Objectives

1. Identify ethical difficulties in the role of parental decision-making.

2. Discuss pediatric assent and the ability to consent for themselves.

3. Recognize the diiculty with applying the “best interest” standard for somechildren.

Case 1

Tommy, 3, sustained a traumatic brain injury (TBI) from a motor vehicle accident. Two weeksinto his ICU stay, physicians presented Tommy’s parents with the option to forgo life-sustainingtreatments (FLST). After a few days of reflecting and discussing the issue, they agreed that stoppingthe ventilator was best, but by that time there was a new ICU physician who, after review ofTommy’s condition, did not think that FLST was warranted. With more intensive therapy, Tommywas able to breathe without the vent, and he was moved to the rehabilitation unit. Because ofhis TBI, however, he continued to be fed through a tube. Neurological scans indicated problemswith the basal ganglia, and Tommy’s parents suggested that Tommy’s condition was not in hisbest interest and asked the palliative care physician about the possibility of stopping feeds. Atthe same time, the physical and occupational therapists working with Tommy, as well as nursesand social workers from the PICU who came to visit him in rehab, believed they saw slight butnoticeable improvements in his cognitive status – possibly tracking, smiling, and reacting tosome stimuli. The entire unit, as well as these PICU staff members, is concerned about the ethicsof what the parents are suggesting.