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Friday
Jun162006

Refusal Forms

On one of my lists, a discussion about how a mom or dad would refuse a procedure in Canada included the information that there doesn't seem to be any such thing as a refusal form there. How can that be?

I know care providers who work so hard to deny a "patient's" rights to consent - oh, it's the law... you have to do . I always wonder why nurses and doctors have such a vested interest in whether a mom and dad give their child a hearing test or a Vitamin K test in the first place.

(I can hear the argument already, actually. Because we are the ones who will have to treat your sick baby because you didn't give them !)

However, if a woman knows why she doesn't want a certain procedure, is it really right to strong-arm her into your type of compliance? Why not document the patient's choice and move on with it.

Perhaps there are a few folks that hear in class they might re-consider a Vitamin K shot or administering Erythromycin eye ointment, but don't really know why they might not want them. Someone might want to explain - offering some informed consent - and let them decide. Instead, what I've seen myself and heard from others includes the worst case scenarios of death and destruction. For goodness' sake, these are parents with pediatricians and access to medical care if anything untoward seems to be happening!

I think the worst right now is the GBS issue. God forbid a woman refuse antibiotic treatment in labor. Never mind that Europe doesn't treat GBS in the same hysterical manner as the CDC and OBs seem to; killing off every normal flora in two bodies is superior to treating a baby with GBS once it is out.

Yes, I have seen babies with GBS. Yes, I know of two that have died (they were not my clients' babies). I also know the babies that died did so because the parents didn't understand the symptoms clearly enough and didn't seek help soon enough. I know GBS can hit hard and fast, but in the major metropolitan are I live and work in, speed isn't the issue it would be if I lived in the mountains of Idaho or plains of Montana.

In Europe, parents are taught what to look for in newborns (remembering that GBS doesn't just affect the newly newborn, but can also cause illness in older newborns) and taught to bring the baby in if there are any questions - or the local midwife makes a visit to assess and refer.

I understand that here in the States treatment on L&D wards tends towards a give-and-get-anything-possible-in-case-we-never-see-them-again mentality, but when someone has researched, has information on risks and benefits, has a back-up plan of what to do if, and still wants to refuse a procedure or treatment, then why can't they be left alone?

Why do doctors and nurses seem to take it so, so personally if a parent exerts their personal desires? Is it that hard to step outside the dance of labor and delivery for half a second to curtsy to the individual who has a brain and a separate need than the herds of sheeple they typically see? Does seeing the patient as an individual - a person - carve into their thick dividing line between clinical care and heart-touching compassion?

Ah, but I think that is a separate issue best discussed in another post.

When I have clients who ask me, "Do I have to do a GTT/AFP/sono/PKU/Vit K/ E-mycin/GBS test/antibiotics/rupture of membranes/vaginal exam/STI testing/etc."

My answer is:

My job is to offer the smorgasbord of options - each dish having the ingredients listed in front of it. I will tell you what the standard of care is in the medical world and the midwifery world, then set you free to research on the Internet. You tell me what you want and I honor it.

That prospect is so foreign to too many women. The possibility of being believed, trusted, honored in their wishes is shocking to so many.

It shouldn't be that way.

Reader Comments (3)

EH? What the heck? I am so going to photo copy the birth notes from my midwives and send them to you! There is notation and signatures on my and their parts over some of these issues.... Not sure where this person is from (Canadian)... but I had to sign forms in the hospital too, to decline the eye goop.... bizarre... Must investigate!
k

June 16, 2006 | Unregistered Commentermm

my understanding is, that at least here in CA, refusal of eye goop, and vit K have to be documented so that if there were to be a problem there is evidence that the parents were educated and made an informed decision. Do you think it is that the medical model doesn't want to deal with any problem that may arise or that they are just too lazy/time constrained to be able to do the education?
I had just this scenario two days ago, when a couple that was supposed to birth at one hospital, had a precipitous labor and didn't make it and so had to pull off at TriCity ER with baby's head crowning and was whisked up to L&D. I won't go into all the horrendous treatment they received, but pertinent to informed consent, the dad asked the (militant) peds nurse 3Xs if they had to do the VitK shot and she insisted 3Xs it was a law!!!! The man had just been panting with his wife on the freeway not 10 minutes before, had just basically had an emergency childbirth with people not of his choosing nor in the hospital of his choosing. I'm amazed he had the presence of mind to even argue with this nurse! He gave in, she didn't give him an option and he wasn't able to continue the fight at that point. 20 minutes later though, he wanted to hire an ambulance to take his wife and baby to the hospital that they had chosen to birth at (meanwhile I was encouraging just go home as soon as you feel ready to go anywhere). You can hear how incensed I still am. Later, at home, ranting to my DH, I decided that in the medical model, Informed Consent means giving only the information that will make parents consent to whatever it is that the doc wants to do to them. In the MW model it is giving all the information that there is, so that the parents can make an informed consent or decline of any procedure.

June 17, 2006 | Unregistered CommenterAnonymous

MM: I have actually heard this from several Canadians. It didn't make any sense to me, but I don't live up there, so couldn't comment with any knowledge. Thanks for saying women *can* refuse!

Anon: I believe it is a time issue... that documenting takes time, that individuality takes time, that it's shorter to make a patient do what they want them to do instead of explaining the pros and cons, etc.

I am so sorry for your client at Tri-City. Sometimes it seems smarter to counsel them to car birth, you know? (I'm sure I'll be smacked for that one.)

Yes, it IS the law, but *with a waiver*, no, the shot doesn't have to be given.

An aside: a large group of doulas and midwives all tried to count how many times we ever saw the waivers in L&D or on the postpartum floor... and it was extremely rare that we ever did. Again, it takes time to FIND the papers for the family to sign - easier to lie/omit/coerce than to offer TRUE informed consent.

(As an aside - I have two very recent horror stories about Tri-City, too. One woman is in therapy after her horrific experience of being forced there because her hospital of choice was full - something she was never told might happen. She says she'd have gotten better care if she'd delivered next to a dumpster. Very sad.)

June 17, 2006 | Unregistered CommenterNavelgazing Midwife

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