Abstract
Introduction
Classically, ethics in pregnancy have revolved around abortion. However, there are numerous issues that require attention including the fetus as a patient, the mother’s autonomy and medical treatment of the pregnant patient amongst others. These are further complicated when the pregnant patient has sustained a traumatic or burn injury. Although there are numerous case reports of managing the pregnant burn patient, there is a paucity of literature that focuses on the ethical challenges in the pregnant patient.
Methods
We report the case of an 18-year-old engaged female who sustained 60% total body surface area full-thickness burns. She was found to be 6 weeks pregnant with a viable fetus on ultrasound. The pregnancy was not planned, but desired. During the early portion of the hospitalization, she was found to lack capacity for both complex medical decision making and assigning of a surrogate decision maker. Furthermore, her mother only intermittently had custody of the patient when she was a minor, complicating whether she would be the best surrogate decision maker. Medical treatments that would significantly decrease morbidity and mortality would have had a negative impact on the viability of the fetus. Morning sickness compromised the nutrition care of the patient. Ethical issues that arose included capacity for complex medical decision making, the mother’s autonomy, surrogate decision making and whether a surrogate decision maker can make decisions regarding the fetus, the fetus as a patient, and medical interventions of the pregnant patient. Later on in the hospitalization, the patient was refusing many aspects of her care, raising the issue of paternalism in the burn center.
Results
The patient was later deemed to have capacity for assigning a surrogate decision maker, but not for complex medical decision making. She assigned her fiancée as the surrogate decision maker, although he initially refused. Medical treatments that would significantly decrease morbidly and mortality were instituted even though some were “contraindicated” in pregnancy. A gastrostomy tube was placed through burnt tissue for direct enteral access even though the patient was alert, oriented, and could tolerate oral intake in order to enhance her nutritional status. The burn center adopted a practice of “benevolent parentalism” as a means to overcome the patient’s resistance of medical care and treatments.
Conclusions
Pregnancy in the burn patient represents a deeply ethically challenging situation which have not been discussed in previous case reports. Ethical guidelines for the management of the pregnant burn patient should be established. Guidelines for surrogate decision making must be followed. In addition, the concept of “benevolent parentalism” must be elucidated and should replace the notion that burn centers are paternalistic.
P3763Surrogate decision-making for life-sustaining treatments in patients with heart failure: sex differences in surrogate decision-maker preferences