Tuesday, March 14, 2006


I try to be honest in my dealings with patients. It's good ethically both medically and generally. When I discuss a patient's condition, I neither sugar coat it nor try to scare the family but am just straight forward.

There have been times when a family has asked me to be dishonest, like when they ask me to write a work excuse for the father and ask me to make it for longer or a different time than it should be. I decline those requests. I figure if I lie for them then they won't trust me when I'm giving them information about their baby.

Sometimes, though, I wonder if I have to tell them all the truth. I think specifically of obtaining "informed" consent. The most common procedure for me to obtain consent for is a spinal tap, also known as a lumber puncture. The purpose of this is to find out if the baby has meningitis. If you miss meningitis in a baby, it can ruin the baby's whole life. In general it is a very safe and useful procedure, and we don't do it unless its benefits outweigh the risks. In one instance I am aware of, though, in a case of a pediatrician acquaintance of mine, a baby was paralyzed by the spinal tap. It was a two month old baby who had hemophilia, although the hemophilia had not yet been diagnosed. The baby had increased bleeding from the spinal tap because of the hemophilia, and the blood compressed and damaged the spinal cord, leaving the baby a paraplegic.

That is a tragic case. It is also extremely rare. My question is, do I have to tell parents about this when I tell them the risks of a spinal tap? Do I have to mention paralysis as a risk? If I were being totally honest, I guess I would, but there is a very real concern that some parents, already skittish about a spinal tap, might decline it if I tell them that, and that would not be good, because it is extremely important we don't miss menigitis. Like I said, I wouldn't do the spinal tap unless the benefits outweighed the risks. A further question might be, should we even have to obtain informed consent for spinal taps? Why do we? I know that patients' rights advocates won't like this, but think about it. As a doctor, I am trained to evaluate the risks versus benefits; the parents are not. Why do they get to choose an option that might not be in the baby's best interests?

I'll stop here. I've probably already said enough that I'll receive some flak. In the meantime, though, I'll try to be honest with parents. I hope I'm honest enough.


Blogger PaedsRN said...

I know our process with procedures of this nature tends to be, "this is what we're going to do" rather than, "is it ok if we do this?" Right or wrong, if you mentioned every single complication for every treatment, not only would we be dealing with constantly terrified parents but we'd never get anything else done.

I mean, the list of adverse reactions for Tylenol alone...

12:28 PM  
Blogger Flea said...

I'm afraid we don't have a choice on the honesty thing. The assumption the patient makes is that you believe procedure X is in the baby's best interest, or else you wouldn't recommend it.

If you don't believe it yourself, for heaven's sake don't even bother asking the parents: don't do it.



3:03 PM  
Blogger Sandy said...

As a parent who had to go through consenting for a spinal tap twice (for the same baby!), I appreciated total honesty in the risks and the procedure was more important than my worry about the small chance that there will be a bad outcome.
How would you feel if you did NOT go over all the risks and then that was the one time your patient was paralyzed? Is that not a legal risk for you also?
And just additional thought, it doesn't help when doctors run through the litany of minor risks in super speed monotone and then end with "...or Death"
What do you think sticks out most in the parent's mind?? LOL. There has to be a better way!

4:45 PM  
Blogger Dream Mom said...

I expect a physician to be honest and to tell me the benefits and risks of any procedure. If it were something I wasn't comfortable with, then I would simply ask more questions or ask about the alternatives. I really try to let the physicians do the job they were trained to do and not interfere with their care plan.

As for the spinal tap, I would not be comfortable with a physician performing this without consent. I would expect he would explain the risks.

As a neonatalogist, your job is slightly more difficult than other specialists in that you are the first specialist parents are dealing with and they often don't have any experience or any point of reference. Over time, as parents deal with more specialists, things become less scary and more routine and therefore there are fewer red flags.

Finally, after dealing with many physicians over the years, there are three things that I appreciate most in a physician: 1) that they know their stuff and are an expert at what they do, 2) honesty and 3) kindness. The best docs have equal parts of all three. You need the last one when they are honest and give you the bad news.

5:35 PM  
Blogger Tara's World said...

My daughter up to the time she was 2 years old would run horrendous fevers. She would be outside, playing and running around and then the next thing she would be runnning 105 fevers. She has had 3 spinal taps done on her. They would not let in the room for they said she had to be completely still and she would be trying to look at me to help her. With that said , they did tell me what the risks are, however the good outweighed the bad. There was no other way and whenever your messing around with the spine its tricky. I have been reading you for awhile and I have come to see what a compassionate Dr you are. You will do the best for your patients and even when the proceduers are risky. One more thing when ever an operation is done or an invasive procedure, there is always a consent for outlining the risks. I knew what risk Megan was under. She is now 17 and out grew those fevers long ago. I wish she had had a Dr like you.

9:22 PM  
Blogger neonataldoc said...

Thanks all. Paedsrn, I agree. Dream Mom, I like your definition of a good doctor. Tara, thanks for the compliment.

8:57 PM  
Anonymous Lindsay said...

Where do you draw the line for not seeking informed consent? For just asserting that 'doctor knows best' and just performing the procedure? Doctors used to think (and some still do) that circumcision is an important procedure for a child's health, or they perform them for simple phimosis.
I understand spinal taps are important for diagnosing meningitis, but how about for a baby whose mother has received good prenatal care but declined antibiotics for strep B (strep B status being unknown). Aren't there other ways to evaluate whether a baby has an infection than through a spinal tap?
These are just a couple of issues, as I am rather uniformed about these things.

But you have said yourself that you don't always know if a procedure is any help to the child. As the parent or patient, I want that information so I can make a responsible choice whether or not to subject my child to the procedure/test for what reasons.

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