Ob-Gyns Address Refusal of Medically Recommended Treatment During Pregnancy

Washington, DC—One of the most challenging scenarios in obstetric care for patients and providers occurs when a pregnant patient refuses recommended medical treatment. Today, in an updated Committee Opinion, the American College of Obstetricians and Gynecologists (ACOG) addresses the ethical considerations surrounding the care of an obstetrical patient who refuses recommended medical treatment and states that ACOG opposes the use of forced medical interventions for pregnant women.

Committee Opinion #664, "Refusal of Medically Recommended Treatment During Pregnancy," provides practical guidance for ob-gyns and other women’s health care providers for these uncommon, yet complicated, situations. It emphasizes that even though it may conflict with the ob-gyn’s professional desire to optimize the health of the fetus, pregnancy is not an exception to the ethical principle that a woman has the ability to make health care decisions for herself nor does pregnancy lessen or limit the requirement to obtain informed consent or to honor a pregnant woman's refusal of recommended treatment.

“The refusal of medically recommended treatment during pregnancy is a complex and challenging, but incredibly rare scenario. While such situations can cause distress to both the patient and her physician, it is imperative that the pregnant woman be supported and that her wishes be respected,” said Sigal Klipstein, MD, chair of ACOG’s Committee on Ethics, which developed the Committee Opinion. “As ob-gyns, we have a vital role in recognizing the interconnectedness of the pregnant woman and her fetus while also maintaining respect for the pregnant woman’s autonomy and decision-making capacity.”

The Committee Opinion notes that cases of refusal of medically recommended treatment during pregnancy often call for an interdisciplinary team approach. The team may include colleagues from other disciplines, such as nursing, social work, chaplains, or ethics consultations. With the patient’s consent, it may also be helpful to include members of the pregnant woman’s family or personal support network. The need for clear, compassionate communication, support and understanding of the patient’s background is also necessary. The Committee Opinion states, “Medical expertise is best applied when the physician strives to understand the context within which the patient is making her decision.”

“This new Committee Opinion reinforces ACOG’s longstanding support of a patient’s right to consent to or refuse medical treatment, and the principle that pregnancy is not an exception to this fundamental right,” stated Mary Faith Marshall, PhD, FCCM, an author of the Committee Opinion. “It acknowledges that a pregnant woman, not any other person, is best suited to make decisions for herself and her family. Respecting this right is vital to the patient’s relationship with her physician, and prevents coercive interventions and incursions against bodily integrity, which are always ethically impermissible. The Committee Opinion encourages a team approach to supporting the patient, resolving differences, and honoring the patient’s decision.”

Resources and counseling should be made available when adverse outcomes occur after a pregnant patient’s decision to refuse recommended treatment. Clinical teams are urged to help the woman with any grief that she may experience. Resources also should be established to support debriefing and counseling for health care professionals when adverse outcomes occur after a pregnant patient's refusal of treatment.

ACOG opposes the use of coerced medical interventions for pregnant women. Further, ACOG strongly discourages medical institutions from pursuing court-ordered interventions which conflict with a patient’s decisions for her care. Likewise, ACOG discourages medical institutions from taking legal or disciplinary action against obstetrician–gynecologists who refuse to perform court-ordered interventions. However, ob-gyns may play an active role in these situations by offering medical advice, guidance, recommendations, or some combination thereof. This directive counseling approach is appropriate and typically is welcomed in the medical encounter because non-coercive medical recommendations do not violate, but rather enhance the requirements of informed consent. The use of coercion, in contrast to directive counseling, is never acceptable as a means of influencing a patient towards a clinical decision.

Dr. Klipstein added, “Women’s decision making regarding their health care, both during and outside of pregnancy, should always be respected. In this way, we can guarantee that women will feel supported when seeking out medical care and not avoid accessing health care for fear of being coerced into decisions that go against their personal values or desires.”

