Refusal of treatment and disagreement over care — formative SAQs

SAQ 1 (10 marks)

A 6-year-old child is bleeding after surgery and requires a blood transfusion to survive. The parents, who are Jehovah's Witnesses, refuse blood products on religious grounds. The child is deteriorating but still conscious. [3] [4]

1. State the principle that sets the threshold for overriding this parental refusal, and explain why the clinician does not override it alone. (3) [1]
2. Outline your immediate and stepwise management of the child and the family. (5) [3] [4]
3. Describe how you would document the encounter and preserve the therapeutic relationship. (2) [1]

Model answer

The harm principle sets the threshold: clinicians respect parental authority until the refusal risks serious and likely harm to the child that is not outweighed by respecting the decision. Once the immediate emergency has passed, the authority to override an ongoing settled refusal belongs to the court, not the clinician acting alone, because the court is the legitimate arbiter of an irreconcilable dispute and protects both the child and the clinician. [1]

Immediate management is to stabilise the bleeding and anaemic child by treating in the child's best interests under the emergency doctrine or safeguarding authority. Continue respectful engagement with the family throughout, explain the clinical need honestly, and explore whether blood-conserving strategies can bridge safely. Escalate to senior clinicians and the ethics service, and seek a court determination for the ongoing dispute; judicial review consistently supports transfusion of a child against parental refusal where life is at stake. [3] [4]

Document contemporaneously and factually: what was offered, the risks explained, the parents' reasons, the child's state, the emergency authority invoked, and the escalation. Continue to offer care and keep the door open, because a child whose family has been alienated still needs a team — preserving the relationship is part of the management. [1]

SAQ 2 (10 marks)

In the PICU, parents of a child with severe hypoxic brain injury demand continued full life-sustaining treatment that the team judges non-beneficial. The disagreement has persisted despite repeated discussions and a second opinion. [5] [6]

1. What is the likely underlying driver of the parents' demand, and how does it change your approach? (3) [5]
2. Outline the escalation pathway for this entrenched dispute and the evidence supporting early ethics consultation. (4) [5] [6]
3. Describe the threshold at which the dispute should be taken to the court, and the role of the clinician versus the court. (3) [1]

Model answer

The likely driver is unmet hope and inadequate prior prognostic communication, not parental unreasonableness. Families who demand treatment the team judges futile are usually asking for hope and time rather than for a specific intervention, so the remedy is a goals-of-care conversation that re-explores what the family most wants for their child and re-shares the prognosis honestly. [5]

The escalation ladder runs from bedside discussion with the treating clinician, through senior review and an independent second opinion, to formal ethics consultation, mediation, and finally a court application. Schneiderman's randomised trial showed that ethics consultation reduced non-beneficial life-sustaining treatment and conflict in intensive care, so these supports should be called early rather than as a last resort, before positions harden. Morrison's national survey confirms that paediatricians find ethics consultation useful and that it is underused when delayed. [5] [6]

The dispute should be taken to the court when the disagreement cannot be reconciled and the refusal or demand risks serious harm to the child. The clinician treats in the child's best interests under emergency authority where there is imminent serious harm, then seeks a court determination for the unresolved dispute. The court, not the clinician acting alone, is the legitimate arbiter once the emergency has passed. [1]