Vitamin K administration legal/ethical nightmare!

danissa, LPN, LVN · May 12, 2008

we have to ask parents permission for vitamin K, and to be honest, people nearly all of the time go along with it. For the tiny minority who dont agree, then oral Vitamin K is available, can be given in two doses..(I'm sure it's two doses!), Only once have I ever come across this refusal, and it was given orally. We have a protocal for it, I must look at that at work tomorrow!

JaneyW · May 12, 2008

OK, I am in CA and maybe we are different. We can refuse vaccines because we have different beliefs (not necessarily religious) and parents can refuse Vit K just like they can refuse any medical treatment to their child. The only time I had this happen was back when I was in orientation and we had the parents sign an AMA form for the Vit K. Maybe things have changed since then or maybe we just handled it wrong then--I don't know. I know I have been back to that hospital recently (as registry) and they had some funky policies now that I know better :-). I'd like to hear what everyone has to say and please let us know what state you are in!

clhRN2b2010 · May 12, 2008

Curious...what state? We also can refuse if we choose. I nixed the eye antibiotic for my babies but absolutely felt that the benefits outweighed the risks for Vit K. I know folks who are adamant about no vaccines though.

Halinja, BSN, RN · May 12, 2008

I have lived in several different states. In all those states children are required to have certain vaccinations. (Actually, technically, I don't think vitamin K is a vaccination, it is a medication.) But vaccinations first. All vaccines can be refused by the parent. You cannot lose your license if you do not give it, but the parents have to sign a form that says they declined. The facility keeps the permanent copy and gives the parents a copy.

As to vitamin K. Not a vaccination, it is a 'medication' that helps baby with clotting, as some babies are born without inherent vitamin K and can bleed, including uncontrolled bleeding in the brain. It is easily prevented by a dose of vitamin K at birth. In all states in the US, medications can be refused. Again, get a signature from the parents saying they have been informed of the risks to the infant and are willing to accept those risks. If something happens later, the PARENTS can be sued for not getting the child appropriate medical treatment.

http://www.gurgle.com/articles/Baby_Health/22490/Vitamin_K.aspx

http://www.womens-health.co.uk/vitk.asp

Some women will take extra vitamin K for a few weeks before the birth of the baby. I don't know if that is effective. There is no hard evidence for the practice of giving it in the first hour of birth. Within a few hours is more than enough. There is some debate that all babies are vitamin K deficient, but the biggest danger is the infant without any. The deficiency may not manifest itself for days or even weeks, and affects 1 in 10,000 full term neonates. There isn't a really good cost effective non-invasive way to screen, it is easier to just give the vitamin K to all. It's a vitamin, and in general will not harm those who do not need it.

Sorry, more info than you probably wanted to know, but it is important to know WHY we give the meds we do. It's hard to convince a parent if you don't really know why other than 'they told us to'.

HM2VikingRN, RN · May 13, 2008

I remember my OB instructor (CNM) sharing in clinical how traumatized the department was after they lost a baby after the parents refused vit k.

The lesson I took from that was just how important good patient education is in helping parents make good decisions. I am pro vaccination so I really struggled mentally with those parents who did not start the hepatitis vaccination series.

Vit K is a vitamin that is Low costand low risk. I think that there was some information read by the patient on the internet that was written by a yahoo claiming that it could lead to injury. I ran across a reference that basically said for BREAST FED infants there is a 1.8 case per 100,000 increase in bleeding injuries/deaths for infants NOT given vit K vs a 1.5 case/100,000 increase in leukemia for infants given Vit K. The risk of death is greater without the VIT. K. I don't know if this difference achieves statistical significance but I think the sheer numbers would make my mind up.

The Numbers
Extracting data from available literature reveals that there are 1.5 extra cases of leukemia per 100,000 children due to vitamin K injections, and 1.8 more permanent injuries or deaths per 100,000 due to brain bleeding without injections. Adding the risk of infection or damage from the injections, including a local skin disease called "scleroderma" that is seen rarely with K injections,8 and even adding the possibility of healthy survival from leukemia, the scales remain tipped toward breastfed infants receiving a prophylactic vitamin K supplementation.

at http://www.babyreference.com/VitaminKinjectORnot.htm .

This stuff drives me crazy as most people have no idea just how small 2/100,000 is as a number.

To put it in perspective. Mn Had 73,515 live births in 2006. Chances are there was less than 1 childhood cancer statewide that could be attributed to Vit K.

babyktchr, BSN, RN · May 13, 2008

I am always fascinated by patients who come armed with legal documents and birth plans and heavily researched this and that. I always ask why they have chosen their path, what their research has taught them, and try to discuss ramifications (other than, this is what I want). With the fact that they brought legal papers to further the NO VACCINE request, I think the prudent thing would've been for the hospital risk management team to draw up some kind of paper stating the potential risks to the newborn for NOT receiving Vitamin K and have them sign it. That way, the hospital can say that they now have reason not to be sued if something adverse happens to the baby because of the parents choices.

