**
Um, I was talking to the OTHER doctor. The OP, DoctorJ, who, IIRC, is in practice in rural Kentucky.
Make no mistake about it as a care provider you are influential, extraordinarily so, but in the in the end it’s all about resources and the reality of limits. As modern care options increase exponentially in number and expense combined with the huge and virtually unlimited social appetite for medical care, there is a supply and demand point where needs, wants and real world resource limits intersect to constrain the delivery of that service. In this context the relative “humaneness” of what we can effectively deliver in the way of medical care is constrained by the limits of what society is willing to pay for. In the US this is actualized in the form of the contractual envelope of actuarial wagers, in the form of individual and group policies, that insurance companies are willing to make with respect the amount of care they can deliver and stay in business.
With respect to pregnant women vs the rest of the population needing care IMO an insurance company has not just the right but the duty to constrain the amount of care delivered for any individual based on the real world expectations about how effectively that care can and will be managed. Having said this, I believe that the delivery of care in the US is often shamefully inefficient, haphazard, unfair and disjoint, especially for the socially and economically disadvantaged but until a better system of administering and delivering care is implemented, which people are willing to pay for, we have to live within the limits of our means.
Complaining about insurance gate keepers and pencil pushers controlling the delivery of care is an absurdist form of performance art by care providers. They are there because someone has to say “no…this is enough” which is something compassionate care providers are loathe to do by nature. If it’s my daughter in the hospital bed or my patient being denied care because of cost I would be agitated but someone has to control costs and to demonize insurance companies/HMOs etc for the unsurprising inability of individuals in need to understand and agree with those limits is pointless. Someone has to be the gatekeeper or the system providing coverage, whether privately or publicly funded, eventually falls apart.
Doctor Paprika:
Easy there, Doc. Take a breath. I’m not staking out any moral ground here, I’m just offering alternative opinions, and questions for discussion. I said nothing about “punishment,” nor have I advocated taking anyone’s rights away. If you think I have, please point it out for me, and I’ll apologize forthwith.
I haven’t offered an opinion before now. Here ya go: I do believe that it is irresponsible to have children without the means to support them. I think it’s irresponsible to endanger the heath of one’s fetuses, against medical advice. I also support ZPG. But that does not mean I advocate any punishment, or the removal of anyone’s rights.
Put that in your stethescope and smoke it.
I only smoke cigars, once in a while.
I was actually looking for answers from the OP, who could answer many of them. But I have writtenyour opinion in the Big Book Which I Keep In The Hall for future reference.
Ah. Since you quoted me, and didn’t address DocJ, I kinda assumed you just might be directing your post toward me. Silly, I’m sure.
My initial response to the OP was to focus on the unborn twins. When it’s a case of an adult choosing to go against medical advice, I’d say that no one has the right to force the person to accept unwanted treatment. But in this case, the unborn twins are the ones who may pay a high price for their mother’s decision. Perhaps I’m out of date, but my impression is that two of the most common problems faced by premature babies are blindness and mental retardation. To me, the mother’s refusal of treatment sounds irrational.
Maybe this needs to wind up in court, with the hospital’s lawyer, the mother’s lawyer, and a court appointed lawyer to represent the twins’ interests?
Your impression is incorrect. Blindness is uncommon and mainly related to gonorrheal disease not treated with antibiotics after birth (as most abies routinely are) or missed retinoblastoma. If the baby is deprived of oxygen it can indeed suffer brain damage but this is a result of chronic hypoxia – and the baby’s body spares the brain so this are the last to go.
At 31 weeks, the organs are eveloped except for the lungs. Babies born at 24 weeks are usually not viable. Your trachea divides into two bronchi which lead to each lung; an adult has 18 further divisions to form a very fine network of bronchioles which are not fully formed until well after birth. At 31 weeks, the lungs are likely formed enough to survive (something like 98% do) but would need surfactant to prevent lung collapse and respiratory distress syndrome. The risk of bronchopulmonary dysplasia in the children is real and they would need NICU care to monitor growth and vitals.
Delaying labour is also risky if there is a good reason for its onset. Infection (chorioamniotis) is a very real risk if the membranes have ruptured, the babies should be delivered if there is evidence of toxemia or severe fetal distress. I did not ask about amniotic fluid volume or the position/presentation of the babies but this is also relevant.
Coincidentally, I just finished a 2 month rotation in obstetrics. We did deliver twins at 31 weeks by Caesarian section, but the complicating factors were a little diffferent in this case. The goal of obstetrics is to have a healthy mother and healthy babies, I don’t think they’re mutually exclusive in this case. If it was 28 weeks, everything would be different.
And surfactant is provided directly by god, or it requires medical intervention? Does anyone have the same questions I do regarding whether this mother will refuse medical care for her premature infants?
-L
Surfactants are produced by the lung starting at about 24 weeks. Ideally, at 31 weeks one would give a dose or two of artifical or bovine surfactant to the mother within 24 hours before delivery. It is unclear how much medical care this woman is refusing, from the OP sounds like refusing a tocolytic to delay labour – not necessarily all treatment.
After the delivery, if the babies are clearly in danger the mother has far less right to refuse them surfactant and the neonatologist would strongly consider giving it anyway even if the mother refused if the treatment was medically essential. This case has too many unknowns to discuss rationally, but from the information we have the only factors threatening the baby are well-controlled (?gestational) diabetes and the 31 wks. gestation.
