Ask Me Help Desk - What is right?

What is right?

I have recently faced an ethical dilemma. I want to hear the thoughts and opinions of people on this issue.

Now, what I present to you is fictional (due to HIPAA laws), but somewhat relates to my experience. I will give you a hypothetical situation and would like to hear your input.

A woman presents to the hospital with vaginal bleeding... she is told that she is pregnant. The tests reveal that she is 23 weeks and 2 days pregnant. The earliest gestational age for survival is 24 weeks gestation.

The patient is diagnosed with a placental abruption (placenta breaks away from the uterine wall), which causes bleeding and both the mother and child are at risk for death due to bleeding out.

Now, an emergent cesarean section is called. The fetus is delivered with a heartbeat, but is not breathing. This baby weighs a little over one pound... 520 grams.

The least a fetus can weigh, according to medical standards is 500 grams, in order to "save" it's life.

Knowing that this baby may not live the flight to a high risk medical center, and knowing that this baby most likely (almost 90%) will have permanent mental and/or physical impairments, what do you do?

Before you answer... the mother of the child does not know she is pregnant before this episode. She is in complete denial and states that she is not ready for a child, but wants you to save the life nonetheless. What do you do?

I would do what I could to save the child which may die despite all interventions. My neighbor was around a pound when he was born, was supposed to die, but grew up to become a lawyer for a major Chicago bank, married a wonderful woman, and had four beautiful children.

There's a big difference between what I would do and what I would want to do.

I'd save the child, because legally I have to. It's above the legal weight. I have no choice. I have to.

Now, if it was my choice, I'd wait to see what happens. If the baby is breathing on its own then I won't interfere, but neither would I interfere if it stopped breathing.

I'd do everything that I'm expected to do. Get the baby warm, clear the airway, etc. etc, but I wouldn't do anything drastic to save it's life.

The thing is, in the situation you described, you have no choice. The mother is begging you to save her babies life. The baby is above the legal weight. You have to try, even if you secretly hope that you fail, because the baby only has a 10% chance of a normal life.

Having said all of this, I truly believe that in cases like these, the outcome isn't in our hands. If this life wasn't meant to be then it wouldn't have been saved, with or without your intervention.

It's early days yet, this child could still die. Maybe that's for the best. Maybe he/she will surprise you and be one of the 10% that lives a normal life.

I do know that you did what had to be done. It's not in your hands. It probably never was. Whatever happens is what's meant to happen. For better or for worse.

However, the legal age of gestation is 24 weeks... this fetus was LESS than 24 weeks according to the ultrasound. But the weight as 2 ounces over the legal weight.

Now... to add insult to injury... Mom gets released from the hospital but continues to deny that she was ever pregnant.

Again, this is all hypothetical. Based on a true story, but certain names and situations have been changed to protect the innocent.

Alty's on the right track, but it's like the no tolerance policy of not bringing knives to school and the kid brings in a knife so that someone can cut his cake. He gets expelled and a bru ha ha erupts.

Your not allowed judgement when there is policy.

You policy didn't include the other variable. Your policy is only based on weight. Should policy allow judgement or should the policy be God?

Nothing heroic. Baby wasn't old enough to have an advance directive.

I think you should be allowed to use judgement or some amount of judgement should be in the policy. It should not be just weight.

Quote:

Originally Posted by KeepItSimpleStupid

It should not be just weight.

That's just it. It's NOT just weight. It's also gestational age, which is 24 weeks. Since mom denied knowing she was pregnant prior to this incident.

According to the ultrasound she was 23 weeks and 2 days. That is 5 days earlier than the earliest date of possible survival for gestational age.

You see, we must meet at least 2 criteria. In this case, only one was met.

Quote:

Originally Posted by J_9

However, the legal age of gestation is 24 weeks...this fetus was LESS than 24 weeks according to the ultrasound. But the weight as 2 ounces over the legal weight.

Now...to add insult to injury...Mom gets released from the hospital but continues to deny that she was ever pregnant.

Again, this is all hypothetical. Based on a true story, but certain names and situations have been changed to protect the innocent.

So she's denying this child?

This has just become a case of medical advancement being a bad thing.

Fifty years ago this baby wouldn't have had a chance. Heck, the mother would have been in danger too, more so then she was. Nature would have selected, and the baby would have lost the battle, maybe for the better.

