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PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1151-1153
AMERICAN ACADEMY OF PEDIATRICS:
Forgoing Life-Sustaining Medical Treatment in Abused
Children
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ABSTRACT |
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Abstract
Recommendation
References
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A decision to forgo life-sustaining medical treatment (LSMT) for a critically ill child injured as the result of abuse should be made using the same criteria as those used for any critically ill child. The parent or guardian of an abused child may have a conflict of interest when a decision to forgo LSMT risks changing the legal charge faced by a parent, guardian, relative, or acquaintance from assault to manslaughter or homicide. If a physician suspects that a parent or guardian is not acting in a child's best interest, further review and consultation should be sought in hopes of resolving the conflict. A guardian ad litem who will represent the child's interests regarding LSMT should be appointed in all cases in which a parent or guardian may have a conflict of interest.
Pediatricians, pediatric subspecialists, and pediatric
surgeons caring for a severely abused child who is supported with
life-sustaining medical treatment (LSMT) face many difficult decisions.
One potential concern may be how to proceed when the child apparently
will survive with seriously disabling neurologic deficits or with
continued reliance on LSMT, such as a ventilator. Moreover, a parent or guardian may have a conflict of interest when a decision to forgo LSMT
risks changing the legal charge faced by a parent, guardian, relative,
or acquaintance from assault to manslaughter or homicide.
Conflict of interest from a parent or guardian should not arise if a
child is declared brain-dead. The declaration of death based on brain
death criteria is not dependent on the cause of the brain injury. Brain
death is a clinical determination based on established criteria,
supplemented (if necessary) by cerebral flow studies,
electroencephalograms, and other ancillary tests.1,2 In
cases of abuse, given the likelihood of criminal prosecution, it may be
prudent to supplement the clinical determination of brain death with an
ancillary test, such as a cerebral flow study.
LSMT encompasses all interventions that may prolong the life of
the patient. These may include cardiopulmonary resuscitation, respiratory and circulatory support, artificially administered nutrition and hydration, and medications, such as
antibiotics.3 Decisions to forgo LSMT for a critically ill
child whose injuries are the result of abuse should be made using the
same criteria as those used for any critically ill child. These
criteria include the reasonable medical certainty that LSMT will fail
to maintain the child's life or the disproportionate burden of
treatment in the face of irremediable and severe brain or other
injury.3-6 The primary consideration in forgoing LSMT
ought to be the best interest of the child after carefully weighing the
benefits and burdens of continued treatment. Decisions to forgo LSMT in
cases of severe brain injury should not be limited to children in a persistent vegetative state.3,6
The parent or guardian may be suspected or accused of the assault
or may be protecting a friend or family member who is suspected or
accused of the assault. If a physician suspects that a parent or
guardian is not acting in a child's best interest, it is appropriate to seek further review and consultation in hopes of resolving the
conflict. The hospital ethics committee may be one mechanism of
conflict resolution. However, the complex legal issues may force the
conflict into court.7 Even so, an ethics committee
consultation may be useful to assure the hospital administration and
other interested parties that the hospital staff has pursued all
possible avenues before asking for a court hearing. The hospital
attorney also will need to be aware of the conflict to safeguard the
interests of the hospital.
Parents and guardians often retain the right of making medical
decisions, such as forgoing cardiopulmonary resuscitation or other
LSMT, despite being suspected, accused, or even convicted of child
abuse. Court proceedings that appoint a guardian ad litem for the
purpose of protecting the abused child often limit the role of the
guardian to determine appropriate placement of the child after
discharge. A separate court proceeding may be necessary to ask for the
appointment of a guardian ad litem for medical decisions Prosecutors may not support a decision to forgo LSMT out of concern
that the case against the alleged abuser may be weakened. Furthermore,
because the prosecutor may bring a charge of manslaughter or murder
after the child's death, the prosecutor has an apparent conflict of
interest in arguing before the court in favor of forgoing LSMT. It also
may be difficult to find a judge who is willing to hear a request for
appointing a guardian ad litem for medical decision-making, given the
notoriety that such cases often bring. Finally, the application of
pertinent child abuse laws varies from state to state, county to
county, and judge to judge, making it difficult to predict with any
certainty the outcome of such court proceedings. The American Academy
of Pediatrics (AAP) recommends the appointment of a guardian ad litem
in all cases of child abuse requiring LSMT in which a parent or
guardian may have a conflict of interest.
Decisions to forgo LSMT should be based on complete and
compassionate communication with the family. The AAP endorses the role
of parents of children receiving LSMT in helping to make these
determinations, even if one or both parents are suspected of causing
the injury.3,6 Regardless of the cause, nature, and extent
of a child's injuries and of the ongoing court proceedings, the
parent(s) or guardian(s) should be treated with respect, compassion,
and due consideration for privacy. As should be the case for all
critically ill children, appropriate support for the parents should be
offered, including a bereavement counselor, chaplain, or other persons
identified by the parents as providing important psychological and
spiritual support.8
Although forgoing LSMT does not require the permission of the
medical examiner or the district attorney, the medical examiner should
be involved early and before the removal of LSMT in child abuse cases.
