What is the most appropriate next step for a critically ill patient with sepsis, respiratory failure, and shock, whose parents are requesting a transfer against medical advice?

From the Guidelines

The most appropriate immediate next step is to arrange a meeting between the care team and parents (option B). This situation requires direct communication to address the parents' concerns while maintaining focus on the critically ill child's best interests. In this meeting, the medical team should compassionately explain the medical risks of transfer during acute respiratory failure and shock, when the patient requires mechanical ventilation and vasopressor support, as outlined in guidelines for the inter- and intrahospital transport of critically ill patients 1. The team should acknowledge the parents' desire to be near extended family while exploring potential compromises, such as planning for transfer once the child stabilizes or facilitating family visits. This approach respects the parents' role in decision-making while prioritizing patient safety, in line with recommendations for supporting the family in the patient-centered intensive care unit 1. Rushing to transfer an unstable patient (option A) could be dangerous, involving social services (option D) is premature and antagonistic, and consulting media relations (option C) doesn't address the core medical and ethical issues that need resolution through direct communication. Furthermore, offering surrogates the opportunity for transfer to an alternate institution, as suggested by an official ATS/AACN/ACCP/ESICM/SCCM policy statement 1, should be considered if the family remains unpersuaded after thorough discussion, but this should not be the immediate next step without first attempting to address concerns and find common ground through open communication.

Key considerations in this meeting include:

• Providing clear and honest information regarding prognosis, as recommended by clinical practice guidelines 1
• Allowing ample opportunity for questions and ensuring that the family's concerns are heard and addressed
• Exploring compromises that balance the family's wishes with the medical team's concerns for the patient's safety and well-being
• Considering the potential for transfer to another institution if the family remains unsatisfied with the current plan, as outlined in the policy statement 1.

By prioritizing open communication and collaboration, the care team can work with the family to find a solution that respects their wishes while also ensuring the best possible outcome for the patient.

From the Research

Situation Analysis

• The patient is a 2-year-old boy in the pediatric intensive care unit with respiratory failure and shock caused by sepsis.
• He is intubated and mechanically ventilated, and his current medications include intravenous antibiotics, vasopressors, and fluids.
• The parents want to transfer the patient to another hospital closer to their extended family, but the resident on-call explains that the patient is unstable and any attempts to transfer him would jeopardize his life.

Communication and Teamwork

• The care team should prioritize open communication with the parents to address their concerns and explain the risks associated with transferring the patient 2.
• Arranging a meeting between the care team and parents can help to clarify the patient's condition, treatment options, and the risks associated with transfer 3, 2.
• This meeting can also provide an opportunity for the care team to understand the parents' concerns and preferences, and to work together to develop a plan that prioritizes the patient's safety and well-being.

Next Steps

• The most appropriate immediate next step is to arrange a meeting between the care team and parents to discuss the patient's condition, treatment options, and the risks associated with transfer (Option B).
• This approach prioritizes open communication, teamwork, and patient-centered care, and can help to build trust and understanding between the care team and the parents 4, 3, 2.