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Thursday, January 6, 2011

Ethical Duties of the NCS

Scenario:

You are on a long term NCS job. The baby has severe reflux and the Dr has prescribed a medication that you know is very dangerous. The Dr. has not tired any other medications. He jumped on this medication as the first one to try.

You have voiced your concerns to the parents. They do not seem concerned even though they know the dangers. They have signed the medicine consent form. The medication does not seem to be helping the reflux at all.

Medication is Reglan. It is a black boxed medication which means the FDA will not approve it. It causes irreversible conditions, once a side effect occurs it then becomes permanent. There are numerous lawsuits against the manufacturers of Reglan.

What would you do? Do we as NCS's have moral or ethical obligation to this infant? Would you administer the Reglan on your watch? How would you feel if the child developed one of the side effects, knowing you had participated in the administrating? Would you feel responsible?

Your answer may be posted in the NCSA quarterly newsletter.


THESE ARE THE ANSWERS I RECEIVED: INSIGHTFUL, CARING AND COMPLETELY THOUGHT OUT:

As a Newborn Care Specialist I am hired by a family to provide exceptional care for their newborn(s) and to provide education and training in all things related to the care and development of their infant. While having a vast knowledge of infant development and medical issues, I am not hired or compensated for dispensing medical advice and actually can be held liable for giving such advice. I am never to take the responsibility that should belong to the parent and the pediatrician for making medical decisions related to the health and well-being of the baby. Of course, I am to provide the best in advice, consulting and guidance and should always voice my opinion and knowledge if I believe that a poor decision has been made by either the parents or the pediatrician. My position is that of care-giver, not parent or medical professional.

This issue becomes difficult when an infant is placed on a medication that the FDA and numerous studies have found to be harmful to an infant. In this case, I believe that it is my responsibility to inform the parents of the studies, provide access to the information and give my professional opinion regarding the matter. However, it is not my position or responsibility to make the decision or pressure the parent into making the decision that I deem best. This decision should always remain that of the medical professional and the parent.

In the event that I feel that the best interest of the child is at stake, I will create a document that states the issues related to the medication and my professional opinion. This document will also include a release from liability clause that states that should there be an issue in the future related to this decision I cannnot be held liable for the dispensing of medication prescribed by the pediatrician. The clause would read similar to what follows:

"I (the parent) have been informed of the Black Box warning related to the medication (name of medication) prescribed by (Doctor's Name) for the treatment of GERD for the infant (Child's name). I have also been informed by the CNCS in my employment (Name of CNCS) that she does not agree that this is the best course of treatment for (infant's name) due to the extreme detrimental nature of possible side effects and heath effects of this medication. However, I (the parent) have chosen to follow the recommendations of the pediatrician and I am choosing to disregard the warnings of which I have been advised. I am also requiring the CNCS to dispense the medication to my child during her shift. I am aware that said CNCS can not be held liable for any medical or health complication that may arise from the use of this medication for my child."

If there is a time when the dispensing of medication or other treatment of the child is philosphically opposed to my personal standards, I will choose to excuse myself from the position. As much as I want to protect children from any and all harm, I am not the parent and should never have to take on the responsibility that is meant for the parent and/or the medical professionals charged with the medical decisions for this child.

In fact, I use a clause similar to the one above if a parent chooses to use bumper pads in the crib, tummy sleep their baby or even sleep their baby in a car seat after being informed that these are all considered SIDS risks.
Angel M. Crow, CISC/CNCS

I read your letter below and the scenario sounded very much like a home care case that I had years ago, not involving Reglan, but herbal supplements. The child was a NICU graduate and went home with nursing care. The mother insisted on giving the infant herbal supplements although we all voiced our concern about the baby's safety. Sadly, the mother continued to give the herbs and the child later died and no investigation was done because the child was medically fragile.

As a home care nurse, you have to remember that you are in someone else's home and taking care of someone else's child. The parent is ultimately responsible for direction of care and can choose to follow doctor's orders or not. The nurse/NCS walks a fine line when disagreeing with a parent. Perhaps the nurse/NCS can request the parent to administer Reglan to their infant but if the parents continue to be awakened during the night or dislike the fact that the nurse/NCS refuses to give the medication, you are pretty much out the door or asked off the case. Personally, I would try to educate the parents and document wherever I could that the parents were educated about the side effects of the medication. If I chose not to give the meds, I would document why. If I chose to give the meds, I would document that the meds were given at the request of the parent even after education to the side effects. Document, document, document!
Mary Ann Amole

After careful consideration... and being uncomfortable with it the first and only time I administered it, I have chosen NOT to administer it to the baby. After researching the product myself, I could not feel comfortable giving it to a baby who was in my care. I would give the family all product information, they would then make their own opinion as to whether they would continue the medication or to discontinue its use... but if they chose to continue, I would have no part of administering it to the baby and they would have to get up in the middle of the night to administer it themselves.
Desiree Nessline

I feel that if you have warned the parents about the danger and you have givening all the facts and they still do nothing...I would quit because it is are ethical duty to protect that child at all cost. And maybe they will realize how important this is to you as a NCS. That you will not be held accountable for their actions to this child.
Summer Hartman

Personally, as a professional I will give you my point of view.

First of all this baby is my client's child, so they have the right whether to choose to follow the pediatrician instructions or to go to another pediatrician as per my advice.

I will suggest to have a second opinion from another professional. If they decided to go with the instructions and medications from the doctor in question I will just do my job.

If they signed the medication consent and they allow me to give to their child such medication I will do it as part of my job. If the side effect takes place. I will never feel guilty or such since I did open my mouth and expressed my concerns.

I always give choices and they are the one who decided which way to go even if sometimes doesn't go with mine. THEY ARE THE PARENTS, THEY HAVE THE RIGHT

As mentioned before, this is my point of view as a professional and the way I will procede,
Veronica Hinojosa Stang


I cannot believe the parents are so unconcerned!!! It really is up to them and if they want baby to have Reglan than YOU ARE NOT responsible for any adverse conditions. As long as the parents are aware of the dangers and fully apprised of the possible side effects and outcome than you cannot be blamed. Whether or not you administer the medication, or refuse is a personal choice. If you feel strongly about its' dangers than I would not administer the medication, looking out for the best interest of the baby. Let the parents administer it, and only the parents, then they are fully responsible.

I have a baby that started showing major reflux issues, spitting up, abdominal discomfort, pooping every two or three days, very gassy, pulling up legs and grunting a lot, and I recommended Simply Thick be added to his formula. The parents did not want him to go on medication so they tried the Simply Thick. The babys symptoms have all but gone away. He is less gassy, pooping twice a day, and not spitting up. Just thickening the formula with this thickener which is odorless, tasteless and adds no calories, did the trick. Also using a Nap Nanny to elevate him for sleeping. They did not want to do the reflux nest as he is VERY wiggly.
Nancy Gerberding