Committee Opinion #664, "Refusal of Medically Recommended Treatment During Pregnancy," is published in the June issue of Obstetrics & Gynecology.

Other recommendations issued in the June Obstetrics & Gynecology:

Committee Opinion #663, Aromatase Inhibitors in Gynecologic Practice
Aromatase inhibitors have been used for the treatment of breast cancer, ovulation induction, endometriosis, and other estrogen-modulated conditions. For women with breast cancer, bone mineral density screening is recommended with long-term aromatase inhibitor use because of risk of osteoporosis due to estrogen deficiency. Based on long-term adverse effects and complication safety data, when compared with tamoxifen, aromatase inhibitors are associated with a reduced incidence of thrombosis, endometrial cancer, and vaginal bleeding. For women with polycystic ovary syndrome and a body mass index greater than 30, letrozole should be considered as first-line therapy for ovulation induction because of the increased live birth rate compared with clomiphene citrate. Lifestyle changes that result in weight loss should be strongly encouraged. Aromatase inhibitors are a promising therapeutic option that may be helpful for the management of endometriosis-associated pain in combination therapy with progestins.

Committee Opinion #665, Guidelines for Adolescent Health Research
Considerable uncertainty exists about what constitutes appropriate levels of protection for adolescents as research participants and about the need for parental permission. The ethical principles that govern research include respect for individuals, beneficence, and justice, as articulated in the Belmont Report. Researchers should be familiar with and adhere to current federal regulations 45 C.F.R. § 46, and federal and state laws that affect research with minors. Investigators should understand the importance of caregiver permission—and ethically appropriate situations in which to waive caregiver permission—for the protection of adolescent research participants.

Committee Opinion #666, Optimizing Postpartum Care
In the weeks after birth, postpartum care often is fragmented among maternal and pediatric health care providers, and communication between inpatient and outpatient settings is inconsistent. To optimize postpartum care, anticipatory guidance should begin during pregnancy. During antenatal care, it is recommended that the patient and her obstetrician–gynecologist or other obstetric care provider formulate a postpartum care plan and identify the health care professionals who will comprise the postpartum care team for the woman and her infant. Ideally, during the postpartum period, a single health care practice assumes responsibility for coordinating the woman’s care. At discharge from maternity care, the woman should receive contact information for her post-partum care team and written instructions regarding the timing of follow-up postpartum care. It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being. Systems should be implemented to ensure each woman can receive her desired form of contraception during the comprehensive postpartum visit, if not done earlier. At the conclusion of the postpartum visit, the woman and her obstetrician–gynecologist or other obstetric care provider should determine who will assume primary responsibility for her ongoing care. If responsibility is transferred to another primary care provider, the obstetrician–gynecologist or other obstetric care provider is responsible for ensuring that there is communication with the primary care provider so that he or she can understand the implications of any pregnancy complications for the woman’s future health and maintain continuity of care.

Obstetric Care Consensus #4, Periviable Birth (Interim Update)
Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

Practice Bulletin #164, Diagnosis and Management of Benign Breast Disorders
Breast-related symptoms are among the most common reasons women present to obstetrician–gynecologists. Obstetrician–gynecologists are in a favorable position to diagnose benign breast disease in their patients. The purpose of a thorough understanding of benign breast disease is threefold: 1) to alleviate, when possible, symptoms attributable to benign breast disease, 2) to distinguish benign from malignant breast disease, and 3) to identify patients with an increased risk of breast cancer so that increased surveillance or preventive therapy can be initiated. Obstetrician–gynecologists may perform diagnostic procedures when indicated or may make referrals to physicians who specialize in the diagnosis and treatment of breast disease. The purpose of this Practice Bulletin is to outline common benign breast disease symptoms in women who are not pregnant or lactating and discuss appropriate evaluation and management. The obstetrician–gynecologist’s role in the screening and management of breast cancer is beyond the scope of this document and is addressed in other publications of the American College of Obstetricians and Gynecologists (1–3).

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org