of delivery for the fetus’ well-being. She declines the operation and requests a natural childbirth. Although the fetus begins to have heart rate deceleration consistent with fetal distress, Jesse continues to decline the recommended cesarean delivery.
1. Does the provider have an ethical obligation to intervene on behalf of the fetus as a patient?
2. What are the best interests of the pregnant woman and how are they determined?
3. What are the best interests of the fetus and how are they determined?
4. What ethical considerations, other than best interests, can inform the decision-making process?
5. Can the pregnant woman refuse the recommended treatment, particularly if harm is expected to come to the fetus?
Case Study #3: Genetic Testing & Screening of Children
Every year, approximately 4 million children undergo genetic testing as part of newborn screening. This is the most common form of genetic testing in the entire population. Other children undergo genetic testing as part of a diagnostic workup for clinical problems (from progressive muscle weakness to developmental delays) or as part of research protocols or family linkage analyses. With the completion of the human genome project, there are hopes that genetic medicine will evolve into personalized medicine and become an integral part of medical practice. The expansion of genetic testing and screening in pediatrics raises ethical issues about the limits of parental autonomy, whose consent is needed, and what rights to privacy, if any, do children have with respect to their parents.
Shari, a 15-year-old, comes to your office with her mother. Her younger brother, Bob, had an abnormal newborn screen for cystic fibrosis (CF), but a sweat test result was negative, indicating that he does not have CF. Bob was found to have one CF mutation (delta F507, the most common mutation). Both parents were screened and found to have delta F507. Shari is very healthy and tall and her parents and physicians are not concerned that she has CF, but her parents wants to know if Shari can be tested for being a carrier. Also, her mother, 2 maternal aunts, and maternal grandmother all had breast cancer in their early 30s. They have been tested and found to have BRCA mutation. Shari’s mom wants Shari tested for the BRCA mutation so that if she is a carrier, she will get appropriate screening even though there is no breast cancer in her father’s family. Shari tells her mother that she is ambivalent about genetic testing.
1. What is Shari’s risk of being a CF carrier?
2. What are the pros and cons of knowing that one is a carrier for an autosomal condition?
3. What role should Shari play in deciding about CF carrier testing?
4. What are the risks and benefits of knowing one is a BRCA carrier?
Case Study #4: Refusing Pediatric Vaccinations
Phoenix, a 24-month-old boy, is brought in by his mother for his annual well-child physical examination. The provider notices that the child has yet to receive vaccination against measles, mumps, and rubella (MMR) and reminds his mother of the need to have her son immunized. The mother is hesitant and states that she has heard of the links between MMR and autism. Citing several recent cases of measles in the community, the physician stresses the need for the MMR vaccine to protect the young child, because they may be in the midst of a measles outbreak. He tells her that mortality rates range between 1 and 3 of every 1000 cases and that acute encephalitis, which may cause permanent brain damage, occurs in about 1 of every 1000 cases. The mother counters that her chiropractor has discussed the issue of vaccination with her, including the topic of vaccination safety. In addition, the chiropractor discussed immune function and noted that treatments such as spinal manipulation and nutritional supplements, although not an alternative to vaccination, may optimize her son’s natural immune function. The provider is frustrated and tells her that he is not comfortable with continuing care for Phoenix if she chooses not to listen to his professional advice. The provider wonders what he could have done differently to avoid this impasse.
1. What is the Advanced Practice Nurse’s ethical duty in the above scenario
2. What is the ethical duty of the parents when thinking about the “best interests” of the child
3. Should the Advanced Practice Nurse continue the patient-parent relationship and why?
4. What information does the Advanced Practice Nurse need to give the parents for them to make an informed decision?
Case Study #5: Contraception for Adolescents
The United States has the highest teen pregnancy rate among developed countries. In recent years, however, the teen pregnancy rate has been dropping, which is attributed largely to improved contraceptive use. Counseling is particularly important in adolescent girls to ensure they understand their contraceptive options and use contraception consistently. One-third of teenagers have not received education in their schools about contraception. Counseling should provide an opportunity for adolescents to explore the emotional, physical, and financial consequences of sexual activity with a knowledgeable, nonjudgmental adult. In the United States, adolescent girls have their first sexual experience at 17 years of age on average, and 7 of 10 have intercourse by the time they are 19 years of age, but most do not marry until their mid-20s. Therefore, they may be at increased risk of unintended pregnancy and STDs for several years. From 2005 through 2008, 84% of sexually active teenaged girls used contraceptives during their first sexual encounter. A sexually active teen who does not use contraception has a 90% chance of becoming pregnant within a year.
More than half of sexually active adolescent girls who use contraception take an oral formulation. Oral contraceptives are a safe choice for them, even those who smoke. The absolute risk of thrombosis with use of combined oral contraceptives in a healthy adolescent is 0.05% per year. However, teens are more than twice as likely to become pregnant while using the pill for contraception compared with women aged ≥30 years, largely due to inconsistent use. Most adolescents have difficulty using any contraceptive method consistently, including the pill. Remembering to take a dose often is difficult during weekends away, family vacations, trips to visit relatives, or visits to noncustodial parents. Given a choice, most adolescent girls choose a long-acting contraceptive option.
Jocelyn is a 15-year-old adolescent girl who asks her primary care clinician for a refill of her prescription for combined oral contraceptives. She began taking the pill 1 year ago to help control her acne. Since then, she has become sexually active. She denies experiencing breast tenderness, headaches, or breakthrough bleeding. However, Jocelyn says that because of her busy schedule in school and in a women’s soccer program, she does not always remember to take the pill on time. She is planning on going to college and has no interest in starting a family for several years. Jocelyn does not smoke and has no chronic medical illness. No positive findings for disease were found during the physical assessment and Body mass index (BMI): 23 kg/m2
1. What is the APN’s obligation to the patient?
2. Is the APN required to inform Jocelyn’s parents about her sexual activity?
3. Can Jocelyn give her informed consent?
4. What type of contraceptive is the best choice for Jocelyn?
Additional Materials you may need as you prepare your answers for the discussion board. 🙂
1. The best interest principle as a standard Download The best interest principle as a standard
2. Ethical issues in neonatal intensive care Download Ethical issues in neonatal intensive care
3. Parental rights and decision making regarding vaccinations Ethical dilemmas for the primary care provider Download Parental rights and decision making regarding vaccinations Ethical dilemmas for the primary care provider
4. Barriers to Effective Contraception and Strategies for Overcoming Them Among Adolescent Mothers Download Barriers to Effective Contraception and Strategies for Overcoming Them Among Adolescent Mothers
5. Ethical issues in predictive genetic testing a public health Download Ethical issues in predictive genetic testing a public health
6. Decisions and Dilemmas Related to Resucitation of Infants Born on the Verge of Viability Download Decisions and Dilemmas Related to Resucitation of Infants Born on the Verge of Viability
7. Applying Ethical Practice Competencies to the Prevention and Management of Unintended Pregnancy Download Applying Ethical Practice Competencies to the Prevention and Management of Unintended Pregnancy
8. The following document discusses the case of Ms. Case where the hospital refused to allow her to have a natural birth at their Florida facility and mandated a cesarean section. Document – Jennifer Goodall Case Download Jennifer Goodall Case
9. A survey of the awareness, use and attitudes of women towards Downs Syndrome Screening Download A survey of the awareness, use and attitudes of women towards Downs Syndrome Screening
