Forced Treatment for Multidrug-Resistant Tuberculosis

MW is a 33-year-old man with multidrug-resistant tuberculosis (MDR-TB). He is homeless, and has a pattern of missing many of his scheduled clinic visits. Upon starting a multi-drug regimen for his condition, MW initially comes to his scheduled clinic visits, but after a few weeks begins missing them. The provider contacts the social work case manager, who arranges supervised drug administration (also known as “directly observed therapy”). Nevertheless, MW often cannot be found and this approach is deemed to be failing.

Sexually Transmitted Diseases and Contact Tracing

MG is a 27-year-old graduate student, recently married, who comes into the student health clinic for a routine pelvic exam and Pap smear. During the course of the exam, the gynecology resident performing the exam obtains the Pap smear, but also obtains cervical cultures for gonorrhea and chlamydia. The examination concludes uneventfully.

B.R. is a term female infant from an unexpected pregnancy. She has Down syndrome (Trisomy 21) and also has a complex cardiac lesion that will require at least two major surgical procedures during early infancy for her to have a chance to survive beyond childhood. B.R.'s parents, ages 44 and 45, have three other children, all in college. They have considerable ambivalence as to what to do: continue to pursue potentially beneficial though burdensome and costly treatments, or forego such treatments in favor of a more conservative approach.

What are the issues involved?

M.S. is a married 35-year-old pregnant childless woman who has lost four previous pregnancies between 16 and 23 weeks gestation. She currently has reached 23 weeks and 3 days of gestation, her fetus is seemingly healthy, and has an estimated weight of 550 grams (+/-1.2 lbs). She has ruptured her bag of waters and is now having labor that seems unstoppable with tocolytics. Delivery seems inevitable.

What are the management options and who decides what form of care should be instituted following delivery?

A 3-year-old presents to the emergency department. She was diagnosed with pyelonephritis by her physician yesterday, treated with an intramuscular injection of antibiotic and sent home on an oral antibiotic. She is vomiting today and unable to keep the antibiotic down. As you prepare to admit her, you feel she should have been admitted yesterday.

Should you tell the parents that their physician made a mistake? How should you handle this disagreement?

A 3-month-old has been admitted to the hospital with a newly diagnosed ventricular septal defect. She is in early congestive heart failure and digoxin is indicated. After discussing the proper dose with the attending physician, you write an order for the drug. Thirty minutes later the baby vomits and then has a cardiac arrest and dies. You discover that in writing the digoxin order you misplaced the decimal point and the child got 10 times too much digoxin.

What is your duty here? Will you get sued if you tell the truth?

An 18-month-old child presents to the clinic with a runny nose. Since she is otherwise well, the immunizations due at 18 months are administered. After she and her mother leave the clinic, you realize that the patient was in the clinic the week before and had also received immunizations then.

Should you tell the parents about your mistake?

A 22-year-old woman in her first pregnancy with an unremarkable prenatal course presents with preterm labor at 28 weeks gestation. Her contractions were successfully stopped with terbutaline. Discharge planning was reviewed with her, and she was instructed to follow a regimen of bedrest and oral terbutaline. She reported that she did not intend to comply with these instructions. She believed that God would not allow her to labor unless it was time for the baby to deliver, and she indicated that He had communicated this to her.