Vitamin K is not a vaccine, it is a medication for clotting, which an above poster explained quite well. In my state, we do not need written permission to give Vitamin K and I can honestly say, I have probably had a handful of no takers in my 14 years of OB. We do require written permission for HEP B for EITHER a yes or a no. If patients refuse HEP B, they have to sign a paper stating they understand the facts yada yada yada. Hep B is required in our state to enter public school.

Just an aside here.......does anyone else find that the "birth plan" usually goes to hell in a hand basket.....and everything they didn't want (C/S, epidural, pain meds, etc) happens??????

Belinda-wales, RN · May 13, 2008

I am always fascinated by patients who come armed with legal documents and birth plans and heavily researched this and that. I always ask why they have chosen their path, what their research has taught them, and try to discuss ramifications (other than, this is what I want). With the fact that they brought legal papers to further the NO VACCINE request, I think the prudent thing would've been for the hospital risk management team to draw up some kind of paper stating the potential risks to the newborn for NOT receiving Vitamin K and have them sign it. That way, the hospital can say that they now have reason not to be sued if something adverse happens to the baby because of the parents choices.
Vitamin K is not a vaccine, it is a medication for clotting, which an above poster explained quite well. In my state, we do not need written permission to give Vitamin K and I can honestly say, I have probably had a handful of no takers in my 14 years of OB. We do require written permission for HEP B for EITHER a yes or a no. If patients refuse HEP B, they have to sign a paper stating they understand the facts yada yada yada. Hep B is required in our state to enter public school.
Just an aside here.......does anyone else find that the "birth plan" usually goes to hell in a hand basket.....and everything they didn't want (C/S, epidural, pain meds, etc) happens??????

There are now 10 studies investigating whether there is an association between vitamin K and childhood cancer. There is no proven risk of cancer or leukaemia. A risk of solid tumours can almost definitely be ruled out but a small risk of leukaemia cannot be excluded. I practice on building a partnership with women and familes-I see them as whole capable people for whom birth is their experience -for some the choice may be to with hold vitamin K I repsect this it is sad when legislation takes away informed consent -

GrumpyRN63, ADN, RN · May 13, 2008

I hand it over to the Peds, I'm sure there is one involved somewhere, he/she can discuss it with the pt, if she still refuses, he/she can have her sign a waiver, I wouldn't give it unless she consents, it's not that critical, I'm sure many babies who are home-birthed don't receive it, JMHO :stone

Jolie, BSN · May 13, 2008

IndigoCarmine,

Can you tell where you are located? And possibly post a link to the law in your state that mandates administration of vitamin K to newborns? I've worked in a number of states, but never in one that didn't allow for some sort of exemption to vitamin K, erythromycin ointment and PKU testing for newborns. It makes me wonder if this is "urban legend" that it can't be legally declined in your state.

As for what I would do: Upon reading the birth plan, I would explore the issue with the parents, explain the risks and benefits and let them know that hospital policy requires me to notify my superiors and the pediatrician of their decision to refuse vitamin K. I would then drop the issue entirely and assist them in bringing their long-awaited, precious child into the world. No reason to make the birth contentious over the issue of vitamin K.

Once the baby is born, it would be up to the pediatrician to assess the child's need for the medication. If s/he feels strongly that it is medically necessary, then social services would become involved to petition the court for permission to administer vitamin K against the parents' will. I have no right to administer a medication to a child against their parents' wishes without a court order. To do so would amount to assault and battery and would destroy the parents' trust in me and the healthcare system. The nursing staff should not allow itself to be drawn into contention with the parents over the issue. If any administrator tried to tell me to give the shot, I would refuse. As a staff nurse, I do not have the standing to deal with the issue.

I seriously doubt that anything would come of a parent's refusal of vitamin K, unless there were some underlying condition that placed the baby at abnormally high risk of bleeding. The parents have the right to refuse vitamn K, and the healthcare team needs to adjust their care plan to accomodate that preference, such as teaching parents safety measures to prevent bleeding in the newborn, and s/s of hemorrhage to watch for at home, should bleeding occur.

OzMW · May 13, 2008

Vitamin K isn't a vaccine, its just that...a vitamin. I'd suspect your ethical /legal dilemma lies in giving a substance to a newborn that the parents have not consented to. Where I am you'd have a greater chance of losing your license if you gave it without the parents consent. The hoo ha over vitamin k deficiency bleeding in newborns is crappola really! Before vitamin k was given routinely it was a rare occurrence, and funnily enough despite the widespread use of vitamin k, it still happens!

My kids had it and any future ones will, but its a parents choice, and I fail to see why governments would be at all interested in such a rare disease!!!!! And if they are, who the hell is allowing them to tell parents what to do with their children.....eeck!

OzMW · May 13, 2008

I am always fascinated by patients who come armed with legal documents and birth plans and heavily researched this and that. I always ask why they have chosen their path, what their research has taught them, and try to discuss ramifications (other than, this is what I want).????

So as nurses are we all aware of the facts in relation to vitamin K deficiency bleeding in newborns? Maybe these parents who came armed with the research are the clever ones! I welcome parents who research and inform themselves...wish there was more of it actually! Our appallingly high rates of intervention around birth would probably be alot less if more of 'em questioned stuff rather than blindly accepting the "professionals" opinion!:heartbeat:heartbeat:heartbeat:heartbeat:heartbeat