There are times when I have to question all the advancements we've made. We're so busy trying to see if we can that we don't stop and think if we should. Who decides when a baby is at the right gestational age or weight in order to survive? Who decides that a 10% chance at a normal existence is good enough?

You weren't the decision maker J, you were the rule follower. You did what you had to do. If you had gone any other way then it would most likely have come back to bite you in the butt. I know that's little consolation but that's the way it is. You did your job, no more, no less.

As for the mother, hopefully she'll come out of her funk and realize what's going on, come back to claim her child, for better or for worse. She seems to be in a state of denial. If the baby had been carried to term she still may have had this reaction. There's a lot on her plate right now. The fact that she didn't realize she was pregnant and now giving birth to a child that will most likely need constant care for the rest of its life. It's a lot to take in. Give her time. I hope she comes around.

Now I'm going to say something that a lot of people will probably disagree with. Thank goodness this is in member discussions and no one can reddie me, because I'm sure that there are a few that will want to.

Personally, my hope is that the baby dies. This poor little mite doesn't deserve the life its been given. The 10% chance is nothing, the odds aren't in his/her favor. His/her mother is in denial and doesn't seem ready to have a healthy child, much less a child that will probably never live a normal life. The best for this child would be for it to drift off, go back and take a place in line to come back again in another child.

That's my opinion.

Anyone can feel free to disagree and I'm sure many will.

Bring it. ;)

I think then it's oops on your part. The piece of info that she didn't know she was pregnant is a bit hard to believe and should have nudged it more to the creiteria.

You could be under the spotlight next. That would not be good.

Virtual greenie for Alty.

Quote:

Originally Posted by J_9

That's just it. It's NOT just weight. It's also gestational age, which is 24 weeks. Since mom denied knowing she was pregnant prior to this incident.

According to the ultrasound she was 23 weeks and 2 days. That is 5 days earlier than the earliest date of possible survival for gestational age.

You see, we must meet at least 2 criteria. In this case, only one was met.

Is that why you're kicking yourself sweetie?

Did you have the option to walk away and chose not to?

If so, you made that decision for a reason. I know you well enough to know that you don't make decisions like this lightly. You chose and the child is alive. You did what you thought was best at the time. Don't go back on that decision now.

J, you are a kind, caring, compassionate, wonderful person. Heck, that's just the basics, there's so much more. You are one of the handful of people on this site that I consider a good friend. I trust you, I adore you. You can be a toughie, but deep down you're just a big softie, like me. Ya, I know, it was supposed to be our secret, but... ;)

Do not let this haunt you. You chose. Time will tell what happens. It's out of your hands. Do not second guess yourself because I know this decision wasn't made lightly.

Chin up chickie. Don't make me haul my butt over to your place and kick you with my thigh high red leather boots. ;)

Personally Would do everything to save the child's life. Every child is precious. That is what I would have done. To Do everything they can to help give a child a fighting chance no matter what might or might not happen.

Edit: I would also like to add that whatever decision was made whether it be considered good or bad does not matter. This is a new experience but it will help form what decisions might need to be made at another time in a different situation. Whatever you did, you did the right thing.

Best wishes in your career,.

Joe

Hi J.

I don't know much about laws or medical stuff but what I do know is that life gives us some tough choices, and this definitely was one of them.

If it were me, I would simply follow orders. If the mom wanted me to fight to save her baby I would, if she didn't I wouldn't. What good would come to save a child's life if it were to be unwelcomed into a home where it is not wanted.

Well, I have a ton of respect for you J and whatever decision you make/made I'm sure was the "right" one.

If this baby lives, I wish it a long healthy life.

...that's just my opinion

I agree Muddy.

J, you did what you had to do, no one can do more.

I too hope that this baby is in the 10%, not the 90%. I also hope it's mom come around, realizes what a gift she's been given.

Still, a part of me just wishes peace for this child. An eternal rest.

Only God can decide. We just stand by and watch.

Quote:

Originally Posted by Altenweg

Did you have the option to walk away and chose not to?

Unfortunately I did not have the option to walk away. I had to do this. We all were crying during the resuscitation, including the 75 year old male pediatrician.

