Decision Making in Nursing: Teen autonomy vs. Parental jurisdiction Presented by Katharine Cella, Claudia Cornejo, Kristina Holmes, Cara LaMotta, & Laura Logan

Tiffany, a 15-year old healthy patient, is dealing with severe acne that has been unresponsive to prior treatment regimens. Today she and her mother are meeting with a family nurse practitioner, Dr. Murphy, to discuss receiving a prescription for Accutane. The only catch – which is significant – is that Accutane is highly teratogenic. Tiffany will be required to concurrently take two forms of birth control to prevent her from getting pregnant OR pledge abstinence from sex. Her mother, Mrs. Jones, is highly conservative and does not want her to be on birth control. Her daughter would like to consider birth control but feels unable to discuss this with her provider given her mother’s opposition. Dr. Murphy knows there are several ways to handle this complex and highly charged situation, all with various potential outcomes. What will she do and how might the patient and her mother respond? What has the highest chance for a good outcome? Where does the line between the patient’s right to choose end and the mother’s right to be involved in her young daughter’s important healthcare decisions begin?

Introducing the Cast

The Setting

The Script

Meeting Dr. Murphy for the first time

Dr. Murphy: Accutane is a strong medication that would work to clear up your skin. However, you would have to come in every month to take a mandatory pregnancy test, because should you become pregnant, Accutane could cause significant birth defects to your baby. You would need to have a negative pregnancy test each month before I could refill your prescription.

Accutane warning label

Tiffany: Yeah, I get it. I just want this acne to go away.

Dr. Murphy: Ok, great. To move forward, in addition to monthly pregnancy testing, you will either have to sign an abstinence pledge or commit to two forms of birth control that you will use throughout your treatment. The most common forms are the birth control pill and condoms. This part is critical.

Mrs. Jones (interjecting): Oh, Tiffany will be signing the abstinence pledge. She will definitely not be going on birth control. She will not be using this prescription as a pass to start having sex.

Tiffany (shrugs and looks dubious): Ok.

Dr. Murphy (addressing Tiffany): I need to hear from you about how you feel about this because this is a medical decision that affects your body and your lifestyle.

Tiffany (looks down hesitantly): I guess I’ll go ahead and sign the pledge.

One day later ...

Tiffany: Hi, Dr. Murphy. My boyfriend drove me back to come see you today. I didn’t want to say it with my Mom in the room, but I think I really want to be on birth control. I just didn’t want to upset her. I’ve been dating my boyfriend for 13 months and we haven’t had sex yet, but I would just rather be ready for when we decide to do it.

Dr. Murphy: I appreciate you coming back to see me. I know it’s a tough decision, especially with such a stringent medication routine. Of course, we encourage honesty with your mother about your medical choices, however, legally, I am not required to inform your mother that you are seeking contraception. Ultimately, this decision is yours to make. At the same time, I have to emphasize how crucial it is that you adhere to taking the birth control. You would have to commit 100% to taking contraception as directed.

Tiffany: Thanks. Yeah, I’d like the prescription and for you not to tell my mom, she’d freak! You saw how strict she was. She still treats me like a kid.

Dr. Murphy: I understand. Do you think you can commit to taking the contraceptive daily as directed?

Tiffany: Definitely!

Dr. Murphy: OK. I feel comfortable prescribing you birth control -- again, as long as you take it as I've instructed. And don’t forget, if you engage in sexual activity while on Accutane, you will also need a second form of protection -- I would suggest condoms. You will need to use 2 forms of contraception for a month and take a pregnancy test before I can start you on Accutane. In the meantime, let’s talk a little about birth control pills, how it works, how you’ll need to take it, etc ...

Several months later: Treatment has started, Tiffany & Mom come in for a follow-up visit

Dr. Murphy: Alright, so your pregnancy test has come back negative. Mrs. Jones, I have a few questions that I need to ask your daughter in private. I’m going to ask you to step out of the room for now. You can schedule the next visit while we chat. I’ll come get you when we’re finished.

Mrs. Jones leaves the room hesitantly

Dr. Murphy: Ok, Tiffany. I need to ask a few questions about your current sexual activity for your safety given that you're now on Accutane. Have you and your boyfriend decided to have sex -- specifically vaginal intercourse?

Tiffany (embarrassed blushing): Yes.

Dr. Murphy: OK , how are things going with the birth control I prescribed you last month? Have you been taking it everyday?

Tiffany: Fine. I take it most days of the week.

Dr. Murphy: Does that mean you are missing doses?

Tiffany: Yeah, I miss a dose here and there.

Dr. Murphy: How often would you say you miss doses?

Tiffany: Umm, probably one pill a week-ish?

Dr. Murphy: Can you tell me why you are missing doses?

Tiffany: I guess I forget sometimes or am too busy to take it.

