Pediatric Court Orders

From Noblood

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Moderator Note

If this is your first visit to the NoBlood Wiki, welcome! I’m new here too. So this is a Wiki, a work in progress. If, after looking this article over, you have some ideas on how to make it more helpful, please send me a private message here. There is also a discussion regarding this article that you can access here. I would especially like to hear about actual court decisions (both those in the past as well as those to come) that had a stipulation attached that limited the scope of the order in some way. Since this is an international issue, it would be good to hear from various parts of the globe.

Here are two practical considerations: when such an emergency hearing takes place, it will probably be the first and last time in a judge’s career that they hear a case involving pediatric bloodless healthcare. If that judge is given a list of a few other cases (which, again, we hope to assemble here and add to the article, these precedents will carry considerable weight. The counsel for the plaintiff (typically child protective services) is not going to have the time in an emergency to research and refute.

Second, this attorney is not going to be happy to hear a list of seven stipulations. It will be up to the family attorney (if one is available or appointed) to argue for all seven. Realistically, a compromise will be struck where some but not all will be included.

Court orders in cases involving minor children may be unavoidable in some circumstances. By inserting the following stipulations, the order will be used much more judiciously, if at all.

One Specific Blood Product

Order must be limited to one specific blood product.

Critically ill patients initially may have perceived need for red cell transfusion; later other blood products may be perceived as necessary. Physicians may not wish to go to the trouble of later obtaining an additional order, and may alter their treatment.

Specific Time Period

Order must be limited to specific time period

Premature infants, for instance, can remain in the hospital for two to three months receiving convalescent care following an initial critical interval. Physicians might desire to have these stable infants remain under court order until discharge, on the outside chance that they might wish to give them a late transfusion, and not go to the trouble of obtaining another order. If the court, however, allows these infants to remain under order despite their stable condition, a dangerous precedent is set. Any Witness child riding in a car, for instance, runs some risk of injury, blood loss, etc. Moreover, there may be other Witness children in the hospital at the same moment being treated for asthma, diabetes, etc. Certainly, these children would not be placed under court order.

Other Treatment Decisions

Parents must retain right to all other treatment decisions.

Unless order is limited, physicians along with legal guardian could have carte blanche to order whatever blood product, whatever surgical procedure, whatever experimental treatments that they desire to.

Three Physicians Must Agree

Three physicians (e.g. attending plus hematologist and cardiologist) must all agree (and document this in medical record) on need before blood is given.

Since decisions to give pediatric transfusions are not based on controlled clinical studies (these have not been performed), there is wide variation in practice. Oftentimes, a physician on dayshift will see no indication for transfusion, but the covering physician that night or weekend may see things differently. Generally, the disagreements are more pronounced between subspecialties. For instance, a neonatologist may feel there is a need for transfusion, but a pediatric hematologist may feel that erythropoietin could be tried, and the pediatric cardiologist may not agree that the signs of heart failure that the neonatologist is concerned about are related to anemia. If the situation involves an older child with malignancy, the hematology attending might be mandated to consult a pediatric pulmonologist, anesthesiologist, and /or critical-care specialist.

Alternatives Tried First

Alternatives must be tried and exhausted first.

There have been occasions when critically-ill children have been started on iron and erythropoietin after multiple transfusions have been given and only hours before death occurred. Other times, attending physicians have refused to speak to consultants at other institutions who have expressed willingness to offer their advice and experience with bloodless alternatives. If the court order includes stipulations to initiate alternatives before transfusion and to discuss the management with all consultants prior to transfusion, the blood products might never be used.

Assignment Of Costs

Assignment of costs, tort responsibility while order active must be spelled out.

Often it is not clear, when a child is placed in the care of the state by means of a court order, who bears the cost and responsibility for the care of the child. Hospital bills for a sick premature infant, for instance, can total more than a quarter million dollars. Reminding concerned parties about this in the court order may cause some to think twice about transferring financial responsibility from the parents to the state. Moreover, if later there were indication of malpractice, that the hospital or physicians did not meet the standard of care, it would be prudent to clarify in the order that the parents will still have the right to seek damages.

If Transferred

Order must be voided if child transferred to another institution.

The court order should specify that transfer to another hospital or the care of another physician in the same hospital will not be blocked. In fact, the order should contain words that encourage that the attending seek transfer to another hospital or physician that would accept the child.

Charges of child neglect must be dropped / expunged if it is later demonstrated that transfusion causes harm, is never given, or was not needed.

Parents whose child has been forcibly transfused under court order may have charges of child neglect on their record for years. This can effectively prevent them from adopting, becoming foster parents, operating day care, etc. It is critical that these stipulations be included. It may be that another physician may be found, even some months later, who on review of the medical record, can testify that the transfusion(s) was(were) either harmful or unnecessary.

Related Articles

Erythropoietin (EPO) | Acute Normovolemic Hemodilution (ANH) | Prepare Now For a Possible Medical Emergency | Epidural Blood Patch (EBP) | Patients_Who_Refuse_Blood_Transfusions_-_FAQs | Intraoperative blood salvage | Blood Fractions Guide