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Multidisciplinary Approach to Ethical Management in Terminal Parturient
Abstract Number: SU-75
Abstract Type: Case Report/Case Series
The American College of Obstetrics and Gynecology and ethicists have come to a consensus that decisions regarding fetal care are dependent upon maternal decision making and autonomy. 1 While clinicians are obliged to advise patients in accordance with their clinical acumen, they are not entitled to overrule the decisions of competent patients, even in terminal cases. In the case of parturients with AIDS, there is the added prerogative to prevent vertical transmission of HIV.
Our patient was a 21 year old G2P0010 at 30.5 weeks with end stage AIDS, acquired via perinatal transmission, who initially presented with symptoms concerning for Pneumocystis Jiroveci pneumonia (PJP). She was started on empiric therapy for PJP but quickly deteriorated requiring 100% oxygen via non-rebreather mask. Discussions were held regarding goals of care for herself and her unborn child. The obstetric team advised her that immediate cesarean delivery would be best for her child to prevent vertical transmission; however, patient was adamant only in case of severe fetal intolerance or impending cardiac arrest would she consent to cesarean delivery. Her clinical condition continued to decline, eventually developing acute respiratory distress syndrome requiring intubation, continuous infusion of muscle relaxant and 100% oxygen to maintain saturations. Intravenous zidovudine was started to prevent vertical transmission. On hospital day 8, fetal tracing showed deep and prolonged decelerations prompting decision to move towards delivery. Cesarean delivery was initially planned; however, fetus was at low station and was delivered via low-outlet forceps in the general operating rooms. The patient was actively treated for another month before terminal extubation in accordance with her family’s wishes. Her child is currently healthy and HIV negative.
Patient decision making that contradicts clinical advice must be met with thoughtful consideration and flexibility in management. In our case, the patient had a known terminal diagnosis and she made clear her wishes to avoid surgical delivery of her fetus unless fetal or maternal death was imminent, despite the risk of perinatal transmission of HIV given her high viral load. Once the mother is no longer capable of voicing her decisions, physician preference does not suddenly prevail. Our patient and her clinical course highlight the fact that a multidisciplinary approach to patient management is vital when approaching maternal fetal decision making that contradicts medical advice. In this case, obstetrics, critical care, obstetric anesthesiology, ethics and palliative care were all in daily contact to ensure that the mother was aggressively treated not only for her well-being, but to provide the safest intrauterine environment possible to facilitate further fetal development.
1 Ali, N et al. Critical Care Clinics 2016; 32:137-143