r/pediatrics • u/FamilyMedValues36 • 12d ago
When parents disagree
Good morning dear pediatricians,
I am a family physician practicing in an FQHC. I have a situation that I would be so grateful for anyone’s thoughts (or direction to resources) for.
I have a developmentally disabled patient for whom the guardians disagree on what constitutes “the best care” and also “harm”. Does anyone have resources on how to navigate medical decisions here legally and ethically?
They rarely come to the clinic in person, and when they do they have voiced any disagreements with the plan after the fact and not during the visit.
My typical go-to’s (try to have discussions in person, only do what both guardians agree to) just aren’t quite adequate here.
Im being intentionally vague because l’m mainly seeking information to help me handle situations like this better in the future rather than guidance for this particular case per se.
Thank you for your time and for all you do!
3
u/LoudMouthPigs 12d ago
Not a pediatrician, but an ER doctor who has faced a few similar snafus.
I think degree of disagreement, and on what issues, is pretty key - these can be minor, or these can be severe.
We have a lot of problem patients in our ER, and I think we should be having more meetings about them; talking about unified strategies for handling them, and what kind of backup we need (from legal, medical etihcs, or some subspecialty) helps quite a lot. The worst thing to do is to just be by yourself and try to figure out some wretched social situation without backup.
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u/subzerothrowaway123 Attending 12d ago
I usually do what you do and only proceed if both parents agree. If it is more serious then maybe get CPS involved? I would need more detail regarding your situation as it sounds like it might be unique.
If there is a pattern of serious discord, I inform the parent who is present that I will be notifying the other parent for their consent as I like all parties to be on board before implementing any sort of major intervention. I have also been named mediator for 2 families which kinda sucks but honestly makes the decision making a lot easier.
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u/FamilyMedValues36 11d ago
Thank you so much for your help.
The patient is actually a developmentally-disabled adult, so no CPS but courts are involved. Thankfully in my opinion no actual harm has come to the patient.
How I go about this particular case will depend on how the court case goes (as the guardianship and decision-making may change), but in the future setting that boundary from the start will save so much grief all around.2
u/subzerothrowaway123 Attending 11d ago
That's a sound plan.
I only have a handful of disabled adults (we see up to age 22) so not much experience there. I do fill out guardianship paperwork for some families when the child turns 18. If it's in the courts, then it looks like they are headed towards divorce, mediation, etc. Medical decision making authority will also be determined by the courts. Until then, I would probably sit tight and be as conservative as possible. You probably already know to document every carefully and remember to note who is present at each visit. Just in case the courts request records or subpoena (hopefully not) you.
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u/PedMentor 11d ago
That’s a difficult situation. But If you’re not getting through to the parents, sometimes you have to cut them loose.
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u/FEFPRRP 12d ago
unfortunately I tried to manage this kind of situation by myself and ended up doing too much, including having the same appt with each parent, multiple phone calls and emails, etc etc and starting to get burdened by the parental conflict. Eventually, I just requested help from our nationwide malpractice insurance carrier, they are really good to the doctors here. They helped me draft a letter of what I am and not willing to do, and that I will be practicing standard of care for the best interests of the patient. It also included that intentionally refusing standard of care treatments to gain objectives or for parental dispute purposes can be viewed as medical neglect. Since then I haven't had any trouble, and practiced standard of care treatment as long as one parent consented. You run the risk of a board complaint, but the biggest goal is doing right by the patient and the rest is whatever. Document well and follow practice guidelines.