I guess I'm beating myself up over nothing. There were no other options for me. :(

Quote:

Originally Posted by J_9

Unfortunately I did not have the option to walk away. I had to do this. We all were crying during the resuscitation, including the 75 year old male pediatrician.

I guess I'm beating myself up over nothing. There were no other options for me. :(

If walking away wasn't an option then you're right, you are beating yourself up over nothing.

Even if you had the option to walk away, you still did your job.

Stop beating yourself up. I'll tell Ben on you! ;)

Quote:

Originally Posted by Altenweg

If walking away wasn't an option then you're right, you are beating yourself up over nothing.

Even if you had the option to walk away, you still did your job.

Stop beating yourself up. I'll tell Ben on you! ;)

I guess it's something I'll get over in time. I hope next time is easier.

Quote:

Originally Posted by J_9

I guess it's something I'll get over in time. I hope next time is easier.

I hope it's easier for you too. Just remember dear, you can't save the world, that's my job. ;)

Big hugs to you. I know I'd be feeling the same way if I was in your shoes. Having said that, I also know you'd be telling me what I'm telling you, if the roles were reversed.

Having had no choice, you did what you had to, J.

Personally, I think it's a crying shame that resources are going to be used on an unwanted infant that has a very low chance of survival.

I can only imagine the heartbreak you are going through, though. Lots of hugs to you.

Thanks Synn. I know I did what I had to, and I really hope that something good does come out of this.

Quote:

Originally Posted by J_9

I know I did what I had to, and I really hope that something good does come out of this.

I'm proud to know you, J, very proud. I will keep my wholly holey holy pea green t-shirt after all and not tease you any longer.

Quote:

Originally Posted by Wondergirl

I'm proud to know you, J, very proud. I will keep my wholly holey holy pea green t-shirt after all and not tease you any longer.

Thank you WG... that means a lot to me! :D

I'll find something else to tease you about.

Quote:

Originally Posted by Wondergirl

I'll find something else to tease you about.

I knew there was a joke in there somewhere.

I just wonder if medical science has gone too far... ya know?

Quote:

Originally Posted by J_9

i just wonder if medical science has gone too far...ya know?

I feel the same way. And it's the same at the other end of life. I know of families that push the doctors to do extraordinary things to keep Grandma alive. The hospitals have the necessary equipment, so, if Grandma hasn't set up a Living Will, she becomes a victim of loved ones who won't let her go.

I'm on the fence about this one.

If it weren't for the miracle of modern science, I'd be losing my ovaries and probably my uterus too, next week.

But... how can we justify some of the things that are done with it? Where is the dignity and best interest of the patient?

I'm glad that for the most part those that are making the final decisions are people with compassionate hearts, who truly try to do the best they can for each patient.

People like our J9.

Quote:

Originally Posted by Synnen

If it weren't for the miracle of modern science, I'd be losing my ovaries and probably my uterus too, next week.

But...how can we justify some of the things that are done with it? Where is the dignity and best interest of the patient?

I guess this expands my thoughts for this thread.

When have we gone too far?

I'm going to counter with a question of my own, J. Simply because I think it's related, though it's probably not the answer to your question:

Why do we feel we have to save EVERY life?

Quote:

Originally Posted by Synnen

Why do we feel we have to save EVERY life?

That is part of my dilemma as well. Have people forgotten that there is a quality of life issue?

I haven't.

That's part of why I've always been for laws allowing assisted suicide, and why I believe that pro-choice is the ONLY option we should have.

The argument is that we shouldn't choose to save some people over others SOLELY because of a quality of life standard. Wouldn't that mean we choose rich over poor, and completely healthy over those with a congenital disease or deformity? Should a child born to a homeless woman be given less a chance than a child born to a woman living on Madison Avenue?

When we start deciding on the medical aspect of such choices, then we have to look at the societal aspect: If the rich are fitter to live because of quality of life standards (and please note that this is just an easy example), then when laws go into effect regarding overpopulation and reproductive "rights", are we going to sterilize anyone born to a household of less than "x" income, because a child born to rich parents has a better chance?

It's a snowball effect, and I know it.

It's just sad that we feel that we must condemn someone to a life we ourselves would not want.

Quote:

Originally Posted by J_9

That is part of my dilemma as well. Have people forgotten that there is a quality of life issue?