I think it would be unethical to not attempt to persuade her of the best decision, using the best information at hand (even show her the results in the preemie ward if necessary) and to absolve yourself of any liability. I would inform her that God has brought her to you as her medical caretaker, and this carries an implication that you should decide what is best for her health. If there is a medical ethics consultant handy (I’ve heard they are used for terminally ill family consultation to refuse treatment), I’m sure he/she could take the responsibility to persuade this women.
Ethically, we assume that all rights imply responsiblities. If society is paying for two mentally incompetent babies from a mentally incompetent mother, then we need to at least safeguard our interests when we can easily do so. When in doubt, the RIGHTS of anyone at anytime falls upon those who have responsibility (financial or otherwise), and it seems to me like you have this responsibility in a medical sense, by representing society. Good luck.
To those who think rights are written in stone, show me where and I’ll show you the spray-painted graffiti of wishful thinking. Rights only exist under certain assumptions that never involve absolutes (ie, we don’t have the right to have a child if one more child would sink the life-raft everyone else is on–bad analogy but you get the idea). Personally, I can’t fathom the absolute right for a baby to survive if it is known to be severely brain-damaged and incapable of survival outside of an icubator. This is merely a spoiled arrogance that takes so many resources for granted.
Sorry I haven’t been back to this thread. I’ve been busy and ill, a bad combination.
I wish I could offer an update, but I really can’t. We (the psych team) did our job–evaluating her capacity to make the decision–and left it alone. I haven’t been back to MFM or spoken to anyone from that team to find out what happened.
Dr. P: MFM believed the risk to the fetuses to be great enough that they were considering a court petition. I believe there were additional complications beyond those I mentioned in the OP. I have yet to have a single day of OB, so I’m going on the fact that the people who are trained to do that sort of thing thought it was far too early to deliver. I don’t know exactly what risk the fetuses faced.
I doubt that they went through with the court action, though, since we felt her capacity to make the decision was intact. That would have made the court order very difficult to obtain.
I posted this question because I’m not sure about the answer myself. Two months earlier, I would have definitely supported this woman’s right to have an abortion. Two months from now, I would fight tooth and nail to protect her babies from her bad judgement. But now? I don’t know.
I think that by making the decision to bring these children into the world (that is, not having an abortion), she has the responsibility to do what is best for them, before and after the pregnancy. However, I don’t know where the “best for them” line is drawn–do we take over the lives of pregnant mothers who smoke? Who fail to control their diabetes? Who deliver with a midwife instead of a physician? A family doctor instead of an OB? Outside of a quaternary care center?
I bring up the issue of money only because my fellow student on the service, who was not nearly as torn on this issue as I was, brought it up. If both these kids have to stay in the NICU for a couple of months, that’s an astonishing amount of money. He argued that we see patients every day who can neither afford their treatment nor get governmental help, and this woman’s decision will divert funds that could be used to help the other patients. I know it isn’t that simple, but I can’t disagree with his point, either.
Dr. J
Request to talk to her pastor/minister if she starts quoting God, it couldn’t hurt (but check to be sure what denomination she is and if you’ve never heard of it, don’t bother).
DoctorJ;
Are you a doctor, or are you a student? And if a student, what kind? Some things about your post imply you are a physician, some impute the opposite. Just for clarity’s sake, please define your role in this woman’s care.
Qadgop, MD
OK, should have checked your profile before posting, I see that you are not yet a physician. I take it you’re rotating thru the psych service and engaging in group consults. Well, it certainly looks like you’re getting great exposure to the world of modern medical dilemmas, and I’m sure you’ll have many,many more. After 2 decades in medicine, I find the problems getting knottier and knottier, and while I still love medicine, and enjoy most of my patients, all I really want to do right now is hit the lotto and retire!
I’m voting for Pastoral Care, too - does your hospital have a staff pastor/minister? Some do, some don’t. If you don’t ask if she wants to speak to her minister (or one of the same faith). You can’t force it, but asking in a supportive way should at least give your medical team points for patient advocacy.
If you do have one, calling them in to consult would have been my first suggestion to the OB team - if she’s competant, and her reasoning is religion-based, you need to discuss it on a religion basis. Which means pulling in the professional help, someone trained in Pastoral Care or Pastoral Counseling. I suspect that a minister might have had more pull to get her to at least rethink her position than any medical specialist would. My mom (a minister) did a pastoral care rotation for her seminary degree, and this is the kind of issue some of them dealt with (she ended up doing her rotation in a Psychiatric Hospital, so not the same type of issues). Sometimes, having someone who will fully support the grounds for the decision, but will also help explore the decision itself is very helpful for making the most balanced decision.
Consider that for further cases.
I’m voting for Pastoral Care, too - does your hospital have a staff pastor/minister? Some do, some don’t. If you don’t, ask if she wants to speak to her minister (or one of the same faith). You can’t force it, but asking in a supportive way should at least give your medical team points for patient advocacy.
If you do have one, calling them in to consult would have been my first suggestion to the OB team - if she’s competant, and her reasoning is religion-based, you need to discuss it on a religion basis. Which means pulling in the professional help, someone trained in Pastoral Care or Pastoral Counseling. I suspect that a minister might have had more pull to get her to at least rethink her position than any medical specialist would. My mom (a minister) did a pastoral care rotation for her seminary degree, and this is the kind of issue some of them dealt with (she ended up doing her rotation in a Psychiatric Hospital, so not the same type of issues). Sometimes, having someone who will fully support the grounds for the decision, but will also help explore the decision itself is very helpful for making the most balanced decision.
Consider that for further cases.
poop