There may be physical evidence, such as photographs of the injuries,
that preferably would be obtained before the child's death.
Federal and state regulations require that the parent or guardian be
given the option of tissue and organ donation. However, the permission
of the medical examiner is absolutely necessary for tissue and organ
procurement to take place, as valuable evidence may be altered or lost
in the process. If tissue and organ donation are options, the physician
should introduce the idea and then request that a person who is trained
and comfortable in discussing tissue and organ donation describe the
options and answer the family's questions. In addition, the medical
examiner should be encouraged to attend the tissue and organ
procurement to ensure that appropriate evidence is collected rather
than routinely deny permission for procurement.9,10
FORGOING LSMT
RESOLUTION OF CONFLICT
an
appointment made necessary given the parent or guardian's conflict of
interest for making such decisions. The physician should impress on the
judge that the request for the appointment of a guardian ad litem does
not prejudge the question of forgoing LSMT and that the guardian ad
litem could not make an informed decision without visiting the child's
bedside to obtain a first-hand understanding of the child's condition.
FAMILY SUPPORT
TISSUE AND ORGAN DONATION
RECOMMENDATIONS
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Abstract
Recommendation
References
Committee on Child Abuse and Neglect, 2000-2001
Steven W. Kairys, MD, MPH, Chairperson
Randell C. Alexander, MD, PhD
Robert W. Block, MD
V. Denise Everett, MD
Lt Col Kent P. Hymel, MD
Carole Jenny, MD
Liaisons
David L. Corwin, MD
American Academy of Child and Adolescent Psychiatry
Gene Ann Shelley, PhD
Centers for Disease Control and Prevention
Section Liaison
Robert M. Reece, MD
Section on Child Abuse and Neglect
Consultant
Robert A. Kirschner, MD
Staff
Tammy Piazza Hurley
Committee on Bioethics, 2000-2001
Robert M. Nelson, MD, PhD, Chairperson
Jeffrey R. Botkin, MD, MPH
Eric D. Kodish, MD
Marcia Levetown, MD
John T. Truman, MD
Benjamin S. Wilfond, MD
Liaisons
Alessandra (Sandi) Kazura, MD
American Academy of Child and Adolescent Psychiatry
Ernest F. Krug III, MD
American Board of Pediatrics
Peter A. Schwartz, MD
American College of Obstetricians and Gynecologists
Section Liaisons
G. Kevin Donovan, MD, MLA
Section on Bioethics
Mary Fallat, MD
Section on Surgery
Consultant
Joel E. Frader, MD
Legal Consultant
Dena S. Davis, JD, PhD
Staff
Darcy Steinberg, MPH
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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LSMT, life-sustaining medical treatment; AAP, American Academy of Pediatrics.
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REFERENCES |
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Abstract
Recommendation
References
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- Parker BL, Frewen TC, Levin SD, Declaring pediatric brain death: current practice in a Canadian pediatric critical care unit. Can Med Assoc J. 1995; 153:909-916 [Abstract]
- Staworn D, Lewison L, Marks J, Turner G, Levin D Brain death in pediatric intensive care unit patients: incidence, primary diagnosis, and the clinical occurrence of Turner's triad. Crit Care Med. 1994; 22:1301-1305 [Medline]
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American Academy of Pediatrics, Committee on Bioethics
Guidelines on forgoing life-sustaining medical treatment.
Pediatrics.
1994;
93:532-536
[Abstract/Free Full Text] - Nelson LJ, Nelson RM Ethics and the provision of futile, harmful, or burdensome treatment to children. Crit Care Med. 1992; 20:427-433 [Medline]
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Fleischman AR,
Nolan K,
Dubler NN,
Caring for gravely ill children.
Pediatrics.
1994;
94:433-439
[Abstract/Free Full Text] -
American Academy of Pediatrics, Committee on Bioethics
Ethics and the care of critically ill infants and children.
Pediatrics.
1996;
98:149-152
[Abstract/Free Full Text] - Nelson RM, Shapiro RS The role of an ethics committee in resolving conflict in the neonatal intensive care unit. J Law Med Ethics. 1995; 23:27-32 [Medline]
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American Academy of Pediatrics, Committee on Bioethics and Committee on Hospital Care
Palliative care for children.
Pediatrics
2000;
106:351-357
[Abstract/Free Full Text] -
Shafer T,
Schkade LL,
Warner HE,
Impact of medical examiner/coroner practices on organ recovery in the United States.
JAMA.
1994;
272:1607-1613
[Abstract/Free Full Text] - Duthie SE, Peterson BM, Cutler J, Blackbourne B Successful organ donation in victims of child abuse. Clin Transpl. 1995; 9:415-418
Pediatrics (ISSN 0031 4005). Copyright ©2000 by the American Academy of Pediatrics
Statement of reaffirmation:
- AAP Publications Retired or Reaffirmed, October 2006
- American Academy of Pediatrics
Pediatrics 2007 119: 405.[Extract] [Full Text] [PDF]
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