Ethics in RN Notifying Social Services

[nursepandra]

I have an ethical question regarding a patient whom I just saw for routine prenatal teaching:

This patient is pregnant and due in May. In reviewing her records, she has an extensive inpatient behavioral health history (i.e. suicidal ideation, among other things), as well as an evident learning disability. She has one living child to which custody was given to a family member at birth. Her significant other was present with her during our teaching session, and I just have an overall bad feeling about their ability to care for newborn. His presence seemed as if he was supervising her interaction with me; it didn't seem as if he was there for the education. When I inquired about her living child, she made a comment along the lines of "I used to be sick in the head, but I'm better now." I feel as though some of her answers were reheorificed, so to speak.

A much more experienced nurse than myself told me to phone our county's social service department. I also addressed my concerns with the L&D department head, who gave me a vague answer about how social services would "probably" follow up being that they were involved in her first pregnancy. I feel like this isn't a definite answer. I don't want to be meddlesome, but I also want to make sure that I am being an advocate for this unborn child. I want to make sure that I handle this in the most ethical way possible, and I want to address it before the birth of this infant (which is quickly approaching) so that we can avoid a "now what do we do?" situation after delivery.

In conclusion, what is the most ethical, discreet, and appropriate way to handle this situation?

Thank you in advance.

[Double-Helix, BSN, RN]

If DCFS removed one child from this woman, they would definitely follow up if they knew about the birth of another child. An anonymous call to DCFS to inform them that X is pregnant and due in May would probably be sufficient enough to warrant a home visit from a case worker- that is, if they aren't already aware, which they very well may be.

Upon admission to the hospital it's standard for us to ask if there has ever been DCFS involvement with any children and if yes, we report the admission to the caseworker assigned to the family. So DCFS will probably become aware when the woman goes to the hospital as well.

Honestly, though, if the woman can show that they have a safe home and that she is seeking or has sought mental health treatment, there isn't much for DCFS to do. Until the baby is born there is no child that can be endangered or removed. Even if social services does find deficits in the home/parents, they will give the parents a chance to fix it before the child is born and follow up then. No official decision is going to be made before the child is born, as you legally can't assume custody of a baby that legally isn't alive yet.

As an aside, do you think it's possible that what you read in her record may be affecting your judgement about their family dynamic and readiness to parent? After all, they are seeking teaching, which is more than can be said for many families. Some of her answers very well may have been reheorificed, as she has likely had to answer them multiple times in the past. A learning disability does not disqualify one from parenting. It's entirely possible that your instincts are right, but just make sure you aren't being influenced by her past. People with mental health disorders can and do recover and can be good parents.

[Jolie, BSN]

Thank you for your concern for the well being of this unborn child and for your desire to act in an ethical and professional manner in addressing your concerns.

Going to your supervisor was the logical and proper first step. Unfortunately, it does not seem as though you received useful guidance or insight. The response that CPS will probably be involved sounds like a cop out on the part of someone too busy or disinterested to work proactively on behalf of this baby. But you did the right thing and tried.

I would suggest a fact to face meeting with your social worker next. Share with him/her the information you have shared here. Ask point blank if s/he will make contact with CPS or whether you should do so yourself. Then work together to formulate a plan of action based upon hospital P&P as to how hospital SS and state CPS will be notified when the mother arrives for delivery.

I don't know your extent of experience with this type of situation, but there are a few points I'd like to share:

1. It is highly significant that the previous child was removed from the mother's care immediately at birth. Most times, there are great efforts made to keep mother and baby together with family and agency support, and a baby is not removed from its mother's care unless there is substantial evidence of abuse, neglect, complete inability to provide care, horrifically unsafe living conditions, criminal activity, etc. The other possibility is that the mother requested or voluntarily agreed to forfeit custody of her child, but again, that is rare and unlikely.

2. Even though the mother has an older child "in the system" it is NOT reasonable for anyone (your nurse manager included) to assume that CPS is aware of this pregnancy and impending birth.

3. Some mothers will go to great lengths to conceal pregnancies and/or deliver at unlikely locations to avoid CPS detection. For this reason, it is important that CPS know her EDC so they can start checking birth records if her due date comes and goes without her reporting to your unit for delivery as expected.

My very best to you and this baby.

[Jolie, BSN]

Honestly, though, if the woman can show that they have a safe home and that she is seeking or has sought mental health treatment, there isn't much for DCFS to do....

It's entirely possible that your instincts are right, but just make sure you aren't being influenced by her past. People with mental health disorders can and do recover and can be good parents.

Ashley, I respectfully disagree with the first part of your post. I have had experience in more than one state with CPS becoming involved during pregnancy due to previous extreme circumstances of child abuse, and the concern that the parents would "go underground" and hide the baby from authorities. While rare (as it should be), prenatal CPS involvement is not un-heard-of. In one instance, the mother was court ordered to be hospitalized under guard for an extended period of time until delivery. All we were told (staff nurses) was that it was necessary to protect the baby. We later learned the circumstances (in the news) and were grateful that the judge had made the order to protect that innocent life.

Again, I understand that this is extreme, and probably NOT what the OP is discussing, but it does happen.

And I agree wholeheartedly with your second point :)

[Double-Helix, BSN, RN]

Ashley, I respectfully disagree with the first part of your post. I have had experience in more than one state with CPS becoming involved during pregnancy due to previous extreme circumstances of child abuse, and the concern that the parents would "go underground" and hide the baby from authorities. While rare (as it should be), prenatal CPS involvement is not un-heard-of. In one instance, the mother was court ordered to be hospitalized under guard for an extended period of time until delivery. All we were told (staff nurses) was that it was necessary to protect the baby. We later learned the circumstances (in the news) and were grateful that the judge had made the order to protect that innocent life.

Again, I understand that this is extreme, and probably NOT what the OP is discussing, but it does happen.

And I agree wholeheartedly with your second point :)

What state are you in? I'm really surprised that its possible to force hospitalization if a mother for protection of the baby when the baby is legally not even seen as a baby. That's very interesting. I've never heard of such a situation.

[debsgreys]

If this mother was a pt. in our Family Health Center, a social worker would be involved with her care.Who ever her OB care is when she delivered a social worker would meet with the mom. Because of her history with the first child, if she had an open DYFS case they would be involved, if not open given situation along with factors noted at time of delivery then DYFS may be called. Behavioral Health would also be involved. I am not very good At writing what I am trying to say, but please let me be clear, we would want her baby to be with her, that is the goal. Social Service can check her home etc. A big thanks to you nursepandra for not putting this pt. out of your mind after she left the office. This happens far to many times with short staffing and decrease staffing.

[NicuGal, MSN, RN]

Social work should be made aware of the mom and then they will contact DCFS when she delivers. I've never heard if a forced hospitalization, but that sounds like the exception to the rule. If the parents can provide a safe home, show they have completed whatever programs they need to do, they will most of the time place the baby with the parents. Sometimes we don't think it is a good idea, but the county will think otherwise