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Ethical and legal implications of informed consent for epidural anesthesia in an sixteenyear-old obstetric patient with acute psychosis
Abstract Number: F-51
Abstract Type: Case Report/Case Series
A sixteen year-old G1 patient at 36 4/7 weeks presented with a history of seven days’ insomnia. According to the patient’s mother, the patient’s history was significant for bipolar I disorder with psychotic features and had been hospitalized four times. The patient’s bipolar disease had been under good control for the past six months and she was not on any antipsychotic treatment. Because the patient was pregnant, she was brought to labor and delivery and was noted to be in labor at that time.
Review of symptoms were significant for distractibility, rapid speech, intermittent auditory and visual hallucinations, and delusional thinking. During the interview, the patient stated several times that "the devil wants to take her unborn child out and use him to get into Heaven." The patient was intermittently tearful and distressed, and responded to internal stimuli, interjecting responses to her auditory hallucinations throughout the interview.
The patient became uncooperative with the OB and nursing staff during the labor process. The OB staff and the patient’s mother desired for the patient to undergo epidural anesthesia to improve the patient’s comfort and to improve compliance with cervical checks. However, the patient refused.
The ethical and legal implications for caring for a gravid minor are complex and vary on a state-by-state basis. Many states specifically authorize minors to consent to contraceptive services, prenatal care and delivery services. However, our case provides additional layers of complexity due to the episode of acute psychosis, the lack of prenatal care and lack of documentation of the patients’ preferences regarding delivery. Providers must determine the patient’s capacity to provide informed consent and what role anti-psychotic treatment has in resolving acute psychotic episodes prior to performing procedures.
There is a paucity of literature concerning the ethical issues in the acutely psychotic obstetric patient. The approach of Beauchamp and Childress requires the principals of autonomy, beneficence, non-maleficence, and justice to be judged and weighed against each other. In our patient, the challenge is how to respect the patient’s autonomy (her refusal for epidural placement) while also helping to prevent adverse consequences for her (provide for vaginal delivery). Additionally, both the patient and the anesthesiologist have beneficence-based obligations to the fetus. When patients are severely impaired, surrogate decision making can apply and a legal framework provided. But when patient’s values are not known -- no prenatal care was obtained, no discussion with the patient prior to the psychotic episode occurred, and the patient lacks capacity -- clinical decision-making can be complex.
In this case, because the patient was thrashing about in the bed, a decision was made to not place an epidural and the patient later successfully delivered vaginally.