Dr. Murphy: Ah, ok. Well, I understand how challenging it can be to remember to take medication. However, as we discussed previously, it’s really important that you take ALL doses, every day at the same time each day. Unless we can figure out a way for you to take your birth control EVERY day, I’m not going to be able to continue prescribing you Accutane. It’s just too risky for your health and your baby’s health, if you were to get pregnant.

I know how important it is to clear up your skin and I’d like to be able to continue prescribing your Accutane.

Dr. Murphy stops to weigh her options...

"How should I handle this situation?"
In which Dr. Murphy attempts to use patient education to get Tiffany back on track

Dr. Murphy: Can we talk about ways that you can remember to take your medication?

Tiffany: Sure. I definitely don’t want to stop taking either the Accutane or my birth control.

Dr. Murphy: Great. Well let’s discuss some strategies for you....

In which Tiffany decides how to handle her mother

Dr. Murphy: Ok Tiffany, unfortunately, I cannot continue to prescribe you Accutane with an irregular adherence to birth control, especially since you are having sex. You needed to have 2 consistent methods of birth control OR pledge abstinence. This rule is not a punishment, but it's to ensure every patient takes this medication safely.

Tiffany: what are you going to tell my mom when she asks why I’m not taking it anymore?

Dr. Murphy: As your provider, I will not disclose anything to your mom that you have not given me permission to discuss. However, I do think it would be beneficial if you were able to have an honest conversation with her so we can brainstorm about ways to proceed with your skin care treatment SAFELY. You have ultimate control in how this conversation happens.

Tiffany: Umm...I think I’m just going to tell her I didn’t like taking Accutane. I’ll talk to her about birth control another time.

Dr. Murphy: Okay. Please don’t hesitate to call me if you ever have any problems with the birth control or need advice about how to talk to your mom. In the meantime, let’s discuss less stringent alternatives for skin care.

In which Dr. Murphy seeks Mom's involvement

Dr. Murphy: OK Tiffany, unfortunately, I cannot continue to prescribe you Accutane with an irregular adherence to birth control, especially since you are having sex. You need to have 2 consistent methods of birth control OR pledge abstinence.

Tiffany: Well, I just don’t know how I can do any better than I’m doing. I’m so stressed out and busy, and I honestly don’t see why it’s that important if I miss a dose here or there.

Dr. Murphy: I can understand why it might not seem that important, but it really is. Even a single missed dose significantly raises the risks to your health. Would you be willing to recommit to taking your contraception as instructed?

Tiffany: Um, I don’t know. I just don’t think I can do it any better. I’m sorry.

Dr. Murphy: While I understand, I’m going to have to take you off Accutane. You needed to have 2 consistent methods of birth control OR pledge abstinence. This rule is not a punishment, but it's to ensure every patient takes this medication safely.

I also feel it is important for me to discuss the situation with your mom so that she is also aware of the risks and implications involved with this decision.

Tiffany: No! Please don’t tell her! She’ll be furious with me!

Dr. Murphy: I’m sorry, but as your provider I feel obligated to disclose significant health information to your Mom, given that you are still a minor. You’re sexually active, not taking your birth control consistently, and are taking this medicine -- these together are high risk behaviors. The risk of harm to your health is just too significant for me to not tell your mother. Many years ago as a new nurse, I committed myself to the ANA Code of Ethics, which describe some fundamental principles that all nurses must adhere to. One aspect of the Code is that nurses will promote, advocate, and protect the rights, health, and safety of our patients. In this instance, your health and safety are at risk and it is my determination that your family needs to become involved in your care.

Tiffany: But I’m 15. I’m legally allowed to make my own decisions and take risks if I feel comfortable with it.

Dr. Murphy: I’m sorry, your health is my highest priority. I do not feel comfortable leaving your mother in the dark about your care....

In which Dr. Murphy tries a different approach to birth control

Dr. Murphy: So there are some other birth control options that don’t require you to take it daily. The 3 less invasive options are a shot, a transdermal patch, or a vaginal ring. The Depo-Provera shot is given every 3 months. The hormones stay in your system for that length of time to prevent pregnancy. The Patch is placed on your skin and changed once a month. You would have to remember to change the patch once per month. The Nuva ring is a small piece of plastic that you would insert and retain in your vagina. You would remove it once a month for your period and when you’re having sex. What do you think about these options? Do any of them sound like a good fit for you?

Tiffany: I really dislike shots, but I like that I don’t have to think about it. Could we try that one?

Dr. Murphy: Sure. We could potentially do the shot today. If you end up not liking it after this dose, we can talk about switching to one of the other forms of birth control. Remember, you'll have to continue using condoms as well. Let's go through the side effects commonly experienced with this type of birth control ...

What would you do?

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