Case 13

A 6-year-old boy with reactive airway disease missed his follow-up medical appointment with his primary healthcare provider after hospitalization for a severe acute asthma exacerbation. His asthma had been previously under control, but exposure to a new family cat resulted in severe respiratory distress and required admission to an intensive care unit. In addition to missing the follow-up appointment, his mother did not obtain a refill for his prescribed medication. Although the appointment was rescheduled, he began wheezing again before he was seen. This episode required an emergency department visit and re-admission to the hospital. A complete history was obtained.

Which of the following factors would lead to a suspicion of medical neglect?

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A. The family lives in a rural area and transportation to the primary care office was not easily accessible.

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B. The family was unable to find a home for their cat.

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C. The mother was informed that missing the appointment and not filling the prescriptions would likely cause the child to become ill again.

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D. The mother was ill at the time of the first appointment.

Which of the following factors would lead to a suspicion of medical neglect?

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A. The family lives in a rural area and transportation to the primary care office was not easily accessible.

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B. The family was unable to find a home for their cat.

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C. The mother was informed that missing the appointment and not filling the prescriptions would likely cause the child to become ill again.

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D. The mother was ill at the time of the first appointment.

The best answer is C

The medical needs of children with chronic illnesses or special health care requirements can be extensive. Healthcare providers are often challenged to provide the family with education regarding medical requirements and the risks of harm due to lack of medical interventions or treatment while also providing excellent health care and services.

In some cases medical neglect undermines the treatment of the child. Medical neglect is diagnosed when it is determined that despite access to appropriate care and documented caregiver understanding of the healthcare requirements, the child’s medical needs have not been met. In children with complex healthcare needs and/or ongoing stressful healthcare requirements, it can be difficult to determine the extent in which parental or caregiver neglect versus disease challenges are affecting the health of the child.

According to the 2007 American Academy of Pediatrics clinical report offering guidance regarding medical neglect, there are several factors that should be considered necessary for the diagnosis of medical neglect. (See reference below.) The first is that the child is harmed or at risk of harm due to lack of health care. In the case above, this criterion was met.

Another factor to consider is whether or not the recommended health care would have offered significant benefit to the child. A reasonable caregiver would be expected to follow through with treatment because the benefit of treatment outweighs the risk.

If access to health care is limited due to transportation or other issues, such as the mother was ill (as in item D above), then it is difficult to consider this a truly neglectful situation.

Some factors are not always easy to determine. For example, did the caregiver understand the medical advice and the importance of the follow up visit? If this was documented in the medical record, such as during pre-discharge asthma teaching when an asthma action plan was provided, then medical neglect is likely. In some cases the education level, mental capacity or health literacy level of the caregiver may interfere with understanding.

In the case described above, the best answer is C. However, neglect cannot be diagnosed without being assured that the family did understand the importance of the treatment and that, despite having access to the office for the visit, did not follow up.

Children with reactive airways may have one or more common triggers for wheezing. In this case the exposure to feline dander was likely a trigger. If a child is at risk of an exacerbation of asthma due to exposure to a family pet, it understandably presents an emotionally difficult situation for the family. The primary healthcare provider must ascertain risks versus benefits of the pet and discuss this with the parents. If it is determined that there is a serious risk of death or serious medical harm, it may be necessary to take a stand regarding removal of the animal to another home or environment. In general, there is no precedent for considering this exposure neglectful, but it seems that a reasonable parent would have to make arrangements for the animal to live elsewhere.

In many families exposure to tobacco smoke is a major trigger for asthma. This exposure causes a known risk of serious medical harm to children with reactive airways, even more than the known risks to healthy children exposed to passive smoking. Many would therefore consider it to be neglectful for parents to continue to expose an asthmatic child to smoke. Reporting such exposures as neglectful would require clear documentation that the parents were counseled regarding significant risks to the particular child. Sometimes a written contract with the parents can assist in helping the parents remember to create an appropriate smoke-free environment. Attempts by parents to quit smoking and minimize exposure to the smoking should be considered prior to diagnosing or reporting medical neglect.

It is important to recognize that healthcare providers may have a different perception, cultural or otherwise, of appropriate and feasible environments for children. Risks and benefits should be weighed as objectively as possible.

The finding of medical neglect may be a symptom of other underlying family dysfunction. Appropriate community referrals as well as a referral to child protective services may be the most efficient way to provide the family with assistance as well as provide improved health care to the child. Situations of potential medical neglect should be examined individually with consideration of the many factors mentioned here and included in the reference below.

Jenny C. Recognizing and responding to medical neglect.. Pediatrics. 2007; 120 (6) : 1385-9

External Link • DOI • PubMed

A caregiver may fail to recognize or respond to a child's medical needs for a …

A caregiver may fail to recognize or respond to a child's medical needs for a variety of reasons. An effective response by a health care professional to medical neglect requires a comprehensive assessment of the child's needs, the parents' resources, the parents' efforts to provide for the needs of the child, and options for ensuring optimal health for the child. Such an assessment requires clear, 2-way communication between the family and the health care professional. Physicians should consider the least intrusive options for managing cases of medical neglect that ensure the health and safety of the child.