But who determines which life has quality? Does the life of a healthy newborn with Down's have quality? Does a terminally ill cancer patient's life have quality? Does the life of a soldier who returned from Iraq with terrible burns have quality? Does a 70-year-old homeless guy's life have quality? Does an imprisoned serial killer's life have quality?

This was the kind of discussion I was looking for.

My situation, while partially true, due to HIPAA laws, was partially hypothetical as well.

The things coming out in this discussion are parts of the reason I don't want to have government controlled health care. Yes, some of the lines on who gets treated for what medical conditions in what way are arbitrary. I think we'd see MORE arbitrary lines if the gov't was involved--and more people screaming "discrimination" when none was intended.

Bah. Some days I'm tempted to say "kill them all and let God sort them out". Other days I think an IQ test should be mandatory, and treatment based on your score. But--those are my cynical (Synnical? ) days.

Synnical! That made me laugh.

I Altyernate my Synnical days. ;)

I'll add a question to a question - I have serious problems with "quality of life" issues. I've posted before that my late husband had a DNR order and a very comprehensive living will - he was resuscitated 4 times. I found out about the first time because he had actual marks from the "paddles" on his body.

He had a very explicit order regarding what he wanted and did not want - he was put on a respirator against his wishes.

I was unable to take him off life support until an Attorney intervened - and my husband was unconscious, unaware, in a fetal position, convulsing several times a day, brain dead (which tests proved), with his eyes open, totally lost to me.

It was a nightmare and I will NEVER get those images out of my mind.

Who should determine quality of life - the patent who had all his paperwork in place; the hospital; the Doctors; the family; the next of kin?

Quote:

Originally Posted by JudyKayTee

I'll add a question to a question - I have serious problems with "quality of life" issues. I've posted before that my late husband had a DNR order and a very comprehensive living will - he was resuscitated 4 times. I found out about the first time because he had actual marks from the "paddles" on his body.

He had a very explicit order regarding what he wanted and did not want - he was put on a respirator against his wishes.

I was unable to take him off life support until an Attorney intervened - and my husband was unconscious, unaware, in a fetal position, convulsing several times a day, brain dead (which tests proved), with his eyes open, totally lost to me.

It was a nightmare and I will NEVER get those images out of my mind.

Who should determine quality of life - the patent who had all his paperwork in place; the hospital; the Doctors; the family; the next of kin?

I'll give you my solution. My living will allows the medical staff to do whatever they want to do, but instructs the administrators that the hospital has to pay for it once I have gone 24 hours with no alpha-wave activity. I've also donated my body and organs for research so I consider anything after I've left the corpus to be research. The lawyer that filed it says it should stand.

Quote:

Originally Posted by Catsmine

I'll give you my solution. My living will allows the medical staff to do whatever they want to do, but instructs the administrators that the hospital has to pay for it once I have gone 24 hours with no alpha-wave activity. I've also donated my body and organs for research so I consider anything after I've left the corpus to be research. The lawyer that filed it says it should stand.

I would like to see the wording on this so I can give it to my Lawyer - I'm not aware if this would hold up in NY but, if so, this would solve MY problem!

Quote:

Originally Posted by JudyKayTee

I would like to see the wording on this so I can give it to my Lawyer - I'm not aware if this would hold up in NY but, if so, this would solve MY problem!

I'll try to dig it out and scan a copy. Might take a while, it's in the safe deposit box.

Yes, it is a hard choice, again for HIPAA . Young person( 18 to 25) with serious brain injury. I am not sure they are aware that I am in the room, they have no control of any body movement and have to be cared for like an infant, There is no opinion that they will improve.

They have to have their body repositioned every few hours, have to be fed by tubes.

Some babies come into this world only for a very short duration. It is their choice. We have nothing to do with what their choice is. Some babies do not have the will to live like other babies do.

J_9 you did everything you could have. The baby just chose not to live regardless of what you did or didn't do.

Quote:

Originally Posted by twinkiedooter

Some babies come into this world only for a very short duration. It is their choice. We have nothing to do with what their choice is. Some babies do not have the will to live like other babies do.

J_9 you did everything you could have. The baby just chose not to live regardless of what you did or didn't do.

Actually, that baby is still alive

In my opinion, there is no decision to be made, you would make every effort to safe the babies life... no question.