Abusive head trauma is a significant and tragic cause of morbidity and mortality in infants and its victims often have a poor prognosis. With such high rates of morbidity and mortality, health care providers and parents are often faced with the decision to continue or discontinue life support for an affected child. Sadly, however, this decision becomes complicated when parents are accused of causing the victim-child's current state. In this situation, if life support is withdrawn, criminal charges for the accused may escalate from assault to murder. This escalation of legal charges creates a conflict of interest for accused parents. As a result, parents have a strong incentive to avoid murder charges by using their parental decision-making rights to keep the child alive, even when treatment is deemed futile or inhumane. In this article, we discuss the legal challenges health care providers may face when parents place their interest above their child’s. We also propose solutions that give greater deference to the rights and interest of these critically ill children while still preserving protected parental rights.
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March 2012
Special Article|
March 01 2012
End-of-Life Decisions in Abusive Head Trauma
Clifford C. Ellingson, BS;
Schools of aMedicine and
Address correspondence to Clifford C. Ellingson, BS, Case Western Reserve University School of Medicine, 1284 Avondale Rd, South Euclid, OH 44121. E-mail: cce7@case.edu
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Jared S. Livingston, JD;
Jared S. Livingston, JD
bLaw, Case Western Reserve University, Cleveland, Ohio; and
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Jonathan M. Fanaroff, MD
Jonathan M. Fanaroff, MD
Schools of aMedicine and
cDepartment of Pediatrics and Rainbow Center for Pediatric Ethics, Rainbow Babies & Children's Hospital/University Hospitals Case Medical Center, Cleveland, Ohio
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Address correspondence to Clifford C. Ellingson, BS, Case Western Reserve University School of Medicine, 1284 Avondale Rd, South Euclid, OH 44121. E-mail: cce7@case.edu
FINANCIAL DISCLOSURE: Dr Fanaroff serves as an expert witness for various law firms. None of the cases involved abusive head trauma. Mr Ellingson and Dr Livingston have indicated they have no financial relationships relevant to this article to disclose.
Pediatrics (2012) 129 (3): 541–547.
Article history
Accepted:
October 27 2011
Citation
Clifford C. Ellingson, Jared S. Livingston, Jonathan M. Fanaroff; End-of-Life Decisions in Abusive Head Trauma. Pediatrics March 2012; 129 (3): 541–547. 10.1542/peds.2011-1988
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I appreciate the authors' handling of this sad conflict of interest, [1] which occurs with tragic frequency during the treatment of abused children. As the lay media presents objections to the diagnosis of abusive head trauma, [2] it becomes increasingly important for Pediatricians to present a unified front in approaching these difficult cases. As such, it might be useful in the discussion of this topic to include the 2000 AAP statement [3] on forgoing life-sustaining medical treatment (LSMT) in the exact nuanced situation addressed in this recent addition to the child abuse literature. Specifically, the AAP Committee on Child Abuse and Neglect and the Committee on Bioethics recommend that, "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." [3] In addition, the recommendations emphasize the importance of impressing upon the judge tasked with assigning a guardian that such an assignment does not presuppose the withdrawal of LSMT, as many judges may be wary of withdrawing care, specifically. Gladsjo, et al., address this position statement and share their own experience with the use of a guardian ad litem, [4] as well as emphasizing the importance of ethics committee consultation. In the end, it remains our most important charge as Pediatricians to think first and foremost of the child in the middle of this tragic circumstance.
REFERENCES
1. Ellingson CC, Livingston JS, and Fanaroff JM. End-of-life decisions in abusive head trauma. Pediatrics. 2012;129:541-547.
2. Bazelon E. Shaken-baby syndrome faces new questions in court. New York Times. February 6, 2011:MM30.
3. American Academy of Pediatrics, Committee on Child Abuse and Neglect and Committee on Bioethics. Forgoing life-sustaining medical treatment in abused children. Pediatrics. 2000;106:1151-1153.
4. Gladsjo JA, Breding J, Sire D, et al. Termination of life support after severe child abuse: the role of a guardian ad litem. Pediatrics. 2004;113:e141-e145.
Conflict of Interest:
None declared