You are the register in the Paediatric Emergency Department. A febrile infant needs a lumbar puncture but the nurse tells you that the parents have refused. What do you do?
Listen to the parents’ concerns
First thing’s first – you have no idea why the parents don’t want the lumbar puncture. In fact, from the info given, it looks like you may not have discussed it with them at all.
Talk to them and find out where they are coming from as they could be refusing for many reasons, for example:
- They had a friend whose baby had a lumbar puncture and they said it was very painful for the baby
- They read a story in the newspaper where someone died after having an epidural
- The dad hates needles
- They are worried the child will be paralysed
- They are not keen on any medical intervention in general
Once you understand the issue then it will be easier for you to address.
Explain what a lumbar puncture involves
Make sure the parents understand what the procedure involves. You should have a general spiel that you give all parents for a lumbar puncture. This should cover:
- what a lumbar puncture is
- what the risks are
- why you are doing it
Specifically address their main concerns.
Weigh up risks versus benefit
Emphasise to the parents that any risk of having the lumbar puncture needs to be weighed up against the risks of not having it.
What are the implications of not having it? – not being able to direct treatment against the right pathogens, and not being sure of the best length of treatment.
Consider the alternatives
You should also consider whether the lumbar puncture is really clinically indicated. Are you sure the child needs it at all? This might differ depending on the age and clinical presentation of the child.
If, for example, you did not lumbar puncture a febrile neonate, that might mean giving a longer course of treatment, monitoring progress and possibly revisiting the discussion at a later date.
Perhaps this would be a reasonable alternative (i.e. don’t get stuck with the view that your original thought must be right regardless of parental view).
What happens if they still don’t want to have the lumbar puncture?
If you feel that the child has a clinical need for the lumbar puncture, and the parents are still refusing, then you need to consider what steps you would take.
This is now an issue of safety to the child – that is your main priority. So, potentially you are now talking about forcing a treatment against the parents wishes through a court order.
This would clearly involve senior input and a discussion much higher up the management chain than you as a registrar.