1. PREGNANCY TERMINATION IN BRAIN INJURED PATIENTS Kathryn Kenny MD, BSc, MSc Candidate Departments of Obstetrics & Gynecology and Medical Science, University of Calgary
Background
Catastrophic neurological events can occur in otherwise healthy pregnant woman. Cerebral vascular events (stroke) can occur in the antepartum period, sometimes before the fetus reaches viability.
Most pregnant woman do not anticipate catastrophic events occurring – no prior discussion of personal values regarding pregnancy continuation if there is loss capacity during pregnancy.
Few case reports published with respect to women with serious brain injury and pregnancy termination.
Case Presentation – Patient JA
36 yr old woman, 2 previous children from different partners
9 weeks gestation at time of massive cerebral vascular accident from thrombosis – secondary hemorrhagic stroke and seizures – required urgent neurosurgical decompression with skull removal
Patient sedated and intubated in ICU at time of Obstetrics Consult for discussion of pregnancy continuation. Following simple commands with right side of body and no speech ability.
Substitute decision maker (patient’s mother) requested pregnancy termination. Termination opposed by partner and remainder of patient’s family
Ethical Considerations in the Case of JAThe
Non-Malifecence
Does continuing the pregnancy risk harm to the patient?
Is termination medically indicated?
Is termination appropriate in this patient if requested by the partner and/or family?
Autonomy - Substitute Decision Maker
What defines capacity?
No available personal directive – who should be the substitute decision maker for this patient?
Substitute decision maker is elderly and physically disabled and unable to care for infant – does her request for termination reflect the values of the patient or herself?
Autonomy - Confidentiality
How should the family be incorporated in discussions normally held in confidence between OB and the patient?
What role should the father of the baby play in decision making for this patient given he is not the substitute decision maker?
Substitute decision maker feared retaliation from family when requesting information on termination – how should she be protected?
Moral Distress of Care Providers
Concerns from health care providers infant may need involvement of social work and foster care as no one physically able to meet basic needs of infant (extended family did not initially offer to care for infant)– does this justify performing a pregnancy termination?
Multidisciplinary Support
When should a formal capacity assessment be performed in a patient with brain injury?
Who should perform the capacity assessment? Who should be permitted to comment on capacity in a patient’s chart?
Who from the Obstetrical Department be involved? General Gynaecology, Maternal Fetal Medicine?
What should be the role of the hospital ethicist and ethics committee and when should they be involved in discussions?
Support in the Literature?
Society of Obstetricians and Gynaecologists…
“The physician must make sure that the woman understands the nature and the potential complications of the procedure and that she has the necessary information to make an informed decision.” – a discussion of mature minor follows but not comment is made about adults with loss of capacity
Future Directions
Development of hospital based guidelines outlining both the steps and key team players who should be involved when pregnancy termination is considered in a brain injured pregnant patient
Improved education of the public about the benefit of advance personal directives in ensuring the values of a patient are respected by decision makers and healthcare teams